Pressure Injury Prevention Madges story CLINICAL EXCELLENCE - - PowerPoint PPT Presentation

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

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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

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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 factors1

• 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

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Risk assessment requirements for inpatients

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Risk assessment requirements for inpatients

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• 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)

CEC resources

• Risk assessment requirements for inpatients
• Prevention strategies
• Care planning and management
• Patient information

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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

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Errors in Health Care

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James Reason proposed the image of "Swiss cheese" to explain the occurrence of system failures, such as medical mishaps.

Review of Missed Opportunities

Relevant details of Madge’s admission

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Emergency Department

• Chest pain pathway
• Discovered strangulated hernia and bowel
• bstruction
• 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

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14/05/2015 2100

Presents to Emergency Department

2110

First hole: Madge PI risk not identified in ED

15/05/2015 1100 18/05/2015 25/05/2015

Timeline for Madge’s admission

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

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14/05/2015 2100

Presents to Emergency Department

2110

First hole: Madge PI risk not identified in ED

15/05/2015 1100 18/05/2015

Second hole: PI risk assessment not correctly completed

23/05/2015

Timeline for Madge’s admission

First ward

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

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14/05/2015 2100

Presents to Emergency Department

2110

First hole: Madge PI risk not identified in ED

15/05/2015 1100

Third hole: PI risk assessment not documented pre or post

• p (from documented

information would score very high risk)

18/05/2015

Second hole: Risk assessment not correctly completed

23/05/2015

Timeline for Madge’s admission

First ward Theatre

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

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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?

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14/05/2015 2100

Presents to Emergency Department

2110

First hole: Madge PI risk not identified

Fourth hole: PI risk identified, pressure relieving mattress offered but declined by Madge as she did not understand why it was needed

15/05/2015 1100

Third hole: PI risk assessment not attended pre or post op (from documented information would score very high risk)

18/05/2015

Second hole: Risk assessment not correctly completed

25/05/2015

Timeline for Madge’s admission

First ward Theatre 1st Ward Post Surgery

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

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14/05/2015 2100

Presents to Emergency Department

2110

First hole: Madge PI risk not identified Fourth hole: PI risk identified, pressure relief mattress

• ffered but declined by

patient as she did not understand why it was needed

15/05/2015

Fifth hole: pressure injury documented with no interventions documented

• r communicated

1100

Third hole: PI risk assessment not attended pre or post op (from documented information would score very high risk)

18/05/2015

Second hole: Risk assessment not correctly completed

23/05/2015

Timeline for Madge’s admission

First ward Theatre 1st Ward Post Surgery 2nd Ward Post Surgery

Discharge

• Patient discharged after 10 day admission
• No communication with daughters about the presence
• f 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

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14/05/2015 2100

Presents to Emergency Department

2110

First hole: Madge PI risk not identified Fourth hole: PI risk identified, pressure relief mattress

• ffered but declined by

patient as she did not understand why it was needed

15/05/2015

Fifth hole: pressure injury documented with no interventions documented or communicated

1100

Third hole: PI risk assessment not attended pre or post op (from documented information would score very high risk)

18/05/2015

Second hole: Risk assessment not correctly completed

23/05/2015

Timeline for Madge’s admission

Sixth hole: Discharge - presence of PI not documented or communicated to family and no follow up care arranged

First ward Theatre 1st Ward Post Surgery 2nd Ward Post Surgery

May 2015

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Unstageable Pressure Injury right buttock

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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.

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June 2015

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23 May 2015

Discharged from Hospital

PI identified by daughter Negative pressure wound dressing removed

July 2015

Rehabilitation in hospital

Aug 2015

Negative pressure wound therapy continues, theatre for insertion of PICC line

Sept 2015

Theatre for debridement, negative pressure wound therapy

24 Sept 2015

Timeline for Madge’s PI to heal

May 2015

Discharged home after 4 months in hospital

June 2015

Removed from social network

Impact on Madge

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Pain and suffering Unable to attend planned appointments Home and garden not being tended as normal Worry about daughters travel, absence from their family and work Loss of independence Ongoing wound management Inconvenience for personal hygiene and toileting Delay in recovery, deconditioning and lengthy rehabilitation

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

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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

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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

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References

• 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel

and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014.

• 2. Pressure Injury Prevention and Management -

http://www0.health.nsw.gov.au/policies/pd/2014/PD2014_007.html

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Questions

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Resource Link

Thank you

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For further information: Pressureinjury@cec.health.nsw.gov.au www.cec.health.nsw.gov.au