Enhancing Pressure Injury Prevention Strategies Based on New Technology: From Learning More to Doing Better

The med-surg health care environment is constantly changing, driving complexity in care. The most recent findings from the Centers for Medicaid and Medicare Services state that pressure injuries develop in nearly 2.5 million patients annually, representing 8.3% of hospital admissions; the resulting financial burden for care is estimated to be between $3.3 and $11 billion annually.¹ Although most occurrences of hospital-acquired conditions sharply decreased between 2010 and 2017, the Agency for Healthcare Research and Quality reported that pressure injuries increased by 6%.²

Pressure injuries develop when there is localized damage to the skin or underlying tissues due to pressure—and sometimes combined with shear—that impacts the skin’s ability to provide oxygen and nutrients and remove waste byproducts. Several risk factors affect the development of a pressure injury. These risk factors include mobility, moisture, perfusion, nutrition, age, skin condition, and sensory perception.

The National Pressure Injury Advisory Panel (NPIAP) is an independent not-for-profit organization recognized as a subject matter expert and key opinion leader in pressure injury prevention and treatment. The 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline³ provides a thorough review of the strength of current evidence and outlines expert recommendations based on clinical evidence to support pressure injury prevention and treatments. The guidelines include a broad review of risk factors, but for the purpose of this article, we will focus on 3 areas of concern as they relate to preventing pressure injuries: mobility, moisture, and patient size and weight.

Mobility. According to the 2019 NPIAP Guideline,³ the primary contributing factor in the development of a pressure injury is impaired mobility. Patients who are unable to move or adjust their weight are at greater risk due to the sustained pressure and shear that damage the structures of the cells. Damage to the cells triggers an inflammatory response as evidenced by the development of edema, ischemia (non-blanching), and alterations in skin temperature in the area of injury.

The patient should be placed on a pressure redistribution surface and turned or repositioned on a routine schedule to provide some relief to the compressed skin area, promote better tissue perfusion, and offset the effects of immobility. Turn schedules should be based on the patient’s response instead of the standard every-2-hour schedule because some patients require more frequent turning to support tissue reperfusion. Optimal turn schedules require a better understanding of the patient’s ability to assist with their mobility and the pressure redistribution capacity of the surface.

If the patient cannot turn on their own, the care team will need to support the activity. Protocols for turn schedules should consider how the team turns the patient and what equipment and resources are needed to accomplish the task safely. The American Nurses Association discourages manual lifting or moving more than 35 lb of the patient’s weight.⁴ Manual lifting during turning and repositioning activities places the caregiver at risk of a musculoskeletal injury.⁴ With the ever-present shortage of caregivers, we need to be aware that our clinical practices do not put the care team at risk of a workplace injury. Working with the care team to develop guidance on when and how to reposition the patient in bed using lift equipment safely helps create a standardized practice protocol that aligns patient and worker safety.

Moisture. Moisture-associated skin damage is often seen as a result of prolonged moisture on the skin in the form of perspiration due to increased body temperature, saliva, incontinence, or other fluids. Moisture in any form weakens skin integrity while simultaneously increasing the coefficient of friction that leads to skin injuries and is associated with pressure injuries.⁵ To counteract moisture-associated skin damage risk, technology, like powered low-air-loss surfaces, circulates air beneath the patient to help lower skin temperature and humidity levels between the surface and the patient’s skin. The circulating air allows for cooling the skin and controlling moisture dissipation to prevent unwanted moisture on the skin that may cause damage, especially when combined with friction.

Migration occurs when the patient unintentionally slides down in bed and needs to be repositioned toward the head of the bed. The care team is then faced with finding a safe way to return the patient toward the head of the bed without causing friction that is often produced by manually repositioning or pulling the patient up in bed using a drawsheet. Several studies on patient migration in bed indicate that the friction, in combination with moisture, likely contributes to pressure injuries.^6,7

Patient size and weight. Individuals with a higher body mass index can be at greater risk of a pressure injury. This is especially true if they have mobility challenges or experience any existing stress incontinence or diaphoresis that may expose them to additional moisture on the skin. The 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline³ states that pressure redistribution and microclimate management should be a requirement when caring for a patient of size due to the higher risk. When selecting the right bed and surface, the patient’s girth, shape, and weight always must be considered. A standard 36-inch surface may not be adequate for a patient who carries most of their weight in the hips or abdomen, even if their weight is less than the recommended weight capacity of the bed frame. A patient of size may benefit from a wider bed frame and surface that allows the patient more ability to self-adjust or shift their weight when possible.⁸ Selecting the right bed with the right surface and advanced technologies helps give the health care team peace of mind that they are addressing mobility, moisture management, and the properly sized bed for patient comfort and pressure injury prevention.

