Pressure Injuries: an ugly sore on the health system

1 September 2012

They rarely grab the headlines but thousands of New Zealanders each year get preventable pressure injuries – and some die. FIONA CASSIE looks at new guidelines, the new name, and new efforts to heal this health system scar.

Bed sores, pressure sores, decubitus ulcers, pressure ulcers, and now pressure injuries. By any name they are ugly – what can start with a simple reddened patch can develop into a gaping wound raw to the bone. The latest name – pressure injury – has been chosen because the vast majority of pressure injuries (PIs) are preventable and avoidable.

Thousands of New Zealanders have experienced a pressure injury of some degree in recent years on their hips, heels, backs, or elbows. At least eight have died as a result.

Good nursing care is one key to preventing them.

But to date, New Zealand has no national statistics on pressure injuries, haphazard reporting of the harm caused by them, and no common standards for measuring PIs and what strategies reduce them.

While falls in hospital dominate the yearly serious and sentinel adverse events, pressure injuries rarely get a mention.

Moves are afoot to change this. For a start, the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury was launched across the Tasman in March. It brings the best evidence together into the first nationally consistent guideline to assessing risk, and preventing and managing pressure injuries.

But first, pressure injuries need to come out from ‘under the sheets’ and catch the attention of the powers that be.

So nurse advocates are calling for debilitating pressure injuries to be reported as serious events, more nurses to lodge ACC claims for pressure injuries, and the adoption of a national quality indicator to measure pressure injuries.

Preventing devastating wounds

Emil Schmidt is clear – he hates pressure injuries. The Dunedin Hospital wound care nurse specialist is often called in once the “horse has bolted” to deal with a nasty and complex wound that can take up to two years to heal, if at all.

He and Pam Mitchell are two passionate nurse advocates for reducing the social, personal, and health costs of pressure injuries. They represented the New Zealand Wound Care Society on the Pan Pacific guideline development steering committee and are now part of a review team developing international PI guidelines.

The impact of pressure injuries was brought home to Mitchell, a former plastic surgery nurse, while working with patients undergoing wound reconstructions following massive pressure injuries.

“For patients who develop a pressure injury, their life changes immensely; the deterioration in their quality of life is huge,” says the Christchurch Hospital wound consultant.

Often, Mitchell and Schmidt’s pressure injury patients are old, malnourished, and have complex co-morbidities. Schmidt says PIs are devastating events for all involved and prevention is the key. “One PI is too many”.

“There’s huge money we could save if we prevent them, along with better quality of life (for patients at risk),” adds Mitchell.

Both see implementing the national Pan Pacific pressure injury guideline nationally as a step in the right direction (see sidebar). But to do this, Mitchell points out, needs national resourcing and backing to ensure nurses and clinicians on the floor have the knowledge, equipment, and management support to make it happen.

Likewise, Schmidt sees a risk that the guideline could gather dust on the shelf without the right impetus. His personal belief is that implementation needs to be driven by the Ministry of Health and the guideline should be adopted as a national tool leading to a pressure injury prevention programme at each DHB and also in residential aged care.

“Pressure injuries must be part of the key performance indicators (KPIs) for every DHB, using an international validated survey around the country.”

Wound Care Society president Wayne Naylor agrees that collecting national data is vital for monitoring the impact of the guideline on pressure injury rates.

No national picture

At present, nobody really knows how good or bad our health system is at preventing and managing pressure injuries.

Some of the worst cases of pressure injury surface as complaints to the Health and Disability Commissioner, and increasingly, claims are being made to ACC for treatment injury costs as a result of developing a debilitating pressure ulcer.

But unlike most other OECD nations, New Zealand does not collect national annual data on PIs.

Many district health boards carry out PI prevalence surveys on an ad hoc basis, usually with the support of the specialist mattress industry, but only some do them annually, definitions of PIs differ, and the results are usually carefully guarded.

Back in 2009, Jan Weststrate, another pressure injury nursing advocate, held a pilot survey of care indicators (including pressure injuries, falls, and incontinence) involving five hospitals and 15 rest homes across three DHBs. The pilot found pressure ulcer prevalence rates of 11.4 per cent and 5.6 per cent, respectively. His approaches to the Ministry of Health and Health Quality & Safety Commission (HQSC) to pick up the University of Maastricht-developed survey nationally to date have been unsuccessful.

However, Weststrate has been part of a nurse expert team working with the Office of the Chief Nurse, under the leadership of senior nurse advisor Paul Watson, to develop quality indicators to measure and monitor the harm from both pressure injuries and falls.

Watson says the data that is available indicates pressure injuries are quite a big problem in New Zealand.

Looking at a breakdown of the National Minimum Data Set (NMDS) for the six months to the end of July 2011, they found 2739 hospital events where pressure injuries were recorded. This was twice the number of falls recorded in the same period.

That figure is likely to be an underestimate, as while the NMDS should, in theory, capture all pressure injuries, the coding of patient clinical data is known to have its limitations. At best, it can only be as good as the initial patient notes which, international research shows, are often poor at documenting PIs.

