Introduction
Within the myriad of incidents that occur in a healthcare organization a small, but significant, number result in avoidable death or life long injury to either patients or members of staff. Creating a framework to review such incidents, learn from them and institute appropriate improvement strategies is central to any risk management strategy. As well as defining what constitutes a serious event in multi professional teams, occupational health departments and staff side committees there are also considerable learning outcomes to be gained from assessing those incidents that do not have tragic consequences for the affected parties. Some, although not defined as serious, may highlight significant risk potential for a local health provider, including loss of public confidence, loss of ability to provide a service and adverse publicity
Within the health economy there is clear value in ‘taking a second look’ at all incidents that do not result in severe harm, as part of the overall safety and quality improvement process. Using a risk assessment tool can help provide a structured management framework to evaluate each incident and assign clear accountability for actions and learning, post event. Instituting a systematic approach to the risk assessment of incidents that do not result in tragic harm (life long injury or death) delivers significant benefits. It enables organizations to introduce clearly defined levels of accountability for action and learning from adverse events and the identification of potential future disasters. It also aids in the exploration of quality and safety failures before anyone is hurt and the development of a safety culture Local teams and organizations can demonstrate ‘due process’ in their decision making and this would also lead to the introduction of qualitative analysis within the incident management process and the systematic determination of which events deserve closer review.
Risk Assessment and Prevention of Pressure Ulcers
Pressure ulcers, also known as pressure sores, bedsores and decubitus ulcers, are areas of localized damage to the skin and underlying tissue. This damage is generally a result of external forces – pressure, shear and/or friction. Pressure ulcer development occurs in institutional and community settings, and is most often seen in elderly, debilitated and immobile (e.g., orthopaedic) clients, those with severe acute illness (e.g., those in intensive care units) and in individuals with neurological deficits (e.g., spinal cord injuries) ( 1995).
The high prevalence of pressure ulcers is a significant health care concern. A recent study reported by (2004) reviewed data that surveyed over 14,000 patients from 45 health care institutions across Canada, and estimated the prevalence of pressure ulcers as follows: Acute Care Hospitals: 25.1% Non-Acute Facilities (Long-term care, Nursing Homes, etc) 29.9% Mixed Health Care Facilities (acute and non-acute) 22.1%
Community Care 15.1% Overall, the estimate of the prevalence of pressure ulcers in all health care institutions across Canada was 26.2%. This data suggests that pressure ulcers are a significant concern in all health care settings in Canada (2004). Estimates have indicated that up to 10% of those admitted to hospital develop a pressure ulcer, the elderly being at the highest risk with approximately 70% of all pressure ulcers occurring in elders (2002). In those individuals who develop pressure ulcers, approximately 60% occur in the acute care setting – usually within the first two weeks of hospitalization (1989). With the increased acuity of those admitted to hospital, it is estimated that 15% of elderly patients will develop pressure ulcers within the first week of hospitalization ( 2002). In the long term care setting, pressure ulcers are most likely to develop within the first four weeks of admission ( 1992). Malnutrition is a significant problem for the elderly, and is a risk factor for the development of pressure ulcers. Rates of malnutrition in the institutionalized elderly are estimated to affect 23-85% of the population, while the rate for those being admitted to hospital is estimated to range from 20-50%. Pressure ulcer risk increases by 74% with the
combination of immobility, stress to the immune system and loss of lean body mass (muscle) (2004).
Mortality is associated with pressure ulcers – several studies have reported mortality rates as high as 60% for elders with a pressure ulcer within one year of discharge from hospital. The pressure ulcer is not generally the cause of death, but rather it develops after a decline in the health status of the older person (2002). The burden of pressure ulcers and their treatment impacts on quality of life for the client and family, but also creates significant financial strain for those living with a pressure ulcer, their families, and the health
care system. Costs associated with the treatment of pressure ulcers in the United States have been conservatively estimated to be 0 to ,000 (US) per ulcer, with more severe wounds being significantly more expensive to manage than less severe ulcers (2001). AHCPR (1992) estimated that the total national cost (United States) for pressure ulcer treatment was at that time .3 billion dollars (U.S.) annually and rising. Although there is no comparable Canadian data related to national costs, the (2004) reported on a study conducted in the late 1990s that estimated the cost of treating an individual with a pressure ulcer within a long term care facility to be an average of ,050 for three months of treatment. Similarly, a recent case study ( 2004) estimated the total cost for 12 weeks of treatment in the community, including electrical stimulation, to be ,632. These costs, however, do not address the burden of pain and suffering and the impact on the individual’s quality of life.
Risk Assessment Outline for Pressure Ulcers
Early intervention is essential for those at risk of developing pressure ulcers. The principle components of early intervention are outlined as follows: (1) Identification of at-risk individuals who need preventive interventions and of the specific factors that place them at risk (2), protection and promotion of skin integrity (3), protection against the forces of pressure, friction and shear and
(4) reduction of the incidence of pressure ulcers through educational programs for health professionals and clients.
