PRESSURE INJURIES WHAT S IN A NAME?

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1 PRESSURE INJURIES WHAT S IN A NAME? LINDA NORTON MScCH, PhD candidate, OT Reg.(ONT) Motion Specialties, University of Toronto and University of Western Ontario The term pressure ulcer has been replaced by pressure injury (1) signaling a change in philosophy that has implications for rehab professionals. The change in terminology from Pressure Ulcer to Pressure Injury may seem like a technicality, however the change in terminology has created controversy in the health care sector and has implications for rehab professionals working in seating and mobility. This paper will begin by discussing the change in terminology and the rationale behind this change. Next, the controversy surrounding this change will be highlighted. Once this context has been established, the implications for health care professionals working in the seating and mobility sector will be described. Finally, the foundational pressure injury prevention and treatment approaches will be reviewed and rehab professionals will be challenged to look at their seating and mobility interventions from a skin injury prevention perspective. Pressure Injury vs. Pressure Ulcer To understand the change in terminology from pressure ulcer to pressure injury, a review of the definition of a pressure injury is required. The National Pressure Ulcer Advisory Panel defines a pressure injury as localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (3,4) Note that by definition, a pressure injury can occur regardless of whether the skin is intact. Recall that Stage 2, 3 and 4 Pressure Injuries are also known as partial-thickness skin loss with exposed dermis, full-thickness skin loss and full-thickness skin and tissue loss respectively (3,4). Each of these types of injuries involve open wounds. Stage 1 pressure injuries and deep tissue injuries however, both describe intact skin that has been damaged by pressure. A stage 1 pressure injury is defined as intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury (2,3) In this definition the idea that the damaged skin is intact is reinforced. It is also important to note that there may be other, nonvisual changes such as temperature, firmness or changes in sensation that precede a pressure injury. These could signal the need for early intervention such as equipment provision. Deep pressure injuries are defined as intact or non-intact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. (2,3) Again this definition stresses that the skin may be intact despite the extent of the tissue damage. The term ulcer refers to a break in the skin or mucus membrane. Since stage 1 pressure injuries and deep tissue injuries do not involve a break in the skin or mucus membrane, the term ulcer doesn t describe these wounds. The National Pressure Ulcer Advisory Panel has changed the term Pressure Ulcer to Pressure injury to promote clarity, and to better describe wounds due to pressure, regardless of whether the skin is intact. (1,3,4) The change in name to Pressure Injury is not without controversy. The primary concern is the term injury may be used to imply that caregivers caused the skin damage. The National Pressure Ulcer Advisory Panel has clarified that the word injury does not assign blame, nor imply that the injury was 14

2 caused by health care providers.(4) Ultimately, Pressure Injury is a label similar to Spinal Cord Injury or Traumatic Brain Injury, denoting damage to the skin from prolonged pressure or shear. An Opportunity for Rehab Professionals Although the term pressure injury was not meant to imply health care providers caused the injury, skin injury prevention is a natural extension to the injury prevention role often fulfilled by rehabilitation professionals. When this author was involved in a study regarding pressure ulcers, one of the potential participants commented, how big does the hole need to be before it is considered a pressure ulcer?(5) Perhaps if a skin injury prevention philosophy had been instilled in this individual and their health care providers, intervention would have occurred earlier, before an open area occurred. An injury prevention approach to pressure injuries starts with awareness. Health care providers (HCP), but more importantly clients, need to be aware of the risk of pressure injuries and the approaches that can be implemented to prevent them.(6) This awareness empowers the client and health care providers to be vigilant about their potential development, take action at the bedside to implement prevention strategies and to respond quickly should a pressure injury develop. Reflecting to the definition of a stage 1 pressure injury, the National Pressure Ulcer Advisory Panel expressly states that changes in temperature, firmness and sensation may precede visual skin changes; patients and caregivers need to be taught to be vigilant for these changes. A traditional public health approach to injury prevention involves the specific steps of surveillance, identifying risk and protective factors, selecting and designing interventions, program and policy implementation, and evaluation and monitoring. (7) While this approach could work for a facility or program, it could also be adapted to an individual client situation. 15

