preventing and managing pressure injuries · preventing and managing pressure injuries. ... alissa...

Implementation of NSQHS - Standard 8:

Preventing and Managing Pressure Injuries

Tracy Nowicki & Cherie FranksClinical Nurse Consultant-

QuEST & Nursing Director Clinical Effectiveness

The Prince Charles Hospital

Acknowledgements TPCH Tissue Viability Committee members

Location and Services

Image courtesy of health.qld.gov.au

•Cardiac and thoracic medicine and surgery •Emergency medicine – adults and children •General medical and general surgical services •Orthopaedic joint surgery (elective) •Acute geriatrics and rehabilitative medicine •Children’s inpatient services •Comprehensive and integrated mental health service •Palliative care Image courtesy of baulderstone.com.au

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Presenter

Presentation Notes

Overview of Metro North Metro North Hospital and Health Service provides the full range of health services including rural, regional and tertiary teaching hospitals. Metro North covers an area of 4157 square kilometres and extends from the Brisbane River to north of Kilcoy. The Royal Brisbane and Women’s Hospital is a general, tertiary referral teaching hospital with a number of specialities including Medicine, Surgery, Orthopaedics, Psychiatry, Oncology, Trauma and Women’s and Newborn Services. The Royal Brisbane and Women’s Hospital is the largest tertiary referral hospital in Queensland. The hospital fulfils a significant teaching and research role with links to Queensland’s major tertiary institutions. Specialised state-wide services include heart and lung transplantation; adult cystic fibrosis; congenital heart disease and heart failure; percutanoeus valve therapies and complex cardiac care.

Accreditation May 2013•

First Public Hospital in QLD to be assessed against all 10

of

the National Standards•

All Standards met

10 Met with Merits•

Medication-

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•

Blood and blood products-

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Falls-

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•

Pressure Injury-

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Image Courtesy of TPCH Newsletter

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• Implementing Standard 8 -Governance

Patient

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Patient

Occupational Therapy

Physiotherapy

Nursing Services /

Community

Medicine / Surgery

Executive / Management /

Quality

Dieticians

Pharmacy

QuEST

Podiatry

Wound Management

Services

Patient

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• Map out your evidence against the standards – and do this early

• Identify the evidence you have already

• What are you doing well?

• Where do you need to focus?

• Where are you gaps?

• What you need to do, by when and by whom?

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TPCH Pressure Injury Prevalence Studies

260 261246

265

335366

349372

408 413

8762 55

3775 66

3054 51

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0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Am

ount

0

50

100

150

200

250

300

350

400

450

Prevalence 16.15% 14.18% 13.82% 7.27% 13.73% 12.02% 5.15% 10.75% 9.30% 6.00%

Hospital Acquired 13.73% 6.90% 11.79% 4.15% 10.45% 7.92% 4.20% 7.26% 7.40% 4.00%

PI on admission 2.41% 7.28% 2.03% 3.11% 3.48% 4.64% 1.40% 3.76% 2.00% 2.00%

Incident report 10.34% 17.74% 18.18% 35% 22% 44% 70% 67% 68% 83%

How many pt surveyed 260 261 246 265 335 366 349 372 408 413

Howmany PI 87 62 55 37 75 66 30 54 51 30

2002 2003 2005 2006 2008 2009 2010 Mar‐11 Nov‐11 2012

Percentage

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8

Presenter

Presentation Notes

Linking not just nutrition to PI & Falls but also adding Continence. Taking the State Integrated Nutrition group one step further

Skin Inspection: It’s Important to Us!

• Measure problem• Audit• Improve• Educate• Make it sustainable• Reward• Evaluate

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Mobility, Impaired Activity and Sensory Perception

• Immobile and bed bound

• Patient physically unable to self reposition

• Use of sedation

• Inability to sense pressure discomfort

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Presenter

Presentation Notes

The ICU patient often encounters prolonged periods of pressure from a number of sources. They are often in an induced coma and as such will be bed bound. The patient can experience periods where they are highly unstable and as a result unable to be turned or repositioned even slightly, without having serious implications on their condition. In addition these patients require invasive devices to support cardiac, respiratory and renal function, as well as the need for lines, wires and tubes to be inserted which increases the risk of mucosal pi’s as a result of placement of Endotracheal tubes, naso-gastric tubes, drains, and drive lines. In order for the patient to tolerate what can be traumatic and painful interventions whilst also limiting the risk of barotrauma and reducing oxygen requirements the use of sedation and occasionally paralysing agents is esential. Although this maintains patient comfort, sedation also has the effect of rendering the patient immobile and unable to sense the discomfort of high levels of pressure and initiate movement. There is also evidence to suggest that the use of sedation causes a deterioration of vasomotion and microvascular response to ischaemia, compromising tissue perfusion. (Lamblin, 2006)