Practice Recommendation for Risk Assessment
A head-to-toe skin assessment should be carried out with all clients at admission, and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences. As pressure ulcers usually develop over bony prominences, it is recommended that these areas be the focus for assessment (1992; 2000; 2000; 2001). Skin inspection should be based on a head-to-toe assessment of those areas known to be vulnerable for each patient. These areas typically include the temporal region and occiput of the skull, ears, scapulae, spinous processes, shoulders, elbows, sacrum, coccyx, ischial tuberosities, trochanters, knees, malleoli, metatarsal areas, heels, and the toes. In addition, areas of the body covered by anti-embolic stockings or restrictive clothing, areas where pressure, friction and shear are exerted during activities of daily living, and parts of the body in contact with equipment are also considered vulnerable. Additional areas should be inspected as determined by the individual’s condition ( 2001; 2001). The client’s risk for pressure ulcer development is determined by the combination of clinical judgment and the use of a reliable risk assessment tool. The use of a tool that has been tested for validity and reliability, such as the Braden Scale for Predicting Pressure Sore Risk, is recommended. Interventions should be based on identified intrinsic and extrinsic risk factors and those identified by a risk assessment tool, such as Braden’s categories of sensory perception, mobility, activity, moisture, nutrition, friction and shear. Risk assessment tools are useful as an aid to structure assessment. In order to determine the client’s level of risk, the AHCPR guideline (1992) recommends the use of a standard risk assessment tool. The Braden Scale and the Norton Scale have been tested sufficiently for reliability and validity to be useful adjuncts to nursing assessments and care planning. The Braden Scale has good sensitivity (83-100%) and specificity (64-77%), while the Norton Scale has a sensitivity of 73-92% and specificity of 61-94%. Positive predictive values are documented as: – approximately 40%; – approximately 20% ( 2002).
Frequency of Risk Assessment
Although the optimum frequency of risk assessment has not been substantiated in the literature, there are clinical standards that are widely accepted and reported. It has been noted that the majority of pressure ulcers develop within the first two weeks after admission to a facility (1996). One prospective study of new admissions to a nursing home over three months showed that of those who developed pressure ulcers, 80% did so within the first two weeks and 96% did so within three weeks ( 1992). These results support the need to identify those clients “at risk” for developing pressure ulcers early in their care, preferably on admission. The literature also supports reassessments for “at risk” individuals ranging from daily to weekly, however, many sources agree that whenever a client’s condition changes, reassessments should be conducted (2000; 2000;1996; 2001;2000). (2001) suggests that the frequency of risk assessments should be based on the findings of the initial admission assessment and the rapidity of the client’s change in health status. Ideally, the client should be assessed for risk on admission, again in 48 hours and as often as the level of morbidity indicates. In addition, (2001) makes recommendations for assessment of specific populations according to the following schedules: (1) Long-term care facilities – At admission, then every week for four weeks and quarterly thereafter. (2)Intensive Care Units – Daily. (3)General medical/surgical units – Every other day. (4)Community – Every home visit.
Intrinsic/Extrinsic Risk Factors in Pressure Ulcers
The determination of risk for pressure ulcer development is established by the combination of the use of a reliable risk assessment tool and clinical judgment. There is discussion in the literature regarding the need to look beyond assessment tools in considering risk, as the development of pressure ulcers may be influenced by factors not addressed within these tools. The potential to develop pressure ulcers may be influenced by intrinsic risk factors that relate to aspects of the client’s physical, psychosocial or medical condition. These factors should be considered when performing a risk assessment, and include nutritional status (malnutrition and dehydration), reduced mobility or immobility, repetitive stress syndrome (involuntary movements), posture/contractures, neurological/sensory impairment, incontinence (urinary and fecal), extremes of age, level of consciousness, acute illness, history of previous pressure damage, vascular disease, and severe chronic or terminal illness (1998; 2000; 2002; 2001; 2000). Extrinsic factors derived from the environment can also influence the development of pressure ulcers. These include factors such as hygiene, living conditions, medication, pressure, shearing, friction, garments, transfer slings, restraint use and the support systems used to relieve pressure (1998; 2000; 2001; 2001; 2000). Clinical assessment of all factors that increase the client’s risk for skin breakdown must be considered to facilitate early identification of those at risk.
All data should be documented at the time of assessment and reassessment. Proper documentation provides an accurate record of a client’s progress and risk status. Any skin changes should be documented immediately, including a detailed description of what was observed and what actions were taken (RCN, 2000) and should be made accessible to all members of the health care team (2001).
