Pressure Injuries: So much to talk about! Catch up on the latest with Wendy White
Wendy will share her thoughts on some of the hot topics and updates in pressure injury prevention and management
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Welcome to Smith and Nephew's Closer to Zero podcast, a bimonthly podcast with leading experts in wound care hosted by Smith and Nephew™, helping healthcare professionals in reducing the human and the economic costs of wounds.
Hello, I'm Ruth Timmins from Smith and Nephew, and it's my pleasure today to host today's episode with our very special guest, wound expert Wendy White, and there's so much to talk about podcast. Wendy is a credentialed wound expert and 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. Welcome, Wendy, and thanks for joining us today. Given the recent update of the International Pressure Injury Clinical Practice Guidelines (1) and all the up-to-date evidence, there's just so much to talk about, isn't there, Wendy?
Thanks Ruth, thanks very much for having me. And yes, it is exciting times, I think here we are, it's 2020, and what a tumultuous year it's been for so many. But if we were to focus on the launch of those guidelines late last year, we've never before had such access to the best available evidence to understand these unique injuries from a prevention and a management perspective, so I think it is exciting and I think what's come out of the guidelines as well too is that there's still so much more to know, there's still gaps in our understanding and our knowledge. And so, we've got some great confident moves in relation to what we should be doing but recognising the expertise of good practice and expert opinions to help us with those gaps. So, I think we've come a long way. Don't you? Like, if you think about, since the last edition in 2014, and then going back to the previous, we've come a long way, but I still think the more we learn, you realise there's just so much you don't know and so much you want to know, and there's so much that's kind of unknown. So, I think it is an important topic. I'm so thrilled to be able to help to disseminate and raise awareness to the guidelines. And I think they truly will have a real impact on the way that we teach, practice, measure quality, you know, an invaluable resource to help us all, so yes, it is exciting times.
It's great Wendy to have these new guidelines. So, what's new overall that you've noticed?
Well, look before I sort of talk about my impressions of what's new overall, because I just wanted to say thank you to the partner organisations, and of course the Pan Pacific Pressure Injury Alliance as a part of that. The 12-member governance group, and it was Professor Keryln Carville that led that for our region with representation from Pam Mitchell from New Zealand and the girls from Singapore and Hong Kong. But the way that the partner organisations engage the global associate organisations and all of the experts. Like, I think there was 174 experts, leaders in their field, who all worked on the working parties. And if you take a look on page five in the full version of the international guideline, you'll see all the names, and if you scroll through, you'll see some of the who's who, and you'll see some of your friends and colleagues as well that were actively involved. You know, they also had fantastic consumer and stakeholder input, you know, about 1200 people. And the methodology, it talks about the fact that they used that feedback when they were meeting in their different areas, so, that's lovely. And I think having Associate Professor Emily Haesler as methodologist and Chief, Editor in Chief, it's given us something that's kind of very structured, easy to use, easy to read. So, you know, I think it's a great start to give our thanks to where it's well deserved. Look, I think it beautifully leads on from edition one and two. So, we see definitely new information in there that wasn't in the 2009 version, and it's that sort of continuing commitment, isn't it, Ruth to research and how that is building over time in the area. I think the other really lovely thing is the way that they've produced the guideline with the quick reference guide, and this concept of not only telling us the strength of the evidence, but the strength of the recommendation. Now, they've used these two arrows up or one arrow up to tell us whether we should definitely or probably be doing something. And when you read the background, it was all about wanting to give us confidence and to give us focus of knowing that if we engaged in this, we'd probably do more good than harm. And that's a really lovely way, I think, of looking at something to practically be able to implement. So, I think if you are asking me sort of what's new, I really actually like that they've not kept the special groups separate this time. So, what they've said is, everything about prevention and management sort of runs across everyone. But if there's anything specific about intraoperative or if there's anything specific about a spinal cord injury or anything specific about the age, they've incorporated it as an additional element within that chapter or within that topic. So, I really liked the way that they done that. So, yeah, there were some things that really stood out for me.
Yeah. Thanks, Wendy. That's really interesting about having the special group separated before and how they've incorporated that. So, what else has really stood out in that sort of prevention of pressure injury?
