Pressure Injury Prevention Madge’s story CLINICAL EXCELLENCE COMMISSION February 2016
This presentation highlights learnings about Madge’s story. Madge and her family hope this will raise awareness about the importance of pressure injury prevention We hope to show the importance of prevention and the impact that a pressure injury has on the patient and family Serious hospital acquired pressure injuries continue to occur throughout New South Wales healthcare facilities 2
Outline • Introduction • CEC resources • Madge’s story • Timeline of admission • Timeline for Pressure Injury (PI) to heal • Communication/documentation • Impact of pressure injury on Madge • Cost of PI • Key learnings 3
Introduction • A pressure injury (PI), also referred to as a pressure ulcer or bed sore, is a localised injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, shear or a combination of these factors 1 • Many PIs are highly preventable. It is recognised that their lengthy healing time has consequences for quality of life, including susceptibility to infection, pain, sleep and mood disturbance. They also impact on rehabilitation, mobility and long-term quality of life 4
Risk assessment requirements for inpatients 5
Risk assessment requirements for inpatients • To guide clinical decision making the two part PI assessment/screening process is to be completed within 8 hours of presentation to the health facility by appropriately skilled health staff • Patients identified as at risk of PI development will have the two part assessment - Daily as a minimum and: - If there is a change to mobility - Pre-operatively, and as soon as feasible after surgery - On transfer of care - If a pressure injury develops 1,2 (Based on current policy and guidelines) 6
CEC resources • Risk assessment requirements for inpatients • Prevention strategies • Care planning and management • Patient information 7
Madge’s story • 85 year old lady • Lives alone, independent at home, uses a walking frame • House proud and loves cooking and working in her garden • Has two daughters, both registered nurses who live over 4 hours away LINK to video 8
Errors in Health Care James Reason proposed the image of "Swiss cheese" to explain the occurrence of system failures, such as medical mishaps. 9
Review of Missed Opportunities Relevant details of Madge’s admission 10
Emergency Department • Chest pain pathway • Discovered strangulated hernia and bowel obstruction • Plan: admission, nasogastric tube and surgery • Transferred to ward prior to surgery • Ward transfer checklist completed - No comprehensive risk assessment attended Documented risk assessment as: N/A 11
Timeline for Madge’s admission Presents to Emergency Department 14/05/2015 2100 1100 2110 15/05/2015 18/05/2015 25/05/2015 First hole: Madge PI risk not identified in ED
First ward • Initial risk assessment attended identified Madge “at risk” • Review of documented information at the initial assessment placed Madge at a higher risk level than documented 13
Timeline for Madge’s admission First ward Presents to Emergency Department Second hole: PI risk assessment not correctly completed 14/05/2015 2100 2110 1100 15/05/2015 18/05/2015 23/05/2015 First hole: Madge PI risk not identified in ED
Theatre • Theatre for a two hour operation • Documented intact skin prior to surgery • Skin intact following surgery • No risk assessment completed or prevention strategies documented 15
Timeline for Madge’s admission First ward Presents to Emergency Department Theatre Second hole: Risk assessment not correctly completed 14/05/2015 2100 2110 15/05/2015 1100 18/05/2015 23/05/2015 First hole: Madge PI Third hole: PI risk risk not identified in assessment not ED documented pre or post op (from documented information would score very high risk)
First Ward Post Surgery • Risk assessment not documented • Documented information would put Madge at “very high risk” • Pain Management - Madge was using Patient Controlled Analgesia, documented pain was still an issue with mobility 17
First ward post surgery • No evidence that pressure injury prevention education had been provided to the patient or family/carers • Madge offered a pressure redistributing support surfaces, but declined - Did Madge understand the importance of the special mattress? - Was Madge able to physically reposition independently? 18
Timeline for Madge’s admission 1st Ward Post Surgery First ward Fourth hole: PI risk identified, pressure Presents to Emergency Theatre Department relieving mattress offered but declined by Madge as Second hole: Risk she did not understand assessment not correctly why it was needed completed 2110 14/05/2015 2100 15/05/2015 1100 25/05/2015 18/05/2015 First hole: Madge PI risk Third hole: PI risk assessment not identified not attended pre or post op (from documented information would score very high risk)
Second ward post surgery communication and documentation • Care plan was completed for only two days of Madge’s stay • No risk assessment/skin inspection documented on transfer of care • Madge’s injury was documented in notes but no interventions were documented or communicated • No IIMS or wound chart completed 20
Timeline for Madge’s admission 1st Ward Post Surgery 2nd Ward Post First ward Surgery Presents to Emergency Department Fourth hole: PI risk identified, Theatre pressure relief mattress offered but declined by patient as she did not Second hole: Risk understand why it was assessment not correctly needed completed 14/05/2015 2100 23/05/2015 2110 15/05/2015 1100 18/05/2015 First hole: Madge PI Third hole: PI risk assessment Fifth hole: pressure injury risk not identified not attended pre or post op documented with no (from documented information would score very interventions documented high risk) or communicated
Discharge • Patient discharged after 10 day admission - No communication with daughters about the presence of a pressure injury • No skin assessment completed prior to discharge - Black mark noticed on buttock by daughter after discharge • Taken to local Emergency Department where Madge lives the day after discharge 22
Timeline for Madge’s admission 1st Ward Post Surgery 2nd Ward Post First ward Surgery Presents to Emergency Sixth hole: Discharge - Department Theatre presence of PI not Fourth hole: PI risk identified, documented or pressure relief mattress offered but declined by communicated to family Second hole: Risk patient as she did not and no follow up care understand why it was assessment not correctly completed needed arranged 2110 15/05/2015 1100 2100 18/05/2015 23/05/2015 14/05/2015 Third hole: PI risk assessment Fifth hole: pressure injury documented First hole: Madge PI not attended pre or post op with no interventions documented or risk not identified (from documented communicated information would score very high risk)
May 2015 Unstageable Pressure Injury right buttock 24
25
Unstageable pressure injury: Depth unknown Full thickness tissue loss in which the base of the PI is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the PI bed. Until enough slough/eschar is removed to expose the base of the PI, the true depth, and therefore the stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body’s natural biological cover and should not removed. 26
June 2015 27
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Timeline for Madge’s PI to heal Discharged from Hospital Theatre for Discharged home Negative pressure debridement, after 4 months in wound dressing negative pressure hospital removed wound therapy May 2015 June 2015 23 May 2015 24 Sept 2015 July 2015 Aug 2015 Sept 2015 Rehabilitation Negative pressure PI identified by wound therapy in hospital daughter continues, theatre for insertion of PICC line
Impact on Madge Pain and suffering Removed Ongoing from social wound network management Inconvenience for personal hygiene and Delay in toileting recovery, Worry about deconditioning daughters and lengthy travel, absence rehabilitation Loss of from their independence family and work Home and Unable to garden not attend planned being tended as appointments normal 30
Cost of PI • A conservative estimate of the cost of Madge’s hospital acquired pressure injury is over $200,000 - Hospital accommodation - Wound management including negative pressure wound therapy 31
Learnings The importance of: - identifying risk - communication and documentation - involvement of patients and/or their carers with clinicians to develop individualised care plans - working as a team to implement appropriate prevention strategies - patient based care 32
Acknowledgement We acknowledge the collaboration with Western New South Wales Local Health District in the development of this resource And special thanks to Madge and her daughters for sharing this story 33
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