Getting your data to sing: Understanding the workings of pressure injury prevalence
This podcast discusses how Australia started its journey on PI prevalence.
Strategies involved in reducing the PI prevalence.
Why was our PI prevalence so high in 2000 ?
Data is powerful, how to interpret the results to decide how to action.
Turning data into action.
Understanding PI prevalence in different populations.
Welcome to Smith & Nephews Closer to zero podcast. Bi-monthly podcast with leading experts in wound care hosted by Smith & nephew. Helping health care professionals in reducing the human and economic costs of wounds. 00:00:02
Hello my name is Ruth Timmins from Smith & Nephew and it's my pleasure today to welcome you to our podcast . ‘Getting your data to sing. Understanding the workings of pressure injury prevalence’ with our special guest Tracy Nowicki. Tracy is currently employed within a major metropolitan hospital in Queensland Health as a clinical nurse consultant of a quality risk management equipment service. She specialises in skin integrity and pressure injury prevention and she has been on the working party for the development of the Pan Pacific and International pressure injury guideline. So welcome Tracy. Thank you for joining us today. 00:00:16
Thanks Ruth. Great to be here. 00:00:55
This is a really interesting topic and I guess it would be good to start with perhaps telling us the history of the Australian prevalence studies. 00:00:58
Okay thanks. Well it was back in the year 2000 and probably 1999 that Keryln Carville and Jenny Prentice, it was mainly Jenny Prentice did a PhD asking the question, 'how many pressure injuries are on patients in Australian health?' And she asked one major hospital in each state to do a point pressure injury prevalence study and this was the first time any of us had really undertaken anything like that. And most states came up with very similar results and it was a big shock to everyone where our prevalence was around about 26 to 33% of the patients on any one given day in every state had a pressure injury. And based on that Queensland Health responded to that in the year 2002 they did a state-wide pressure injury prevalence. So they started a quality improvement project and it took a year to go and measure everyone and the results were very similar to the findings of Jenny Prentice. So we then did another year's worth of study. After we made two significant changes. And that was that though we introduced the risk assessment tool Waterlow and got rid of the vinyl mattresses and replaced them with pressure reducing mattresses. That might sound quite odd to most people because most people work in health haven't seen a vinyl mattress and there's always been some form of risk assessment tool. So that's how basic things were back in 2002. Now just based on those two initiatives, we saw a 50% reduction in pressure injuries giving a prevalence for the state around about 14%. After two years of studying the state this was then dropped again until about 2008 and then we started again and our prevalence continued to drop. In the meantime, Western Health in Western Australia, they were also doing annual prevalence studies and were getting similar results maybe not quite as reduced as that. And I know New South Wales also did some studies. So everyone was doing independent studies and then what happened was by about the year 2010 we were mandated to get those pressure injury prevalence down to under 10% and then in 2012 we saw further changes with the introduction of the National Standards. And what we've seen now is in the state of Queensland the average prevalence was between three to five percent. So it's pretty phenomenal and demonstrates that how powerful data is. 00:01:07
So how did we get our prevalence results from 28% down to the 3 to 5%? 00:04:03
I find this question absolutely fascinating because there are many variables as to how we got those results down and I've seen other facilities outside of the state of Queensland do the same thing. And even coming to me with prevalence as high as 40, big metropolitan hospitals in some of their states coming with a prevalence of 44% and after implementing certain strategies they got it down to eight and the most interesting thing is there are lots of things that work, but one of the most important things is in the year 2000 we were calling everything a pressure injury. So we were calling skin tears, incontinence associated dermatitis, moisture lesions, we were calling leg ulcers, corns. Everything was a pressure injury and that was really putting our prevalence up. Now the other thing that separated it was we were calling all pressure injuries pressure injuries. However, we now separate them into hospital acquired pressure injuries or facility acquired pressure injuries and present on admission pressure injuries 'cause we know we can't stop the pressure injuries coming into us, but if we have good strategies in place like risk assessment within well, in our facility it's two hours, but the national standards demand eight hours. Risk assessment and skin inspection, we can find the pressure injuries that are actually being admitted to us rather than owning them as hospital-acquired. So that's another thing that pressure injury prevalence used to be just about the pressure injuries in the organization, whereas now most people are only measuring hospital-acquired pressure injuries. So that was the biggest challenge but there are many other things that came along the way. As I said in 2002, there was the introduction of risk assessment. In Queensland it was Waterlow. Other states have adopted Braden. Some states have adopted one or the other and then changed and then changing just the base mattress. From then we led onto after we fixed up the basic foam into trying to get a fleet of alternating devices. In 2008 was the introduction of evidence-based skin care. In 2009 was the introduction of prophylactic dressings on the sacrum and heels. In 2010 was when Queensland first introduced pressure injury penalties and in 2012 we saw a new staging system where we moved from four stages to six-seven categories and it's when the Pan Pacific led the way internationally of changing the terminology from ulcer to injury. And now in 2009 we saw a national introduction of a pressure and penalty system through the HACS, hospital acquired complications system. So there are many influences as to how we got down from 28% to three to five percent and some facilities are getting lower than that. 00:04:09