HOSPITAL-ACQUIRED PRESSURE INJURIES

Patients with a hospital-acquired pressure injury (HAPI) often report increased pain levels, especially during movement. Pain may contribute to a decreased likelihood of participating in the activities most people take for granted as part of everyday life. Patients also report sleep disturbances and feeling self-conscious about appearance or odor from their pressure injury. The psychological and social impact of developing and recovering from a HAPI leaves many without adequate financial or assistive resources to heal the pressure injury, making it difficult to return to their previous quality of life. Some patients may require temporary post-acute or residential facility placement while the pressure injury heals, thus increasing the financial burden of HAPIs on the facility during the stay and on the patient after discharge.⁹

BEST PRACTICES

Research efforts using pressure injury prevalence and incident rate data, along with review of treatment protocols and their outcomes, help wound and ostomy care nurse experts determine best practices and offer improved guidance and protocols to prevent and treat pressure injuries. Performing precise assessment, understanding the root cause, and selecting the proper treatment are essential to reduce the frequency and severity of HAPIs.

At Hillrom, we understand how important it is for caregivers to be confident their patients are being cared for on support surfaces that effectively manage the risk factors for skin breakdown, which can evolve as pressure injury risk increases. The Hillrom pro+ surface is designed to address the risk factors of skin breakdown to help facilities provide optimal wound prevention and healing and enhance the patient experience.

The pro+ surface is the only med-surg surface with an integrated, internal pump targeting airflow into the sacral area, where 48% of HAPIs occur.¹⁰ The air flows up and then horizontally through the crush-resistant spacer allowing for continuous airflow under the patient’s skin, resulting in the removal of up to 4 times more moisture and up to 2.5 times more heat,¹¹ following S3I test methods, as described in RESNA SS-1:2019.¹² Caregivers no longer need to install an external pump or transfer their patient onto a low-air-loss surface, helping optimize workflow and efficiency.

To help manage pressure, the pro+ surface’s foam design contours to the patient’s shape and helps decrease peak sacral pressure as it redistributes pressure away from bony prominences. The foam-filled bladders are anatomically designed to be firmer in the seat section and softer in the head section, providing targeted pressure redistribution. The bladders are interconnected, and as pressure changes, the valves release displaced air. As the patient sinks into the surface, the foam-filled bladders self-adjust to the patient’s weight, shape, and movement, providing every patient with personalized pressure redistribution, resulting in up to 8% less peak sacral pressure.¹¹

Utilization of this technology helps to follow the NPIAP guidance by enabling care teams to address pressure injury risk and support prevention and treatment. Access to the right surface and technologies to address mobility and moisture through the pro+ surface by Hillrom can provide better outcomes for patients.

REFERENCES

1. Padula WV, Delarmente BA. The national cost of hospital-acquired pressure injuries in the United States. Int Wound J. 2019;16(3):634–640. doi:10.1111/iwj.13071

2. Agency for Healthcare Research and Quality. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017. AHRQ; 2019. https://www.ahrq.gov/hai/pfp/index.html

3. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. EPUAP/NPIAP/PPIA; 2019.

4. American Nurses Association. Safe Patient Handling and Mobility: Interprofessional National Standards. Across the Care Continuum. ANA; 2013.

5. Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurse. 2011;38(3):233–241. doi:10.1097/WON.0b013e318215f798.

6. Lustig M, Wiggermann N, Gefen A. How patient migration in bed affects the sacral soft tissue loading and thereby the risk for a hospital-acquired pressure injury. Int Wound J. 2020;17(3):631–640. doi:10.1111/iwj.13316

7. Davis KG, Kotowski SE, Coombs MT. Stopping the slide: how hospital bed design can minimize active and passive patient migration. J Nurs Care Qual. 2017;32(1):E11–E19. doi:10.1097/NCQ.0000000000000205

8. Wiggermann N, Smith K, Kumpar D. What bed size does a patient need? The relationship between body mass index and space required to turn in bed. Nurs Res. 2017;66(6):483–489. doi:10.1097/NNR.0000000000000242

9. Rutherford, C, Brown JM, Smith I, et al. A patient-reported pressure ulcer health-related quality of life instrument for use in prevention trials (PU-QOL-P): psychometric evaluation. Health Qual Life Outcomes. 2018;16(1):227. doi:10.1186/s12955-018-1049-x

10.  Lachenbruch C, Ribble D, Emmons K, VanGilder C. Pressure ulcer risk in the incontinent patient: analysis of incontinence and hospital-acquired pressure ulcers from the International Pressure Ulcer Prevalence™ Survey. J Wound Ostomy Continence Nurs. 2016;43(3):235–241.

11. Hillrom Internal Test Results. Lab Reference Request: LR0001446, LR0000972, LR0005304, LR0005564, LR0004760, LR0005772, LR0010466, LR0010106, LR0010316, LR0010304. Data on file.

12. ANSI/RESNA SS-1:2019. American National Standard for Support Surfaces –Volume 1: Requirements and Test Methods for Full Body Support Surfaces. 2019. https://www.resna.org/Portals/0/AT_SS1_SellSheet_2_10_21.pdf

Innovative Moisture Management was made possible through the support of Hillrom (https://www.hillrom.com). The opinions and statements of the clinicians are specific to the respective authors and not necessarily those of Hillrom, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.