Assessment and Prevention of Stage 2 to 4 Pressure Injuries in Long Term Care
Summary
There was an opportunity to improve resident care and the organization’s current performance on quality indicators related to stage 2 to 4 pressure injuries, as well as enhance the current Skin and Wound Program.
The fellowship focus took place in three identified stages:
1) Identify the unit to pilot with the highest incidences of pressure injuries
2) Gap Analysis with the interprofessional team
3) Develop and implement change ideas, evaluate and modify according to evaluation/outcomes
The organization’s quality indicator data from 2019 related to pressure injuries were reviewed overall, and one unit was identified with the highest incidences of pressure injuries. This unit became the focus of my fellowship. The best practice guidelines for pressure injuries were thoroughly reviewed for further knowledge on evidence-based recommendations. Next, a gap analysis was completed as one of my fellowship activities and from there the fellow worked with the fellowship participants in developing and implementing change ideas to improve resident care related to pressure injuries. Evaluation and modifications were done in accordance to the outcomes.
Overall Learning Goal & Skills, Knowledge and Expertise Gained:
The overall learning goal for the fellowship was to increase the fellow’s clinical knowledge, skill and expertise related to wound care in the geriatric population of long-term care, specifically on how to prevent and manage stage 2 to 4 pressure injuries based on the implementation of evidence-informed best practices and evaluation. This goal was achieved through some short-term outcomes, while other long-term evaluation outcomes remain pending until the end of this quarter (July – Sept 2021).
The fellow has been able to expand her knowledge about evidence-based research related to pressure injuries and quality indicators and how these are applied in the long-term care setting. In order to provide quality care for residents who have or are at risk of developing pressure injuries, this knowledge is needed. The fellow has learned how quality indicators are tracked and how it informs nursing practice.
The fellow completed a comprehensive assessment of current practices in the home, identification of gaps and opportunities for improvement. The fellow completed a gap analysis; reviewed the home’s policies, procedures and Skin and Wound program. Quality indicator data for the home was also reviewed and analyzed. Findings were shared at the Skin and Wound committee meetings. A Skin and Wound committee bulletin board was also made in order to share data and trends with families, residents and other staff in the home.
Knowledge, skills and expertise gained included assessment of pressure injuries. The fellow took part in educational experiences such as completing online modules, shadowing the wound care nurse and working with the registered staff on the piloted unit. The fellow learned how to properly stage pressure injuries, conduct thorough assessments and complete appropriate documentation of a pressure injury wound. These learned outcomes were shared through provision of educational in-services with the registered staff on the piloted unit to ensure that the necessary documentation was completed using the home’s assessment tool. Some dressing changes were done together with the fellow to ensure proper wound care practices were being followed.
On the pilot unit, the fellow also focused on the importance of management and prevention of pressure injuries. The fellow reviewed residents with pressure injuries and those at high risk of developing pressure injuries (determined through a Pressure Ulcer Risk Scale (PURS) score of 4 or more). Care plans were reviewed to identify current interventions in place, including contributing factors. Using the Braden Scale as a reference, the fellow developed a guideline to use to identify a variety of preventative measures that can be applied to resident care. Furthermore, in order to expand the knowledge of the staff and peers, education was provided through our vendors, related to therapeutic air surfaces, proper positioning and offloading, and continence care. In the home, we began to implement a few initiatives based on evidence-informed best practices such as promoting the use of repositioning sheets and reduce the use of soaker pads. We are currently looking at improving our continence practices by providing education to staff about proper incontinent product use, proper peri-cleansing, and promoting the use of soft wipes for care as many residents in our home have fragile, aging skin.
The final objective focused on successful completion of knowledge transfer for front line staff on the pilot unit regarding best practices for wound care. In-services were held by the fellow to share proper wound care management as per the best practice guidelines. To ensure sustainability, monitoring of nursing practice was conducted through tracking of the skin and wound assessments to ensure completion. Any new interventions implemented were also tracked by the fellow to monitor wound healing.
Outcomes
Client population
Short-term outcomes for the client population that were experienced as a result of the fellowship included:
1. Improved pain management and satisfaction
-This was done by providing education to front line staff presented by the fellow and/or stakeholders. The education was coordinated by the fellow and stakeholders presented to the pilot unit, and to the other units in the home. The education that was provided focused on the use of therapeutic air mattresses, uses and management of ROHO cushions, and how to properly offload and reposition residents. The fellow provided in-services to the registered staff on the pilot unit about pain management, referencing the best practice guidelines.
-The fellow also provided support to registered staff during wound care dressing changes. Education on signs of verbal and non-verbal pain were reviewed, and to always monitor for pain before and after dressing change. The fellow shared types of wound care products used to assist with pain management.
2. Improved resident-centered care based on their condition and individualized needs
-In the gap analysis, there were some areas identified that required improvement. Such included that many of the supplies and devices needed for resident care were not readily available to front line staff. Supplies included items such as extra pillows, dry soft wipes, wet soft wipes, and positioning aids.
-Also, old nursing practices that are not best practice were still being done in the home. This included soaker pads being used for all residents regardless of continence status, and for using them as repositioning aids; another practice was that staff were using towels for care for almost all residents.
-The fellow, in collaboration with the mentorship team and skin and wound committee implemented the following: supply of offloading wedges for residents that cannot be offloaded properly with pillows; plan to reduce soaker pads on the units and providing education to staff on how to use transfer/repositioning sheets for residents that require this assistance.
