Pressure Injury Prevention in the Hospitalised Elderly: A Medical Perspective

Transcription

1 <Insert cover image here> Pressure Injury Prevention in the Hospitalised Elderly: A Medical Perspective Samuel TH Chew MB BCh BAO (NUI), MRCP (UK), CCT in Internal and Geriatric Medicine (UK), FAMS, FRCP (Edin) Senior Consultant Geriatrician Department of Geriatric Medicine Changi General Hospital

2 2 Overview 1. What Is The Definition of Pressure Injury? 2. What Is The Epidemiology? 3. Why Are Pressure Injuries Good Friends With Elderly Patients? 4. How To Stage Pressure Injuries? 5. What Are The Medical Risk Factors for Pressure Injuries? 6. Why Pain Management Important? 7. What Happens If We Do Nothing? 8. Evidence Based Care

3 3 Definitions A pressure ulcer is a localized injury to the skin and /or underling tissue, usually over a bony prominence, as a result of 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. (National Pressure Ulcer Advisory Panel (NPUAP) 2016) Moisture injury and pure skin tears excluded Community vs Hospital Acquired Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

4 4 HOW PRESSURE ULCER DEVELOPS Pressure ulcer occur when there is localized trauma/injury to the skin and its underlying structures Resulting from pressure, shearing force and friction Common sites are bony prominence of the body

5 5 Epidemiology Agency for Healthcare Research and Quality 2.5 million Americans develops pressure injury per annum, 2012 [Singapore Citizens 3.37 million, 2015] NICE UK 2014 Prevalence 4.7% to 32.1% in hospital populations 22% in nursing homes Costs 1.4 billion to 2.1 billion per annum in UK [SGD $2.52 to $3.78 billion] 1214 to 14,108 per ulcer for Grade 1 and Grade 4 respectively [SGD $2185 to $25,000] Putting things in perspective

6 6 PU and the Elderly High risks community acquired Inadequate training carers Lack public awareness Inevitable High risks hospital acquired Poor pre-morbid Rapid decline (physical/metabolism) in critical illness Immobility (hemiplegic stroke, complicated hip fractures, advanced dementia, Parkinson s Disease) Incontinence High morbidity and mortality Pain and consequences Sepsis and shock High costs of care (financial, physical space, practical, emotional)

7 7 PRESSURE ULCER STAGING

8 Unstageable

9 Deep Tissue Injury

10 DTI Heel

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13 Force Pressure Momentum

14 Diagnosis is retrospective Diagnosis is by history

15 Medical Risk Factors for Pressure Injury 6 cases over 5 months, Male, Nursing Home Non Weigh-bearing Dementia, Sacral Ulcer, Sepsis 83 Male, Home 38kg, Recurrent Falls Sacral, Hip, Ear Ulcers Sepsis 81 Male, Home 53 kg RA, Falls, Immunosuppressant, HSV, Sepsis Cardiac Arrest, Stroke 86 Male, Home 34 kg, Falls, Girdle Stone, Extreme Frailty, Sepsis, BGIT, Carer Stress 82 Male, Nursing Home MCA Stroke, Non Weighbearing, Contracted 12 Pressure Injuries, 7x3x3 cm Iliac Crest, Sepsis 85 Male, Home Non Weight-bearing, Shortness Of Breath Recurrent Falls, Dementia, Bedbound 1 year Un-diagnosed Lt Hip Fracture Lt Hip Ulcer 11x7 cm, Osteomyelitis 15

16 16 Medical Risk Factors for Pressure Injury 25% of all deaths 5 months 168 bed days total 28 bed days average

17 Medical Risk Factors - Aetiology Disease Aetiology Dementia Stroke/Parkinson Disease Unrepaired/Unrecognised Hip Fractures Frailty/Sepsis/Immunosupressed Heart Failure Calcium Channel Antagonist/Alpha Blockers/etc Hypomania/Hypermania Mobility/tone/contractures /cognition Mobility/tone/contractures Nutrition/catabolic state/poor healing reserve Localised Oedema Pedal oedema 17

18 Medical Risk Factors - Interventions Disease Dementia Stroke/Parkinson Disease Unrepaired/Unrecognised Hip Fractures Frailty/Sepsis/Immunosupressed Heart Failure Calcium Channel Blockers/Alpha Blockers/etc Intervention Avoid over-sedation Thrombolyse/Dopamine Advocate repair/screen for occult hip fractures Treat underlying causes Diuretics Avoid/Suspend Offending Drugs 18

19 19 Consequences of Pain Avoidable Suffering Hypertension Raised cardiovascular risk Hampers Care of wound Sleep/Eat/Cognition/Delirium/Aggression Increased tone Increased rigidity Contractures Increased pressure at contact points Increased pressure ulcers and pain

20 Pain Management Challenges Unrecognised Unable to assess severity Unstable incident pain Unfortunately part of care Unwilling patient or relative Unavoidable side-effects at therapeutic doses Interventions Screen all patients Use FLACC scoring tool/clinical assessment Prescribe for break through pain dosing Reassure with pain charting, daily review of side effects and explain rationale Treat side-effects symptoms adequately 20

21 Impetus for action Why am I here? 21

22 What happens if we do nothing? Nature will take it s course 22

23 Impetus for actions

24 Evidence Based Care Managing change 24

25 25 Evidence Based Care NICE Guidelines 2014 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers 2014 European Wound Management Association Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. AHRQ, 2006.

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27 27 Are All Pressure Injuries Avoidable?...

28 Medical, Surgical and Physiological Risk Factors Vasodilators/Calcium Channel Antagonist/Alpha Blockers Severe Diarrhoea/Phosphate Enema/Incontinence Associated dermatitis Heart Failure Dementia/Stroke/Parkinson Disease Unrepaired/Unrecognised Hip Fractures Frailty/Malnutrition Sepsis/Immunosupressed 28

29 Change management is key Quality Care Essential 29

30 Improving Quality of Care AHRQ Toolkit Are we ready for change? 2. How will we manage change? 3. What are the best practises that we want to use? 4. How should these be organised in our hospital? 5. How do we measure PU rates and practices? 6. How do we sustain the redesigned processes of care? 7. What are the tools which we need? 30

31 Team Work and Collaborative Care Engaging Family/Assess Needs Planned Discharge/ Follow-up

32 Individualisation of Care Targeted Resources and Outcomes 32

33 Good Rehabilitation Potential Wound Care Pressure Injury Prevention Functional Optimisation Independent Living (resources)

34 Extremely Disabled with poor rehab potential Wound Care Pressure Injury Prevention Functional Optimisation (resources)

35 35 Summary Elderly Population, Multimorbidity, Frailty Are Pressure Injuries Inevitable?

36 Can We Provide Individualised High Quality Care? Mobility Continence Nutrition 36

37 37 Moving Forward Create self-sustaining system Provide enhanced tools to front line staff Nursing e-docs/e-guidelines/e-certification/e-learning PU database/registry for tracking Digital imaging and 3D-planimetry Set new aims (device related and deep tissue injury) Expand collaboration in research and development Reach out to community and professional colleagues

38 Pressure Injuries are Preventable (well at least 95% are) Together We Can! 38

39 C E L E B R A T E A C T I V A T E LIBERATE

40 40 Thank you!