Pressure Injury Prevention
for
Critically ill Adults
Sarah L Jones
CNC St George Hospital
Co chair – Evidence Pressure Inj...
Overview
▲ Background
▲ Guideline Development
▲ The Guidelines – recommendations
▲ Intensive Care Unit (ICU) & the experts...
Older and larger
Older and larger
Younger and faster
Guideline Development
▲ NHMRC & AGREE II tools & taxonomy
▲ PICOt & Guideline Scope
▲ The technical report
● Evidence of t...
Technical report
GDN - Scope
May 12
Systematic
Review
June12- Jan13
Consensus
meeting
March 2013
Guideline
writing
Mar-July 13
Internal
Val...
The guidelines
Incidence & prevalence
• Critically ill 4% - 53.4%
• IIMS 2009 – 2011 2427 incidents
▲ Sacrum
▲ Heels
▲ Buttock
▲ Lips & M...
Risk assessments
Risk factors
Recommendations
▲ Patient and carer
▲ Pressure Injury Risk Assessment
▲ Interventions
● Skin inspection
● Nutrition
● Supp...
Recommendation
Grade of
recommendation
2 Use a pressure injury risk assessment in conjunction with a
comprehensive visual ...
Recommendation Grade of
recommendation
5. The skin and mucosa impacted by invasive medical devices
(including but not limi...
Recommendations
▲ Patient and carer
▲ Pressure Injury Risk Assessment
▲ Interventions
● Skin inspection
● Nutrition
● Supp...
Recommendation
Grade of
recommendation
8. Implement prevention strategies to protect the patient’s skin as
soon as possibl...
Recommendations
▲ Patient and carer
▲ Pressure Injury Risk Assessment
▲ Interventions
● Skin inspection
● Nutrition
● Supp...
Recommendation
Grade of
recommendation
11. As a minimum, use high specification reactive (constant low
pressure) support f...
Recommendations
▲ Patient and carer
▲ Pressure Injury Risk Assessment
▲ Interventions
● Skin inspection
● Nutrition
● Supp...
Recommendation
Grade of
recommendation
15. Unless contraindicated at risk patients should be repositioned at
least every 2...
Recommendations
▲ Patient and carer
▲ Pressure Injury Risk Assessment
▲ Interventions
● Skin inspection
● Nutrition
● Supp...
Intensive Care Unit experts –
Support and Mentors
PIP groupICCMUACI
Project
manager
Kaye Rolls
Project officer
Janet Maste...
Intensive Care Unit (ICU) experts
The wound care consultants – Debbie Blanchfield, Sue Monaro, Jane Rodgers
Attrition
Lessons learned
Number of reviewers - determine attrition
rate at outset
Ethics Early. Seeking approval for multisite
prac...
Guidelines into practice
Barriers
▲ Access
▲ Navigation
▲ Assessment tools and continuity
Preparation
▲ Existing resources...
Search box
Where to find the guidelines
http://intensivecare.hsnet.nsw.gov.au/icwiki/index.php/Welcome_to_ICWiki
QUESTIONS
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Sarah L Jones, The St George Hospital - Best Practice Guidelines for Pressure Injury Prevention in the Adult Intensive Care Patient

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Sarah L Jones, ICU Cert , Grad Dip (Nursing Ed), Clinical Nurse Consultant, Intensive Care Unit, The St George Hospital & Co Chair, Evidence for the ACI/ICCMU Pressure Injury Prevention Project Group delivered the presentation at 2013 Reducing Avoidable Pressure Injuries Conference.

The 2013 Reducing Avoidable Pressure Injuries Conference featured a comprehensive case study led program covering topics such as prevention of pressure injuries during the surgical patient journey and in people with Spinal Cord Injuries, meeting Standard 8, translating research into clinical practice and more.

For more information about the event, please visit: http://www.informa.com.au/pressureinjuries13

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Sarah L Jones, The St George Hospital - Best Practice Guidelines for Pressure Injury Prevention in the Adult Intensive Care Patient

