Report from the 2014 EPUAP Conference Aula Magna, Stockholm University, Stockholm, Sweden 27 th 29 th August, 2014 Thank you to the New Zealand Wound Care Society for the scholarship, that assisted with my travel, there were so many highlights at this conference. The most amazing was the launch of the 2014 International Guidelines for the Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines It is has been an absolute privilege to represent the New Zealand Wound Care Society (NZWCS) on the Guideline Development Group. The launch letter was distributed by the NZWCS. NB: Pressure Ulcer is synonymous with Pressure Injury (the term used in the Pan Pacific Region). I am going to highlight several interesting sessions and some articles that you may or may not be aware of: Databases / Auditing Our population is ageing and their increasing list of co-morbid states will naturally increase the risk of chronic wounds and the burden of treating them. This is a growing problem worldwide. To address this the UK, Netherlands and many other countries and in New Zealand have set up outpatient community wound care clinics to manage this increasing area of health care. Sweden has set up national quality registry across the care continuum, to where they tracked hard to heal wounds. The aim was to detect healing times and antibiotic treatment. Healing time and antibiotic therapy decreased significantly during the time of the trial. Known as RUT (Registry of Ulcer Treatment) this included all types of ulcers one of which is Pressure injuries. This is exciting project that may work well in New Zealand. http://bmjopen.bmj.com/content/3/8/e003091.full.pdf+html The Pressure Risk Assessment Register and the Pressure Ulcer Register, are currently in the process of being linked across Sweden so the patient pathways can be reviewed. This is a very interesting concept and on a local and national level would provide accurate data about the largely unknown extent of the problem in New Zealand.
Department, Facility or Regional Prevention Strategies There were several presentations on quality improvement in regions or facilities or departments. In many of the reoccurring theme was the development of a facility Pressure Injury Prevention team most were interdisciplinary. a. Prevention strategies looking at the person from their first Point of Contact are becoming more important. In Sweden, the results of research indicated 40% of # NOF patients develop pressure injuries. Those who were in outlying wards had an increased Length of Stay in acute care, rehabilitation and an increased risk of complication. Mortality within 4 months with administrative delays for surgery or patient journey and if pressure injuries developed. Response: Planned pressure prevention from first point of Care: Ambulance for their #NOF patients now have a nurse on them to review skin, and pressure reduction strategies implemented immediately Emergency department: Fast track to ward - RN review within 5 minutes and DR within 30 minutes, within 30 minutes of arrival they are on a bed with a pressure relieving mattress and every endeavour was made to ensure they remained in the orthopaedic department. b. Gerontology, especially the frail elderly have multiple complex illnesses 4 out of 5 have a high falls risk and 3 out 5 develop Pressure Injuries. Risks are high and preventive strategies should be appropriate and constantly reviewed to ensure they are effective. c. Multi-layered silicone border dressings have had a lot of research on one of the available dressings. The ICU research by Brindle and Santamaria is well published. Peggy Kalowes presented a session on the reduction in Pressure injuries in ICU this was a follow on from the Tod Brindle and Nick Santamaria trials. Her study Mepilex Sacral Border applied and changed every 3 days in the trial and post-trial extended to every 7 days, The study had 2 end points: 1. Primarily the incidence of Pressure Injury 2. Secondary Cost benefit
Major indicators for Pressure injury in ICU were Mechanical Ventilation, sedation and Vasopressors SURVIVAL ANALYSIS in the intervention group: reduced mortality, decrease in pressure injury development 18 months since implementation $US 850,000 cost savings in Pressure Injuries. Annual product cost of $US 40,000. Effective translation of an RCT to clinical practice for patient benefit and cost benefit d. Nick Santamaria s research which is already well known here and being considered by a number of DHB s as a preventive option for the very high risk ICU patients. There is further coming on the use of multilayered silicone border dressings in other health environments and this will be very useful information. e. Sarah Kipps (Great Ormond St) multimodal prevention programme for the Infant to youth with oversight of a Risk Management team and working with the families. A publicity campaign, SSkin Care Bundle, Risk Assessment and investment in new prevention technology (i.e. dermal pads and specialist beds) Interactive teaching programme for staff and a Root Cause Analysis tool adopted by the Risk Management team. f. Nancy Donaldson