Another source of data is ACC claims for treatment injuries due to pressure injuries. These have been steadily growing from 35 in 2005-2006 (the year ACC switched focus from “medical misadventure” to “treatment” injuries) to 143 in 2010-11.

Rachel Taylor, a registered nurse and ACC clinical analyst, says the increase in PI claims lodged is probably one of the strongest they have seen in the area of treatment injuries.

Exactly why is unknown, but Taylor believes the trend is likely because of passionate senior nurses being proactive in lodging claims so their clients can get the help they need, especially equipment like special mattresses.

Upping the ante

Taylor says a flow-on effect from the rise in PI claims is that ACC, which has a duty to report public risk, is reporting on pressure injuries to the Ministry of Health, which in turn, gives feedback to DHBs.

“It has become something the chief medical officers noticed … they seem to be starting to talk to nurses about what do they need to prevent these (PIs) happening.”

However, it appears most DHBs pressure injury rates still remain hidden under the sheets, with only a handful (including one death) last year reported to the HQSC as a serious or sentinel event.

Paul Watson says this is where we differ from the US where the National Quality Forum regards stage three and four PIs as events of “serious” harm, and in the United Kingdom, PIs of that level are regarded as serious incidents requiring investigation.

“They are not captured in serious and sentinel events in New Zealand. For whatever reason, hospitals are not coding pressure injuries, particularly stage III or IV, as serious (events).”

Unlike falls, which have gained ‘burning platform’ status by dominating serious and sentinel event reporting, PIs often go under the radar.

The chief nurse’s office’s development, in league with stakeholders like the directors of nursing and DHB quality managers, of a national quality indicator aims to get PIs back on the radar screen.

Watson says a regular prevalence survey – giving a snapshot of the number and severity of PIs at any one time – is seen as the best way to improve the pressure injury data collected and raise awareness at the coalface.

A final report, The Development of Quality Indicators on Measuring Harm from Falls and Pressure Injuries, is now due to go to the Health Minister, and a decision will follow.

Stick or carrot?

Meanwhile, pressure injuries were put into the ‘too hard basket’ when HQSC recently put out a consultation document on its 17 proposed quality indicators for the health system.

Falls made the 17 but pressure injuries missed the cut this time round, being described as an “important area” but requiring “significant further work” to develop an indicator and collect data.

Chief Nurse Jane O’Malley still hopes her office’s work will lead to PIs becoming a quality indicator but says, more importantly, it has lead to a common language to describe PIs and measure the success of strategies to prevent them.

Watson emphasises the work’s aim is to improve PI reporting and monitor quality improvement, not to benchmark DHB against DHB or create league tables.

Naylor believes the only way to ensure good national data is collected on pressure injuries is to make it mandatory.

“We need to have some bite behind it, so people actually report on it.”

He says a likely next step for the society is writing to the HQSC requesting DHBs be required to report all stage II pressure injuries and above as serious events. Schmidt backs this, saying this will help understand the size of the problem.

Weststrate believes another way for pressure injuries to garner the level of attention given to falls is for nurses to fill in an ACC claim every time they see a patient with a stage II pressure injury or more. This would also help bring home the dollar cost to the country of pressure injuries.

The dollars spent are just part of the total cost of pressure injuries – an unsightly sore on the health system now coming out from under the sheets.

MOVES AFOOT IN AUSTRALIA

Failure to meet pressure injury standards may hit Australian hospitals in the pocket from next year.

Preventing and managing pressure injuries is one of the ten National Safety and Quality Health Service Standards (NSQHS) recently developed by the Australian Commission on Safety and Quality in Health Care.

From January next year, all Australia’s states and territories have agreed that hospitals and day procedure services will be accredited to the new NSQHS standards.

So from then on, if a health service is assessed as not meeting the standards, the state health department will be informed and may take action and/or provide support to health services to address these issues.

Jan Rice, Australian wound management guru, says many see Australia heading in the direction of the USA and withholding funding from a facility not meeting pressure injury prevention standards.

In the States, insurance companies refuse to pay for extra days if a patient’s hospital stay has to be extended because of a hospital-acquired pressure injury.

“It is seen as negligence,” says Rice.

She says in Australia, all states have data available on pressure injury prevalence and incidence, and it was the initial high prevalence levels (24 per cent) that frightened her home state of Victoria into funding education and equipment to bring the levels down.

PAN PACIFIC GUIDELINE: Working off the same page

A simple flow chart – capturing in a single page the best evidence and advice for preventing and managing pressure injuries - is now available at the click of a button.

Comprehensive risk assessment, nutritional advice, which mattress and when, patient education, regular repositioning and pain advice, and how to classify PIs are all summed up in a nutshell.

The flow chart is part of the new 120-page Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury released in March and downloadable from the New Zealand Wound Care Society website: www.nzwcs.org.nz It is the first PI guideline jointly developed by Australia, New Zealand, Singapore, and Hong Kong clinical – mainly nursing – experts.

The next aim is to get the voluntary guideline adopted nationally, so for the first time, as Pam Mitchell puts it, “everybody is working off the same page”.