  1. 1. Pressure Injury Prevention for Critically ill Adults Sarah L Jones CNC St George Hospital Co chair – Evidence Pressure Injury Prevention Group24 September 2013
  2. 2. Overview ▲ Background ▲ Guideline Development ▲ The Guidelines – recommendations ▲ Intensive Care Unit (ICU) & the experts ▲ Guidelines into practice
  3. 3. Older and larger
  4. 4. Older and larger
  5. 5. Younger and faster
  6. 6. Guideline Development ▲ NHMRC & AGREE II tools & taxonomy ▲ PICOt & Guideline Scope ▲ The technical report ● Evidence of the literature and CPGs reviewed ● Practice review ● Systematic review ● Summary report ▲ Clinical Consensus ▲ 28 recommendations – built on the foundation of the PANPAC ▲ Consensus on recommendations 3 stages
  7. 7. Technical report
  8. 8. GDN - Scope May 12 Systematic Review June12- Jan13 Consensus meeting March 2013 Guideline writing Mar-July 13 Internal Validation July 13 External Validation August 13 Organisation consultation August 13 Launch - IC Wiki Sept 13 Development History
  9. 9. The guidelines
  10. 10. Incidence & prevalence • Critically ill 4% - 53.4% • IIMS 2009 – 2011 2427 incidents ▲ Sacrum ▲ Heels ▲ Buttock ▲ Lips & Mouth ▲ Nose & Nares 29% medical device ▲ ETT tapes 21 - 29%, NG tubes 14 -16%, TEDS 9 - 18%, Cervical spine collars 4 -7% 73% in 2011 were ICU acquired
  11. 11. Risk assessments
  12. 12. Risk factors
  13. 13. Recommendations ▲ Patient and carer ▲ Pressure Injury Risk Assessment ▲ Interventions ● Skin inspection ● Nutrition ● Support surfaces ● Repositioning ▲ Infection prevention ▲ Workplace Health & Safety ▲ Governance & Education
  14. 14. Recommendation Grade of recommendation 2 Use a pressure injury risk assessment in conjunction with a comprehensive visual assessment to determine the patient’s risk of pressure injury and to inform the development of a prevention plan Consensus 3 The Braden scale is the recommended validated and reliable tool for assessing pressure injury risk in the critically ill B 4 Inspect all of skin and mucosa of the patient within two hours of admission, at each repositioning and each shift change to identify indications of pressure injury including: •For fair skin races – erythema or for darker pigmented skin – persistent blue or purple hue •Blanching response •Localized heat •Oedema •Induration •Skin breakdown C
  15. 15. Recommendation Grade of recommendation 5. The skin and mucosa impacted by invasive medical devices (including but not limited to nasogastric tubes, tracheal tubes, IDUC, feacal management devices, nasopharyngeal airway and intravascular devices) should be inspected •At the beginning of a shift •Each repositioning or adjustment and •Where applicable at dressing change Consensus IIMS 6. Documentation of pressure injury risk assessment scale and visual inspection to occur at a minimum once a shift Consensus 7. All patients are to be regularly assessed for pain, especially in relation to repositioning and in the presence of pressure injuries. If the patient has a pressure injury this should include wound pain assessment C
  16. 16. Recommendations ▲ Patient and carer ▲ Pressure Injury Risk Assessment ▲ Interventions ● Skin inspection ● Nutrition ● Support surfaces ● Repositioning ▲ Infection prevention ▲ Workplace Health & Safety ▲ Governance & Education
  17. 17. Recommendation Grade of recommendation 8. Implement prevention strategies to protect the patient’s skin as soon as possible following admission or identification of high risk Consensus 9. Conduct nutritional screening and assessment using a validated screening and assessment tools appropriate to the population and clinical setting B 10. Ensure individual caloric requirements are met for patients at risk of pressure injury B
  18. 18. Recommendations ▲ Patient and carer ▲ Pressure Injury Risk Assessment ▲ Interventions ● Skin inspection ● Nutrition ● Support surfaces ● Repositioning ▲ Infection prevention ▲ Workplace Health & Safety ▲ Governance & Education
  19. 19. Recommendation Grade of recommendation 11. As a minimum, use high specification reactive (constant low pressure) support foam mattress on beds and trolleys for patients at risk of pressure injuries. no one specific high specification reactive (constant low pressure) support foam mattress is better than any other A 12. Those classified as high risk of pressure injury should have a active (alternating pressure) support mattress A 13. Any device used to prevent heel pressure injuries should be selected and fitted appropriately to ensure pressure is adequately offloaded and hyperextension of the Achilles tendon is avoided Consensus 14. When seated in a chair or wheelchair patients at risk of pressure injury should have the appropriate reactive or active cushion C
  20. 20. Recommendations ▲ Patient and carer ▲ Pressure Injury Risk Assessment ▲ Interventions ● Skin inspection ● Nutrition ● Support surfaces ● Repositioning ▲ Infection prevention ▲ Workplace Health & Safety ▲ Governance & Education
  21. 21. Recommendation Grade of recommendation 15. Unless contraindicated at risk patients should be repositioned at least every 2 hours (2,6,10) even if on an active or reactive support surface C 17. Reposition patients to reduce duration and magnitude of pressure over bony prominences and heels A 18. As a minimum position patients using 30 o lateral inclination alternating from side to side or a 30 o inclined semirecumbant position (2,6,11) C 19. Ideally patients in seated positions should have pressure relief every 30 – 60 minutes. For specific patient groups e.g SCI this may need to be more frequent (2,13) Consensus
  22. 22. Recommendations ▲ Patient and carer ▲ Pressure Injury Risk Assessment ▲ Interventions ● Skin inspection ● Nutrition ● Support surfaces ● Repositioning ▲ Infection prevention ▲ Workplace Health & Safety ▲ Governance & Education
  23. 23. Intensive Care Unit experts – Support and Mentors PIP groupICCMUACI Project manager Kaye Rolls Project officer Janet Masters Academic mentor Paul Fulbrook Chair Leila Kuizmik Co Chair EvidenceCo Chair Evidence Sarah Jones Co Chair - Practice Deirdre Powers Pressure Injury Prevention Group Wound Care CNC group Yve Robertson Kimberley Flood Stuart Cook Catherine Hennessy Kylie Mackenzie
  24. 24. Intensive Care Unit (ICU) experts The wound care consultants – Debbie Blanchfield, Sue Monaro, Jane Rodgers
  25. 25. Attrition
  26. 26. Lessons learned Number of reviewers - determine attrition rate at outset Ethics Early. Seeking approval for multisite practice review Guideline Scope – seek what the consumer and user want Implementation – Conscious not compromise Research Guidelines into practice
  27. 27. Guidelines into practice Barriers ▲ Access ▲ Navigation ▲ Assessment tools and continuity Preparation ▲ Existing resources ▲ Risk assessments - scenarios ▲ New equipment
  28. 28. Search box Where to find the guidelines http://intensivecare.hsnet.nsw.gov.au/icwiki/index.php/Welcome_to_ICWiki
  29. 29. QUESTIONS

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