s (CALNOC, USA) study investigating the characteristics of a clinical unit impact on the prevention of Hospital acquired Pressure Ulcers / Injuries (HAPU). The patient + nursing + clinical processes of care resulting in fewer HAPU however these were in a low prevalence area <3%. The results were for patients; shorter length of stay, fewer patients at risk, fewer male patients none of which are easily modifiable. RN Workload more hours of care, greater patient turnover; RN Expertise the more years of experience and fewer contract staff hours decreases HAPU. It would be interesting to repeat this or do a similar study here. g. Evan McCall session on heel protection. Pillows alone haven t worked for all sorts of reasons. The design features impact on microclimate (holes, vents channels create ventilation). The materials macro and micro
impact on breathability. Cooler, dryer environment with air movement is the best option for the foot. Currently I have been unable to locate the reference for this study. Pathophysiology Pressure Injuries The Biomedical Engineering sector has made significant gain in further determining facets of the pathophysiology of pressure injuries. The focus of their presentation at this conference was on deformation and microclimate. a. The effect of sustained loads / deformation on cells. Deformation or sustained stretching of cells is an area of much research. Deformation causes the cell membrane failure and disruption of the cytoskeleton. It is fast and non-reversible Moderate but sustained deformation, will result in cell death even if oxygen and nutrient supply are normal. Higher sustained deformation and occlusion of vessels lead to a change in metabolism with accumulation of waste products, ph decrease, and cell death. Importance of turning regime for patients no matter what surface they are on. b. Microclimate. The increase in moisture on the skin increases the coefficient of friction. Excess humidity softens the stratum corneum and increases permeability and susceptibility to irritants which disrupts the lipid lamellae barriers and tissue breakdown occurs. The fabric against the skin can have a large impact on Microclimate. For every 1 o C increase of temperature there is a 13% increase in metabolic demand. The fabrics such as those used in space are being looked at to reduce temperature and moisture. These smart fabrics transfer heat away controlling temperature. Skin Care and Incontinence Associated Dermatitis There were several session on the skin from neonates to elderly. Ireland has a programme called SKIN Champions for kids there research highlighted a gap in education of careers about the skin of young people with
neurological disabilities (ie Cerebral palsy). They taught the SKIN bundle to careers with improvement. Here are several articles of interest: 1. Doughty,D., Junkin J,._Kurz, P, Selekof, J, Gray, M, Fader, M, Bliss, D.Z., Beeckman, D, Logan, S. (2012). Incontinence-Associated Dermatitis Consensus Statements, Evidence-Based Guidelines for Prevention and Treatment, and Current Challenges, J Wound Ostomy Continence Nurs.39(3):303-315. 2. Beeckman, D. Van Damme, N. Schoonhoven, L. Van Lancker, A. Kottner, J. Beele, H. Gray, M. Woodward, S. Fader, M. Van den Bussche, K. Van Hecke, A. Verhaeghe, S. (2015) EBM Reviews - Cochrane Database of Systematic Reviews, Cochrane Incontinence Group Cochrane Database of Systematic Reviews. 4. [Protocol] [Protocols] AN: 00075320-100000000-10027 3. Lichterfeld, A; Hauss, A; Surber, C; Peters, T; Blume-Peytavi, U; Kottner, J (2015) Evidence-Based Skin Care: A Systematic Literature Review and the Development of a Basic Skin Care Algorithm Journal of Wound, Ostomy & Continence Nursing. 42(5):501-524, September/October. Prevention & Implementation This requires a whole organisational and specified team approach designated to this task. When that happens there are major reductions in incidence / prevalence and benefit to patients, staff, organisation and the entire health sector. a. Starting with Analysis of the current situation and facilitators and barriers. b. Understand the context - Ministry of Health and other government organisations, fiscal constraints, local organisations, Management support, nursing and other health professional roles. c. Target groups determine key people who have Knowledge, Skill, Attitude & Motivation d. Strategies for Attitude involving shifting perspectives and anticipating regrets The key issues are to start small and then roll out the project how to change things when things are hard and how to make those changes stick.
Brainstorming the attitudes, facilitators and barriers in your areas would be a start. The Ministry of Health, Health Safety and Quality Commission and Accident Compensation Commission are all involved in International Stop Pressure Injury Day, 19 th November, 2015. Let us continue to improve our practices and patient outcomes in the area of Pressure Injuries. Thank you very much for assisting me to attend this conference. This is the second part of the report the first was the launch of the guidelines. Kind Regards Pam Mitchell