3 Seating and Mobility Interventions at the Facility Level 2018 Canadian Seating & Mobility Conference W2 Prevalence and incidence information can help inform our practice by identifying trends for the locations of wounds on the client, and the locations/programs/services where clients are most at risk. Depending on the process of the prevalence study, there may be the opportunity to add custom questions such as: Does the client have access to a pressure management cushion when sitting? Does the client have a pressure distribution mattress in bed? How does the client transfer? These types of questions can potentially describe the relationship between equipment availability and pressure injury prevention. This information can be used to advocate for resources within the facility or program. Valid risk assessment tools should also be implemented at the facility/program level and referrals made to seating and mobility providers based on the individual risk assessment. Risk and protective factors, from the viewpoint of seating and mobility providers should be reviewed, for at risk populations, within the facility/program. Depending on the facility or program, it may be possible to trigger referrals, or standard protocols (such as repositioning techniques) based on the recognition of these factors with a specific client by the front-line care providers. At the facility/program level, seating and mobility professionals can be involved in designing standard protocols such as repositioning programs, early mobilization programs, and programs to ensure seating and mobility equipment is used correctly with clients. Seating and Mobility Interventions at the Facility Level Surveillance at the individual level is important for skin injury prevention. Regular skin checks are recommended to help prevent pressure injuries.(8) Clients and their caregivers need to be vigilant for skin changes, including non-visual indicators such as changes in temperature, firmness and sensation. There is also research to suggest that a specialist seating assessment may help to reduce the development of pressure injuries. (9) As part of the seating assessment process, a personal risk profile could be created. A risk profile identifies the factors that could increase a client s risk of developing pressure injuries as well as the factors that act as buffers and help to reduce the risk.(10) Creation and discussion of this type of profile with the client and their caregivers as appropriate can help the client develop their own strategies to reducing risk throughout their other daily activities. A comprehensive assessment is required to determine the most appropriate seating and mobility interventions and equipment that will meet the client s needs as well as reduce the risk for pressure injuries. Clients need to receive education about how to use the equipment, when to consider replacement equipment, how to identify the need for new equipment and the positioning and repositioning strategies that should be incorporated into their day. In general, equipment provision and strategy development to reduce the risk of skin injury should focus on: Reduction of shear forces since shear doubles the impact of pressure(11), reducing shear should be a focus of the interventions.(6) Shear can be reduced through the properties of prescribed seating, the provision of repositioning equipment and teaching of specific repositioning techniques. Reduction of pressure forces ultimately one of the primary causes of pressure injury is pressure (3,4), so minimizing pressure through the provision of seating devices and optimizing the client s posture is a priority Maximizing mobility ultimately, fostering mobility is best for the client s overall health and wellbeing, and is the recommended approach.(12) Limiting mobility or prescribing bed rest is associated with other complications.(13,14) 16

4 Regular follow up and review of the client, their equipment and the techniques used will also help to reduce the risk of pressure injuries over time. Not only will this help to identify the need for equipment changes, but prevention behaviours tend to degrade over time(15). These prevention behaviours tend to be better preserved with regular follow up. Summary: At first glance, the change in terminology from pressure ulcer to pressure injury may seem minor, but signals the opportunity for a change in philosophy. Rehab professionals, especially those involved in seating and mobility can extend their role in injury prevention to include skin injury prevention. In this way they can target both facility and program interventions as well as interventions for their individual clients. References: 1. National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury [Internet]. National Pressure Ulcer Advisory Panel Web p Available from: 2. NPUAP (National Pressure Ulcer Advisory Panel). NPUAP Pressure Injury Stages [Internet]. Pressure Injury Stages [cited 2018 Feb 27]. p. all. Available from: 3. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound, Ostomy Cont Nurs. 2016;43(6): National Pressure Ulcer Advisory Panel. NPUAP Position Statement on Staging 2017Clarifications. 2017; Private communication. Potential pressure ulcer study research participant. 6. Norton L, Parslow N, Johnston D, Ho CH, Afalavi A, Mark M, et al. Best Practice Recommendations for the Prevention and Management of Pressure Injuries [Internet]. Toronto; Available from: 7. Pike I, Richmond S, Rothman L, Macpherson A. Canadian Injury Prevention Resource An evidence-informed guide to injury prevention in Canada [Internet]. Toronto ON; Available from: 8. Houghton PE, Campbell KE, Panel C. Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury, A Resource Handbook for Clinicians Kennedy P, Berry C, Coggrave M, Rose L, Hamilton L. The effect of a specialist seating assessment clinic on the skin management of individuals with spinal cord injury. J Tissue Viability Jul;13(3):

5 10. Clark FA, Jackson JM, Scott MD, Carlson ME, Atkins MS, Uhles-Tanaka D, et al. Data-based models of how pressure ulcers develop in daily-living contexts of adults with spinal cord injury. Arch Phys Med Rehabil [Internet] Nov [cited 2013 Dec 25];87(11): Available from: Orsted HL, Ohura T, Harding K. Pressure Ulcer Prevention - pressure, shear, friction and microclimate in context a consensus document. London; Registered Nurses Association of Ontario. Assessment and management of pressure injuries for the interprofessional team. Third Edition Norton L, Coutts P, Fraser C, Nicholson T, Sibbald RG. Is Bed Rest an Effective Treatment Modality for PressureUlcers? Chronic Wound Care 4th Ed. 2004; Norton L, Sibbald RG. Is bed rest an effective treatment modality for pressure ulcers? Ostomy Wound Manag [Internet]. 2004;50(10):40--2, ; discussion 53. Available from: %5Cn effective+treatment+modality+for+pressure+ulcers?.&aulast=norton&pid=%3cauthor%3enor ton+l;sibbald+rg%3c/author%3e%3can%3e %3c/an%3e%3cdt%3ecase+r eports%3c/dt%3e 15. Jackson JM, Carlson M, Rubayi S, Scott MD, Atkins MS, Blanche EI, et al. Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury. Disabil Rehabil [Internet] Jan [cited 2013 Dec 25];32(7): Available from: Speaker Bio Linda is an Occupational Therapist who is passionate about the prevention and management of chronic wounds. Her diverse experience in various settings including hospital, community and industry; and experience in various roles including clinician, educator, manager and researcher give Linda a unique perspective. In addition to consulting on several best practice documents, she was the lead author on the Pressure Injury Prevention and Management Best Practice Recommendations for Wounds Canada. She teaches at two Ontario Universities and is the Education and Client Relations Specialist at Motion Specialties. 18