So that's really interesting history there and how that's evolved. So what are some of the challenges around pressure injury staging? It's obviously a very important part of this. So you know in your experience what have been some of those challenges? 00:07:24
Ruth you're asking so many fantastic questions. It's really allowing me to set a great picture here and when you read the journals, all we see is a lot of data flying around, but there are many variables that make that data robust and meaningful and I don't think that internationally we appreciate how those numbers can be unreliable and the data that I found to be consistent with most other facilities is that 30% of the pressure injuries that we stage are actually staged incorrectly and what's even more worrying is that out of that 30% that we stage incorrectly, 60% of them are not even pressure injuries. But I think a lot of the staff are so in tune to pressure injuries and so scared of being penalized that they're calling everything a pressure injury to be on the safe side. So one of the challenges is trying to... I think often we want to talk about the more complex subjects but we really need to continue to teach on staging and I really love the series that Smith & Nephew you put on recently and they reiterated the staging model probably about three times through this series and I think that's really important that we continue to do that. I know in Queensland Health and our state pressure injury meetings we talk every year about what do we want to educate on and of course we all want to talk about all this some really groovy cool stuff, but what we do need to do is every year, we constantly need to be educating on how to stage a pressure injury and what was even more interesting was I had the opportunity to go to the USA in 2016 when they did their staging consensus forum. And so there was 400 people there for two days talking about how to stage a pressure injury and that's when they actually changed the staging system and actually adopted an eight category system and even after two days of talking about nothing else but staging, we could not get the whole room to agree on how to stage a pressure injury. 00:07:41
Why is a correct staging so important Tracy? 00:09:54
It's about making your data meaningful. So the executives are relying on us to feed up to them the problem and pressure injuries are really quite... they're a strong focus for a hospital now 'cause they're a quality indicator and we are constantly being benchmarked against each other all the time. So for example at the health round table. So if that data is inaccurate the executives can't rely on it. The other thing is now with this national penalty system we're actually being penalized, not for all pressure injuries but for stage three, stage four, unspecified, suspected deep tissue and unstageable. Now that unspecified is a really important one and that actually gets benchmarked at the health round table as well because people that aren't sure how to stage a pressure and some people interpret that stage as the ‘I don't know’ category or they're not really sure so they put it as unspecified or they could be actually trying to avoid a penalty around a stage three or four. So they don't actually say, they just say it's a pressure injury. They don't say what stage or category it is and they end up getting penalized more with an unspecified pressure injury. But the most important thing if we get away from our data and we actually talk about the person, I'm talking about your mother, your child that sits behind that wound and that injury. We know that if we diagnose what actually caused this injury and we understand that it's shear and pressure causing a pressure injury and we understand how deep it is, this guides correct treatment and correct care. And this is also a professional responsibility that we all hold to make sure that our patients are getting the right treatment. So if we're not staging correctly or we're calling it a moisture lesion or a skin tear, it's not getting the right treatment. So if we talk about data, it means that the executives are getting accurate data. We talk about data, it means our penalties are being penalized fairly and if we talk about making our data comparable, it needs to be accurate. Otherwise, it's being very misrepresented. But really what I want you to hear is that behind that wound is a person and a life and a whole lifestyle, and when that injury isn't being healed because it's not being treated properly or prevented, then that's when that's really what we need to understand, why we need to be able to stage a pressure injury. 00:09:59
It is so important isn't it? That it's staged correctly in those considerations. So why are some sites still plagued with high pressure injury prevalence do you think? 00:12:30
