Pressure Injuries: Are some interventions ‘non-negotiable’?
Wendy looks at the latest evidence and guidelines to discuss her thoughts on the non-negotiable interventions in pressure injury prevention.
Welcome to Smith and Nephew's Closer to Zero podcast. Bimonthly podcast with leading experts in wound care hosted by Smith and Nephew helping health care professionals in reducing the human and economic costs of wounds.
Hello. I'm Ruth Timmins from Smith and Nephew. And it's my pleasure today to host our episode with our special guest wound expert, Wendy White. We'll cover some of the non-negotiable's in pressure injury prevention and management. Wendy is a credentialed wound clinician and qualified educator with over 30 years of wound and skin care specific clinical expertise from a wide range of settings and in private practice. So, welcome Wendy and thank you for joining us today for this podcast and we're really looking forward to hearing you share your knowledge in this really important area of prevention and management of pressure injuries. So, we are really interested to hear your thoughts on some of the non-negotiables in pressure injuries.
Thanks Ruth. It is great to be here with you and as a clinician facing these problems every day. And with the guidelines presenting as they are, you know, it's important for us to actually look at what is so important that we just can't overlook it. And I think we need to recognise that pressure injuries aren't going away, are they? I mean they've been with us throughout the ages and they're going to continue to be a problem not only for us, but around the globe. and as we see our populations ageing, well, the risk is just going to increase, isn't it? And so I don't think we can sort of take our foot off the pedal in relation to momentum. You know, there's a lot of international and national awareness campaigns and state-wide audits, some local benchmarking and quality eating indicator measurements and monitoring. You know, like, there's just so much going on. But it is important for the everyday clinician and their organisation to think, OK, these are new guidelines. What is it that we need to get on to straight away and then continue to roll out. So, what are these sort of non-negotiables? And I think we just have to keep talking about this, Ruth, because, I mean, it was back in 2011 that the declaration of Rio de Janeiro stated that the prevention of pressure injury is a universal human right. So, we've got a lot to get right for them if we possibly can modify their situation. So, yeah it's good to be here to sort of talk about those things that just aren't negotiable anymore.
OK. So, what would you say is the first non-negotiable to consider? The first thing we should think about.
Well, I think it's that considering that we have the use of best available evidence, and if that isn't available to us embracing expert opinion within clinical practice documents, and also the work, the external work of consensus as well that these things fill the gaps, don't they? They identify where we've got enough good strong evidence to just guide our practice. And while we're catching up with all of that research in so many different areas, filling those gaps so that it can guide our care appropriately. I think it's non-negotiable today. It wasn't in the past. We can do whatever we liked. I can remember egg whites on pressure injuries and Vegemite or Marmite, I can't remember what it was. Incredible. And we just did whatever we liked. Well, that's not the case now. And I think we need to commit to that as healthcare professionals and organisations that we will use this approach that's been provided for us that helps us really focus in on the person, the individual, their unique characteristics recognising their lived life and their preferences. If we were developing plans that are based in evidence, but it's not their preference, it's this some non-negotiable that they have the common right for us to provide safe and quality care. So, I think that's one of the first things to embrace that. And the international guidelines for the prevention and treatment of pressure ulcers injuries, clinical practice guidelines and the quick reference guide from 2019 (1). They've been designed to complement each other, work together. It's the most recent review. It aligns itself with current concepts and frameworks, and it really does help us better understand their risk. So, I think there's some foundational stuff that we've just got to start off with. To be honest, it's not negotiable anymore. These things along with our wound related standards, they should all be part of the foundation of our policy procedure. And it's this thing of taking theory and practice, isn't it? Or the science and the art and bring those different levels of evidence into that practice.
That's right, Wendy. But you know, obviously, you know, there is so much information and the guidelines themselves are over 400 pages long. So, sometimes maybe we may feel a bit overwhelmed. So, if we're going to start somewhere, what are the things that the guidelines say we should definitely be considering in the prevention and management to pressure injuries?
Look, I think that that is absolutely the place to start because they design these clinical practice guidelines with the strength of recommendations with the two arrows up. It just says you should definitely be doing this. Now, that's obviously in the context of the individual preference and their absolute ability to refuse or to not engage in something that might be suggested or recommended. But I think that is a perfect place to start because if we're going to take this large amount of information, then why don't we start with those non-negotiables? The things that have been deemed with a strength of recommendation that, "we should be doing this." So, why don't we start there?