The literature addresses the need for the use of clinical judgment, in conjunction with a recognized risk assessment tool, in the identification of risk (2000;1998; 2000). Both the development and revision panel strongly support the need for clinical nursing judgment in conjunction with the overall client profile as a basis for determining risk and planning of appropriate care. This recommendation is based on current practice, clinical experience and opinion.
Intervention
Voluntary and involuntary movements by individuals themselves can lead to friction injuries, especially on elbows and heels. The use of products to minimize contact with surfaces (including bed linens) can reduce the potential for injury (1992; 2000; 2003). Use turning devices such as sheets, trapezes, or manual or electric lifts that will decrease the risk of skin damage (1992; 2000). After using turning equipment, slings, sleeves or other components of the device should not be left underneath the individual after repositioning (2001).
Consider the impact of pain. Pain may decrease mobility and activity. Pain control measures may include effective medication, therapeutic positioning, support surfaces, and other nonpharmacological interventions. Monitor level of pain on an on-going basis, using a valid pain assessment tool. Consider also the client’s risk for skin breakdown related to the loss of protective sensation or the ability to perceive pain brought by analgesics, sedatives and neuropathy, and to respond in an effective manner with it and the impact of pain on local tissue perfusion.
Pain is a factor that may result in decreased mobility in clients who are dealing with chronic conditions such as arthritis, multiple sclerosis, cancer, and musculoskeletal injuries. Any decrease in mobility as a result of such pain may increase the risk for the development of pressure ulcers. At the same time, however, analgesia and sedatives may depress the central nervous system. This may result in reduced mental alertness, activity and mobility, thereby altering the individual’s ability to respond effectively to ischemic pain ( 2003).
A systematic review conducted by (2004) examined to what extent pressure-relieving surfaces reduced the incidence of pressure ulcers compared with standard support surfaces, and reviewed how effective different pressure-relieving surfaces were in preventing pressure ulcers, compared to one another. It was concluded, from the 41 randomized controlled trials included in the review, that in those at high risk of pressure ulcers, the use of a higher specification foam mattress (low interface pressure) should be considered rather than the standard hospital foam mattress. Standard hospital mattresses have been consistently outperformed by a range of foam-based, low pressure mattresses and overlays, and also by “higher-tech” pressure-relieving beds and mattresses in the prevention of pressure ulcers. Clients at very high risk of developing pressure ulcers may benefit from an alternating pressure mattress or other high-tech pressure redistributing systems ( 2000; 2000). Alternating pressure devices generate alternating high and low interface pressures between the body and support surface (bed), usually by alternate inflation and deflation of air-filled cells. These devices are available as mattress overlays, and single or multi-layer mattress replacements. The systematic review conducted by (2004) indicates that the relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear. (2001) outlines criteria and selection modalities for the use of support surfaces in the prevention of pressure ulcers. Regardless of the type of surfaces used for high-risk clients, thorough and frequent skin assessments should be conducted for evidence of tissue damage (2004; 2003).
Clients experiencing surgery are at risk for development of pressure ulcers because of factors that cannot be controlled – length of procedure (2002), hemodynamic state and the use of vasoactive medications during surgery. There are, however, many risk factors that can be controlled to reduce the incidence of pressure ulcer development, including pooled prep solutions, negativity, shearing, friction and the use of warming blankets beneath the client. Another factor that can be controlled in order to decrease pressure ulcers is the surface on which the person is placed during the surgical procedure ( 2001; 2003).
Wet skin is fragile and more susceptible to friction and tearing injuries, especially during cleansing. Moist skin also has a tendency to adhere to bed linens, potentially leading to damage when linen is removed. In addition, it is more susceptible to irritation, rashes and infections, such as candida. When the source of moisture cannot be controlled, use of protective barriers and moisture absorbing products are recommended. Absorbent pads, dressings or briefs should be changed as they become saturated, rather than delaying until they reach their absorptive capacity. These products should not interfere with any pressure-redistributing surface an individual may be placed on ( 1992;2000; 2000). When skin is moist from perspiration, cotton linens are recommended to promote evaporation, skin aeration and faster drying. Frequent changing of moist linens is recommended to maintain dry intact skin.
Rehabilitation Program
Immobility and inactivity has been associated with larger ulcers, and bed and chair-bound persons are at higher risk for pressure ulcer development. Researchers have reported that the use of active and passive range of motion exercises promotes activity and reduces the effects of pressure on tissue. Exercise, ambulation, proper positioning, strengthening and increased range of motion all assist in the prevention process ( 1992; 2000).
Conclusion
All health care providers should receive relevant education in pressure ulcer risk assessment and prevention. Frequently, the focus of care is on maximizing functional gains in activities of daily living and mobility, and education is informal or minimal. It is essential, however, that individuals be provided with the basic knowledge necessary to return them to home and their communities ( 2000),
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