For a start, a survey of more than 600 clinicians in the four countries involved unanimously supported adopting the name pressure injury over the previously favoured pressure ulcer.

The word ulcer implied broken skin, but in some pressure injuries, like stage one PIs and suspected deep tissue PIs, the skin remains intact.

“There was some confusion because people had this intact skin but they were calling it an ulcer,” says Mitchell.

But there was also a push to label them ‘injuries’ in recognition that the international literature indicates 95 per cent of PIs are preventable and avoidable.

At present, there is ad hoc use by district health boards and rest homes of different guidelines. Some use the European (EPUAP) or North American (NPUAP) guideline and others the predecessors of the Pan Pacific guideline, the AWMA guideline.

The Pan Pacific guideline is built on the best of all of them, including the 2011 Trans Tasman Dietetic Wound Care Group guideline, and adopts the NPUAP/EPUAP pressure injury classification system.

The Australian Wound Management Association (AWMA), the instigator of the voluntary guideline, has a health research grant to develop an implementation plan for Australia. Across the Tasman here, the wound care society has less resources, but Wayne Naylor, society president, wants to see it implemented here too – and is starting with its nearly 500 members. It has also sent the guideline to the Office of the Chief Nurse, the district health boards, and residential aged care as part of an initial awareness raising.

SENSITIVITY OVER NURSE SENSITIVE INDICATORS

Pressure injuries are one barometer for the quality of nursing care.

The level of pressure injuries are one of the so-called nurse sensitive indicators used in assessing whether a facility meet Magnet Hospital status.

Or as Chief Nurse Jane O’Malley puts it, in the absence of decent nursing staffing and good systems, pressure injury levels go up, and under good staffing and leadership, they go down.

While there is a direct link between good nursing, bad nursing, and pressure injury levels, there is also sensitivity to labeling pressure injury levels as a nurse sensitive indicator when other factors also come into play.

Nurse and ACC analyst Rachel Taylor says a fairly consistent theme in ACC claims for pressure injuries is a gap in patient care. So patient notes show no risk assessment, or an inappropriate assessment was done on the patient’s admission, or the assessment is done correctly but the needed special mattress never arrives, and five days later, a pressure ulcer is reported on the left heel.

“And you think, so what was happening in between times?

“It’s about consistently, across the board, doing the risk assessment, doing it correctly, putting a plan in place, following through on the plan, and if you can’t follow it through, putting another plan in place,” says Taylor.

“It’s that mindful, thoughtful nursing that says, ‘okay, I can’t get the mattress, but what can we do instead until we can get the mattress’ – those are where the gaps are coming.”

But nurses point out the gaps are not just by nurses.

“Pressure injuries are a painful, debilitating, and serious outcome of a failure of routine medical and nursing care,” says wound care nurse specialist Emil Schmidt.

Likewise, as wound nurse consultant Pam Mitchell puts it, “It is seen as a nurse sensitive indicator – it is actually an interdisciplinary indicator, not just a nurse one, but it lands at the nurses’ door”.

DEFINITION OF A PRESSURE INJURY

A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear, and/or friction, or a combination of these factors.

NPUAP/EPUAP/Pan Pacific Pressure Injury Classification System

Stage I Non-blanchable erythema (redness) of an area usually over a bony prominence like a heel

Stage II Partial thickness skin loss

Stage III Full thickness skin loss

Stage IV Full thickness tissue loss (exposing bone, tendon or muscle)

Unstageable pressure injury

Depth or stage of the PI can’t be determined because the wound is covered by slough or dead tissue

Suspected deep tissue injury

Skin unbroken and depth of damage unknown

Pressure injury statistics

• 2739 pressure injury events were recorded for hospital patients discharged in the six months to the end of July 2011.*

• This was twice the number of falls recorded in the same period.

• Nearly 630 claims for treatment injuries due to decubitus ulcers (pressure injuries) were accepted by ACC between July 1 2005 and 31 December 2011 (just under 75 % of the PI claims lodged).**

• Eight of these claims related to a fatal outcome.

• 143 claims for pressure injuries were accepted by ACC in 2010-11 (compared with 35 in 2005-2006).

• Only 5 serious and sentinel events related to pressure injuries (including one death) were reported by DHBs in 2010-11.***

• In comparison, in that same year, 714 treatment injury claims for falls were accepted by ACC and 195 falls reported by DHBs as serious and sentinel events to the HQSC.

• 88% of the pressure injury ACC clients in past six years were aged over 65.

• 91% of the claims related to events in DHB facilities.

• A pilot national survey of care indicators of 570 hospital patients in 2009 found a 12% prevalence of pressure injuries compared to 10% in the Netherlands survey and just under 5% in Austria.****

Sources:

* National Minimum Data Set and Chief Nurses office.

** ACC treatment injury statistics.

*** Serious and Sentinel Events reported by DHBs to Health Quality & Safety Commission in 2010-11.

**** NZ Pilot National Survey of Care Indicators 2009 (University of Maastricht).