I would encourage everyone's that's listening to make sure that they've got a quick reference guide down the track after listening to a podcast like this and just doing, using it. It's been laid out like a table and it tells you the topic and it gives you the statement and you can see the strengths, etc. And then it does gives you the strength of the recommendation. So, I think what we could look at is the things that had the two arrows up and then really just sort of doing a little audit ourselves back in the workplace. What are we doing? Is this in our policy? Is this something we've never done before, but maybe we should be? So, it's a great place and they started when, if you look at the overall guideline, there appear to be more of those two arrows up that we should definitely be doing it. When they were talking about organisations, Ruth, and their teams, and they were emphasising this endeavour. This constant ongoing endeavour to reduce the risk of pressure injury as a quality improvement element. So, it didn't say if you're working in acute care do this or if you're working here do this. It's just saying across the board no matter the site, no matter the setting, no matter the population, do we have a quality improvement program that our organisations can support their teams with that absolute bottom line of how can we reduce the risk of those that have modifiable risk factors. So, if I was to summarise what they kind of chatted about in this topic, they really just said everyone should have a program, that your policies and procedures should be based on best available evidence. And we have that now. And we have some recommendations and good practice statements to fill the gaps. And they also said that we should standardise documentation as a part of that process as well. They go on and say that there should be supporting tools to help clinicians make some decisions. Now, I know that there are people listening to this podcast that might be existing Smith and Nephew customers and others that are not. But many of the tools that have been developed by you guys helping and guiding clinicians how to make choices and how to learn the best way to guide. I think that's a really fantastic start, but it may even be that organisations want to start developing some of their own decision making support tools based by some of the recommendations in the clinical practice guidelines. They say that we should have leadership. There should be clinical leadership with knowledge and expertise that can not only drive the programs, but really ensure the commitment of everyone to pressure injury prevention and treatment all with this intent to reduce the incidence. And they also suggest that all of these things I'm saying to you sort of non-negotiable. They're the things that definitely should be done that we should understand the knowledge base of the health care professionals in our organisations. And then based on that, develop and implement education programs and just make sure that that's an ongoing thing so that we just don't drop the ball. We just keep the message going. I think also really interesting from an organisation perspective, they say that it is the organisation's responsibility to kind of make sure that they know what equipment that they've got, what resource and are they using it correctly? Is it safe? Is it functioning? And, do people know how to use it? I thought that was really great. And that one actually got two arrows up as well as everything that I'm talking about. And then finally, that ability to benchmark yourself, I guess. And there's no excuse to not do that anymore, Ruth. Even for organisations that haven't done this before because it's all included in the clinical practice guidelines. So, there's a whole chapter there for you of what are the clinical indicators that you would be measuring. So, fantastic support for people that have never gone down that track before.
That's right Wendy, to have all those things more from that organisational level that's been recommended in a quality improvement programs and from that bigger picture, I guess. So, what would you say from the clinicians from the everyday sort of clinical practice can take back really from today as being non-negotiables that they should be doing and considering in their own everyday practice.
Look, I agree with you. I think there is a differentiation, isn't there? Because sometimes what I just spoke about might be out of our control. Yeah. And so, yeah, I think there are things and we talked in one of the webinars where we talked about the concept of bundling care, that there are lots of recommendations that have been made that the everyday clinician is actively involved in, but they can sometimes just deliver it in silos or not sort of in a broader sense. And we looked at the acronym, which isn't in the clinical practice guideline called "aSSKINg", and I thought maybe I could have a look at some of these everyday things following that acronym so that we could look at what is being recommended that we absolutely definitely should be doing, but maybe do it in a sort of a structured way. So, when it comes to assessment it just says, you know, you just cannot disregard mobility and limitations in activity. I think that one step would make such a huge difference from assessing their medical history, diabetes and its link with pressure injury. And we've seen very clearly that risk with lower limb and heel pressure injuries. Again, these are all absolutely things we should be doing. The vascular status assessment. And we chatted previously about the fact that sometimes people don't have the knowledge or the skills or the equipment, but it's saying we should be doing this. So, this is a really great thing that people can focus on, making sure we're overseeing their pain assessment and that we're measuring their wounds in a consistent way. And whatever system we use whether it's linear and a ruler, or whether it's using digital or advanced software in technology, no matter what we're using be consistent with it and make sure we're downing tools every two weeks to make sure that we can understand if that wound is progressing. So, I think there's some of the really great things that have meant to be non-negotiable. They also talked about not debriding dry eschar unless there was infection and also the fact that if there is infection and inflammation and biofilm then debridement, and continual debridement in conjunction with antisepsis was really important. So, these are sort of fundamental principles of practice now that we kind of need to be engaging and double checking what we're doing and what we're not.