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Presenter

Presentation Notes

Mr X was unable to be turned for pressure area care due to his unstable condition. The positioning of ECMO cannulas or a patient having an open sternum can also contrindicate being turned. As such the use of a Jordan Frame is required. The ICU guidelines recommend Jordan framing these patients twice during a 12 hour morning shift. Although, this can take up to an hour depending to co-ordinate. To gain an understanding of the difficulty of transferring a patient or inspecting a patient’s skin in this environment there is a need for 3 to 4 qualified staff to perform this duty each time. Depending on how complex the patient may be. One nurse to hold the tracheotomy or endotracheal tube. One ECMO/VAD trained nurse to hold the VAD/ECMO lines. One qualified person to operate the manual handling equipment. One nurse to perform nursing duties. At times there is a perfusionist in the area too for compromised patients such as Mr X.

Prevention: It’s Important to Us!

• Risk Screening: Waterlow & Glamorgan• Updated to now include new terminology • Time• Procedure expects risk assessment within 8

hours• Compliance: 84% (State: 77%)• Pre & post knowledge tests• Updated Management Plan• Procedure

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• Increase in MST completion from 58 to 95% (n=304)• 2009 – moving MST to top increased completion 14%

State Leaders in Screening

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Adjunct Devices for the Heels Prevention is important to us!

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Prevention is important to us!

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Standardisation of Skin Care

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Simplifying Education & Measure

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The Prince Charles Hospital Pressure Injury Prevention Action Plans 2010/2011

Programme: Nursing Director: Mary Wheeldon

Issue Action By Whom By When Outcomes

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Treatment: It’s Important to Us

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Incident Report Evaluation It’s Important to Us! Immediate response

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Pressure Injury Prevention: Current Research

• Systematic review of interventions to reduce pressure injury in immobile critically ill patients.

Alissa Anderson, Paul Fulbrook

• Validity and reliability of four pressure injury risk assessment scales for use in intensive care.

Paul Fulbrook, Alissa Anderson

• Predictive validity of a new pressure injury risk assessment tool for critically ill patients.

Alissa Anderson, Paul Fulbrook

• Metro North survey of nurses’ knowledge of skin integrity and its management. Petra Lawrence, Paul Fulbrook, Sandra Miles, Cherie Franks & Debra Cutler

• Prevalence of pressure injury: a ten year analysis.Sandra Miles, Paul Fulbrook, Tracy Nowicki, Cherie Franks, Debra Cutler

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Consumer Engagement: It’s Important to Us!

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Anita Rush, ClinicalEquipment Specialist - Berkshire Equipment

Right Equipment………But Watch Out!

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Lessons Learnt

• Cyclic process- Continuous quality improvement cycle• Keep all evidence: measure, measure, measure • Utilise resources wisely- use one tool and adapt• Identify key/ high use areas and focus energy/ time on these • Continue with gap analysis and action plans for each service line

and utilise unit champions• Develop relationships across all disciplines- its not just the Doctors

and Nurses!• Be passionate- its not about ticking as many boxes as possible• Strong leadership and Executive buy-in• Start planning early

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Where to from here?

• Consumer engagement• Keeping action plans ACTIVE• Evaluate time on Waterlow• Skin Failure • Documentation• New Staging System• Heel Pressure Injuries• Continue to engage all disciplines• Research• Shear, pressure, moisture• Staff knowledge surveys• Mucosal, head, heel PIs

Keep the Wind in Your Sails!

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Pressure Injury Prevention & Management is Important to ALL of

us

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Cherie FranksNursing Director Clinical [email protected]

Tracy NowickiClinical Nurse [email protected]

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mailto:[email protected]

mailto:[email protected]

preventing and managing pressure injuries · preventing and managing pressure injuries. ... alissa...

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