-Education was also provided on therapeutic air surfaces for the wheelchair and bed, proper offloading and repositioning techniques; and the fellow is working to involve the Continence Representative as a stakeholder to support the above-mentioned best practice guideline initiatives.
Long-term outcomes will be expected in the upcoming quarter and will include:
1. Decreased percentage of residents whose Stage 2 to 4 pressure ulcers worsened using RAI MDS
2. Decreased number of residents with newly acquired stage 2-4 pressure ulcers
3. Peel Manor to be below provincial average of pressure ulcers
4. Reduce number of hospital transfers related to sepsis of wound
Colleagues/Staff
1. Be a resource leader and expert for the staff to utilize
-Interdisciplinary team members were very comfortable with communicating any skin issues on the units. They would share their assessment findings and relevant information and what their anticipated next steps would be. We collaborated together in ensuring processes were followed and that all interdisciplinary team members were involved in the plan of care.
-Registered staff were open to approaching the fellow to ask questions, share assessment findings and discuss possible interventions to put in place. The fellow also utilized the home’s current tools for reference such as the Pressure Ulcer Guideline, Skin and Wound Mobile App Assessment, Braden Scale Risk Assessment, guide on discovery of new skin issue.
2. To achieve 100% compliance with assessment completion with improved documentation standards
-The fellow worked closely with the registered staff on the pilot unit by providing online education modules, in-person presentations and hands-on support with wound care and documentation using the home’s assessment tools. The fellow regularly tracked and reviewed weekly assessments and followed up with staff to share any feedback or further support to ensure compliance
3. Build capacity amongst front line staff on how to accurately assess and manage residents with stage 2 to 4 pressure injuries
-The fellow worked closely with the registered staff on the pilot unit by providing online education modules related to assessment of pressure injuries
-The fellow provided in-person education presentations on characteristics of pressure injuries and prevention interventions tailored to resident needs
-The fellow educated registered staff on the importance of using PUSH (Pressure Ulcer Scale for Healing) scores to measure wound healing in order to determine if current interventions in place need to be re-evaluated or not. The score was provided after full completion of a weekly assessment. The fellow tracked the weekly assessments of residents with pressure injuries on the pilot unit, including PUSH scores and any changes in score. The fellow followed up and shared with the registered staff to further collaborate on plan of care.
4. Increase knowledge transfer and collaboration amongst the interdisciplinary team
- Knowledge transfer was shared via attendance at skin and wound committee meetings, unit meetings, etc. During the fellowship, we implemented a weekly skin care huddle that would occur on all units to communicate and discuss any related skin issues
-Education was arranged for staff with the collaboration of vendors and through the results of the gap analysis. Education was focused on proper positioning and offloading techniques, proper use of therapeutic air surfaces. The fellow is working with another vendor to provide education on continence best practices.
-Implementation of repositioning sheets was trialled. Education on its use and the benefits for both staff and residents were shared. Initially, the repositioning sheets were being used on a few units. With further staff education and buy-in, we were able to circulate these sheets throughout the home
-During the fellowship, the fellow also established weekly skin care rounds on all units for the teams to meet and discuss skin-related concerns and ensure a plan was in place (whether it be initiating new interventions, re-evaluating interventions, addressing challenges and so forth).
Organization and Stakeholders
1. Improve Skin & Wound Care program for sustainable changes by identifying and addressing gaps
- Sharing gap findings with the management team and clinical team through meetings and looking at updating the program to include current evidence-based practices, and clinical pathways
-The fellow is being asked to join leadership meetings and share the initiatives and practices implemented in the home as a result of completing the fellowship
2. Ensure nursing practice is consistent and based on evidence-informed best practices
-Working to improve the Region of Peel’s Skin and Wound Care Program
3. Improve assessment tools to better monitor pressure injuries, standardization of wound care products and therapeutic surfaces
-Working with stakeholders and providing feedback and suggestions to improve assessment tools
-Working with our vendor to standardize wound care products
-Working with our vendors to standardize therapeutic surfaces and provide based on individual resident needs
Overall experience
The organization will support the sustainability of the fellow’s knowledge and skills post-fellowship through opportunities to share fellowship learnings and outcomes to the other units in our home at Peel Manor. This will include a number of training workshops and education in-services related to proper assessment and documentation, how to complete an assessment using the home’s standardized tools, wound care management, and prevention measures.
Through the fellow’s learnings, a guide was developed to assist registered staff with identifying appropriate prevention measures for residents. In-services will be provided to registered staff on how to use the guide to tailor resident care. This will also be shared and discussed at weekly skin care huddles on units, as well as at our skin and wound committee meetings.
There will be ongoing training for new staff during orientation and will go into detail about the Skin and Wound program, processes, tools used, etc.
There will be scheduled continuous education throughout the year with support from our vendors. Online learning will also be available for staff so that they may review the education on their own time.
Audits will continue to be done to ensure compliance with the assistance of the nursing leadership team, quality improvement nurse and the fellow. This will include audit of weekly skin assessments, skin and wound audits, ROHO cushion audits, air mattress audits, and much more.
My learnings and outcomes will be sustained with the support from the home’s nursing leadership team, Program Support Nurse, Chair of the Skin and Wound committee and committee members.