That's fantastic information, Wendy. Thank you. What comments do you have around perhaps for skin care?
The skin, we know, it's just non-negotiable. We need to be doing skin inspections and that's part of their recommendation. Differentiating between non-blanching and blanching erythema to diagnose stage one but recognising that if someone's got a stage one pressure injury, then knowing that they're at risk of developing a stage two or greater and just having that awareness and noting that in the way that you practice is going to change things. There in relation to moving it says that we should reposition based on individual requirements their risk presentation and your clinical expectations. Offloading heels is just non-negotiable now. And supporting that weight through the whole limb and the use of those prophylaxis in dressings as adjuncts adding to these non-negotiable elements. Skin care ranges now are a part of what is expected that we have if people are suffering from, not suffering but living with incontinence and having that range to provide not only cleansing, but moisturisation and barrier. So, there's a lot in skin care that the clinical practice guidelines said that, well, they don't use the word 'non-negotiable'. I've kind of used that word. But what they've really said, you should be doing this.
It's really important that skin care regime being implemented. So, maybe other things as well that you feel is really important that's come out from the guidelines?
I think if we looked at nutrition and there's a whole chapter in nutrition, but there were several definitely do's as recommendations regarding screening, regarding getting comprehensive nutritional assessments done if they screen as malnourished or at risk of. The plans are created by dietitians as individual nutritional plans. And I think nurses and other individuals maybe we should stop sort of sometimes pretending we're a dietitian and ensure that we follow these recommendations for comprehensive review. It's very clear they've talked about protein and calorie and vitamins with recommendation strength of two up arrows. So, I think it's really important. And you know, the other thing too, Ruth, you had Tracy Nowicki who did a presentation on medical device related pressure injury and there's a sort of a non-negotiable there as well too. If anyone wants to look it up, it's in Section 8 and it really just gives you some nice check points to look at if you are using devices, and this was a recommendation that should be done.
Well, that's been some fantastic highlights there and some key things there to remember, Wendy. So, just for our listeners just to sum it all up, I guess, is there one key message or one take home message you'd like listeners to take today?
Yeah, look Ruth. I think it's important that we commit to this. If if there was a take home message I think we have to commit to this. It's not going away and it's going to take commitment of health care professionals and teams and organisations. So, we've just talked briefly today about the what I've termed 'non-negotiable'. May be looking at those things that I recommended that we should definitely be doing. But remembering that just because something got a one arrow of one up of you should probably be doing this, or if it got a good practice statement, they should be brought along with this to complement, to provide that comprehensive approach because as we move forward we're going to see more and more evidence and things change as we move forward. So, let's just get started and embrace what these guidelines can do to direct our care.
Thanks, Wendy. We are very lucky to have such strong and clear recommendations and this clinical practice guideline to support our practice. So, thank you for taking us through these non-negotiables today. It’s given us food for thought and hopefully will inspire our listeners. So don't forget to listen to our next podcast. And thanks again Wendy for joining us and to our listeners for joining us today.
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- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. Available from www.PPPIA.org
- Joy H, Bielby A, Searle R. A collaborative project to enhance efficiency through dressing change practice. J Wound Care. 2015 Jul;24(7):312, 314-7.
MWoundCare. BEd. RN. Plast Cert. MACN. FWA
Credentialed Wound Clinician (CWC)
Fellow Wounds Australia
Wendy has 30 years of wound & skin care specific clinical expertise from a wide range of settings and in private practice. She is a qualified educator and has delivered quality education, clinical and professional support services in national and international arenas including healthcare, residential, government, industry and insurance settings for the past 13 years.Wendy’s areas of wound related clinical interest, research or publication include skin tear prevention and management, minimising wound related pain (including low resource setting), assessment & differentiation of neuropathic pain, wellbeing when living with a wound, clinicians as advocates, person engagement & partnerships, pressure injury prevention & management frameworks for change and advancing debridement knowledge & practice skills acquisition training programs. Wendy is a recipient of a Wounds Australia Fellowship (previously known as the Australian Wound Management Association), in recognition of her contribution to clinical practice, education, research and leadership in wound management throughout Australia, and the Asia Pacific region.