Well, the one word I'd like our listeners to write down is culture and culture in pressure injury prevention is that it's everyone's business. And I really can't speak strongly enough for people to understand that this is about a person and often people when they come in to have their operation they're not expecting to be sitting there six months later looking down the barrel of an amputation of their foot because someone didn't elevate their heel. So I think the most important thing is that we all own the responsibility of preventing pressure injuries, that we're all moving in the same direction and that this needs to be all levels of staff. So I've often seen in residential care, there are a lot of carers and assistant nurses and their job is to do the hygiene and the moving of the patient, and the pressure injury prevention practices and the registered nurse's job is to do the risk assessment. So for example Waterlow or Braden, but there's a big gap between the two because the eyes and ears of the carers who are looking at the skin, they've never seen a Waterlow tool and so they don't understand what the registered nurse is trying to document. So what I'm trying to explain here is there's a big disparity. There's like two highways that haven't got a bridge going across them and something as simple as training the carers to understand the type of information you need to accurately fill out a Waterlow tool is, it can only be understood by going through that tool with them. And the other thing that we need to understand is that we have no international agreement with coding. So now we have the Europeans basically using a four staging system or they call grades. We have in the Pan Pacific we've got seven categories and then with the American system they've got eight categories. So the coding is now very different. The other challenge we've got is the fundamental basics of understanding the difference between a stage one and reactive hyperaemia which is the normal body response to pressure like at the moment all our listeners are probably getting red backsides and red knees where you've got your legs crossed. And then when you take that pressure off you get that little red flush of on your skin and it looks terribly like a stage one, but in fact it's the healthy body's response to pressure. Now, often when our patients have been in the emergency department on a trolley for a few hours and then we move them over to do a skin inspection, we may find these spots of reactive hyperaemia and often they mis- documented by classifying them as a stage one, when really they dissipate within half an hour and there were never a stage one. So these are one of the many challenges and then if we look at now, if we move right through to the year 2020, we now have the greatest mimicker of all, COVID which is creating these incredible skin changes and some of these patients are presenting with what looks like a suspected deep tissue. When in fact it's an inflammatory response from the COVID causing like a thrombolytic injury at a sub-dermal layer and it's actually not a pressure injury but it looks terribly like a suspected deep tissue. So there are many reasons why we're having trouble getting this accurate data. 00:12:42
RUTH TIMMINS: So what future directives do we need to take then Tracy in your opinion? 00:16:18
I think we need to value that data. I mean prevalence studies are expensive in large organisations that can cost up to 10,000. I think it's really important that we understand why staff are having trouble staging pressure injuries and continue on with their education and once again I really want to thank you Ruth with Smith and Nephew putting on a fantastic webinars and podcast that you have done, I've really loved listening to them and seeing the Wendy watch presentations with those fantastic graphics were a brilliant way of being able to digest quite a large amount of information. I think I'm getting pressure injuries as a priority. So we know that international pressure injury day is coming up. Which is great but we need to make pressure injuries more than just a day's event. I noticed with the Pan Pacific, the previous guidelines that a lot of people didn't even know that the new guidelines were available. So once again attending the webinars like you've done, one on a summary of the guidelines has been fantastic. So that the guidelines are like 480 pages. So we need leaders to digest them for the clinicians. So into small pockets so we can implement them. And I think we've got when I talked about those two hallways with the bridge, I think we've also got that between ward staff and specialty staff. So the specialty staff think it's the wards job and the wards think specialty staff are going to do it. And all this leads to time delays in appropriate interventions, and that is why you've seen the national standards out of all the things in our complicated health system like initial first version of the National Standards, had a whole standard for pressure injuries and doing that for the three years that the first version was out. We saw a huge reduction in air pressure injuries so putting it in the limelight. And the national standards demand that we do a skin inspection within eight hours. We do a risk assessment, we check to see is it working for the individual? There are lots of things in those standards that are very reasonable to implement into clinical practice and we also need to be aware of how we work internationally. So for example, some countries their prevalence looks fantastic because they haven't included the stage ones and we know that about 90% in our pressure new prevalence studies, 90% of the pressure injuries are stage ones and twos. We can't even agree on what we're going to call the stages or the category. So as I said before the Europeans call them grades. In Australia, we call them stages but then we have categories. So there's fluctuations in terminology and I think the other thing is, your organisations need to understand that there is a lot of skill required to actually get this right. And I've even seen podiatrist and NUMs and wound services all trying to debate it out on is this actually a diabetic foot ulcer or is it a pressure injury? And so it takes a real collaborative approach. So I'm giving you very long answers, I'm sorry Ruth again. 00:16:23
It's really interesting and very important and I'm sure our listeners are finding it really thought provoking as well. So I guess like you say it's been a lot of information there. So what would be your sort of few key take home messages you'd like to get over today, Tracy. Just to sort of sum it all up for our listeners. 00:19:45
There's a couple of keywords and the one is individual. So I'm not trying to... I think nurses keep wanting algorithms and I think we need to think about the individual. Is this working for this person rather than wanting a wall of, ten I do this on a wall of 15 I do that. We need to look at is this working for this person. I think the most important thing is that we understand behind that person is a whole family, is a job, is a whole lifestyle that can be taken away from them. People die of pressure injuries, people lose their legs over pressure injuries and that's why I'm so grateful to have the opportunity to talk at this web, this sorry podcast and hopefully engage you on understanding where we need to be heading. So the second thing is, don't stop doing pressure injury staging education, keep on doing it just keep on doing it and keep on doing it. Working in a team. I've seen the best results when we get all the different disciplines together, the O.T. the physio, the podiatrist, the wound, the dietitians, the doctors and we go around and we say what's going to work best for this person? The other thing is it's not easy. You know, this does take it's usually years of work to get to change the culture. So that's the next word I want you to take home. So that this is how we do things in this organisation. I've seen some hospitals in your state Ruth, in New South Wales that have done fantastic work around reducing pressure injuries just by changing culture.And understanding when you are collecting data about reducing seasonal variance, about working with your wound service and your podiatrists to getting your data confirmed, rather than just putting pressure onto the ward staff, supporting them and understanding when you're comparing yourself, are you comparing yourself with a maternity hospital or a spinal hospital. I think as we educate ourselves the biggest thing I want you to take home is, how many patients did you stop from getting a pressure injury? How many patients didn't die because you intervened and diagnosed a pressure injury correctly and put the right treatment in and we looked at comparing some of the Queensland health data and when we dropped our prevalence so significantly from 14% to 10%. It was something like saving three jumbo jets of patients every day. It was the equivalent running cost of a 749 bed hospital, that we save. So we're talking about saving lives, creating better experiences for the patient and saving money. So they are the big things. So it's individual, culture, time and teamwork. They are the kind of things that I can think of off at the top of my head. I hope that's been interesting and helpful. And don't forget International Pressure Injury day, it's coming up tomorrow. The 19th of November so it's gonna be pretty fantastic. So I'd love to hear all the great initiatives and creativity that come up with that. So thanks very much for your kind invitation Ruth. I've loved being able to have a chat with you. 00:20:07
Thank you, Tracy, we really appreciate your time and yes, Stop Pressure Injury day tomorrow, for all our listeners we've also got some other webinars and podcasts, so join us. Thank you. Thanks Tracy. 00:23:33
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Pressure injuries are a costly burden that cause immense patient discomfort and potentially longer hospital stay. Most can be prevented. Enhance your prevention strategy with ALLEVYN Life™ shown to reduce pressuring during development by 71% (1) and reduce costs by 69% compared to standard care (2). For more information, contact your local Smith and Nephew representative or email us at, Profed.ANZ@Smith-Nephew.com 00:23:49
The information presented in this podcast is for educational purposes only. It is not intended to serve as medical device. Products listed, outline of care are examples only. Product selection and management should always be based on comprehensive clinical assessment. The detailed products information including indications for use, contraindications precautions and warnings. Please consult the products applicable instructions for use prior to use. Helping you get closer to zero pressure injury incidence.
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1. Forni C. et al. Effectiveness of using a new polyurethane foam multi-layer dressing in the sacral area to prevent toe onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomized controlled trial. Int Wound J. 2018;1-8
2. Forni C, Searle R. A multilayer polyurethane foam dressing for pressure ulcer prevention in older hip fracture patients: an economic evaluation. J Wound Care. 2020;29(2):120-12
Clinical Nurse Consultant
Tracy is currently employed within a major metropolitan hospital in Queensland Health as Clinical Nurse Consultant of a quality risk management equipment service. A significant focus of her role has been to bring innovation in the development of a central equipment service so as to ensure optimal patient outcomes through safe, equitable equipment management, education and maintenance. This service also specialises in pressure injury prevention, management of the Bariatric patient, falls injury prevention, bed safety, Smart Pump Technology, skin integrity and quality risk management.
She is the coordinator for QBig (Queensland Bariatric Interest Group), has been on the working party for the development of the Pan Pacific & both versions of the International Pressure Injury Guidelines.
Tracy has extensive experience in presenting innovative approaches to quality risk management. She believes in fun through learning and looking at new horizons of how we do business.