Look, the number one thing that I came away with was that they've really challenged the traditional way that risk assessment is undertaken, I think they've really drawn a line in the sand. That's my opinion only as an everyday clinician looking at these and seeing how we can use these to support others and to support our own practice, you know? I think they've demanded in a way that none of this can be done without clinical judgment and critical thinking. This isn't easy, it's actually quite complex. So, I think I'm also stating that just filling in a risk assessment tool is not what is meant by doing a risk assessment. So, and the other element that they've incorporated is sort of separating out quick screening and doing comprehensive assessments. So, there were some really nice ideas in there that were very practical and I think might help to take us forward cause sometimes, I think in this area, we might get a little bit stuck in the way we've done risk assessment in the past. I liked the fact that when they were talking about sort of two steps, that there's just some groups that you just don't even have to screen them. Like, you should just automatically consider that they're at risk. And I like this thing, you know, because when we're looking at risk assessment tools, we've often used the language, you know, high risk, moderate risk, you know, etc. And they've just said, look, they're at risk. And so, do something now, do your comprehensive. And I guess the aged and acutely unwell, spinal cord injury, the neonate, with heels, it was the paediatric population. So, I think that's going to help us to act a bit faster and maybe have that sort of sense of urgency that sometimes can be missing. But when, for instance, if any person over 65 and advancing age comes into your facility, that you would just go, right, they're at risk of pressure injury, now let's find out their unique risk by doing that assessment. I like the way they've built on what we understood about prophylactic dressings in the past, and there's this very clear message now about, you know, don't delay, use these kinds of adjunct therapies earlier. And I think that's probably where there's a little bit of a growing body to just sort of say, yeah, that early intervention is going to help. I think the whole element of continence care and differentiation with incontinence-associated dermatitis and all of our roles as clinicians, of needing to have our regime or our approach within our facilities to make sure that we're protecting their skin. And I guess, finally, I think this sort of separate chapter on the heel, doing some webinars with you Ruth and with Smith and Nephew, in one of those, we've looked at the heel and I think the heel, if I was to just use the words, I think it's a bit undercooked. I think we tend to be a little bit more reactive to this anatomy and I think this chapter is also going to help people to really understand its unique risk. So, I just thought there was some really great elements to it. And every time I read it, Ruth, I see something else, or I'm again, amazed at how clever the editing was to be able to take so much information and kind of condense it for the everyday user.
And so, what about on the treatment side, Wendy? What sort of stood out for you there that's new or different?
Look, again, I think there's just that natural progression and building on what we've known before, but there's definitely a clear message regarding pain, and an entire chapter obviously. And maybe that thought that we need to exclude it, you know, to not presume that it's not painful, to maybe presume that it is painful and be pleasantly surprised if we find out that it's not. So, it is saying that as part of our assessment, this is important. It is one of the most impactful symptoms that people with pressure injury live with, and that's part of their review process as well. So, I think that encouragement, that building on of what we've understood about pain and prevention and assessment and appropriate management, I thought that was really lovely. You know, it's really saying, gather your data every week when it comes to your clinic metrics but down your tools every two weeks, down your tools and say, are we getting there?
Whatever we introduced, has that helped? Is there better bed tissue, less exudate or the quality has improved? Is there less pain, you know? Is the wound literally changing in its size or depth if it's an open wound? So, that sort of concept of going back and reviewing the person and their environment and all of those risk factors that are relevant for them and the care plan, it's sort of saying, don't put your care plan in place and look at it again in three months’ time, which can sometimes be the process. Make things a little bit more dynamic and individualised. And again, they've built on the work of infection, but because the International Wound Infection Institute published their best practice document in 2016, that update of the 2008 version, they have incorporated a lot of that in there. Not everything, but there's many elements in there that they refer to that. And again, they talk about, there are areas that there isn't high levels of evidence, but this sort of consensus and this movement where we know that we're going in the right direction. And so, there was a direct link with that and biofilm, so that concept of cleansing, debridement, antiseptics, those basic principles now are not going away and they apply to pressure injury just as much as any other wound.
Thank you for that summary, Wendy. So, was there anything that took you by surprise with the new guidelines?
I was a bit delighted, really. I don't know whether surprise is the right word, but I was delighted to see that when it came to screening and risk assessment, they'd sort of taken time out of the equation. And I've definitely worked with different groups that have said to me, literally, no, we can't get that done. We can't get a risk assessment done any faster than we're doing it now. And our policy says twelve hours or eight hours. Or trying to get it done in six hours, or even earlier. It was seen as an onerous task that actually just couldn't be done. And really, they've just said, you've got to be in there. If they're not one of those high risk groups, you need to be in there screening them, this quick screen which they've begun to sort of highlight what we should be looking for. We should be doing that as soon as possible via a healthcare professional who can just sort of scan and screen and go, right, we've got a problem here. We need to move on and do a comprehensive assessment. So, I guess I was a bit delighted to see that there's now this more of a sense of urgency. Let's get in this and let's do it well, and let's do it quickly so we can get things sorted out.
So, Wendy, what can be taken from the guidelines to really make an impact in improving clinical practice?
Well, look, I think if you've got to take something out of a clinical practice guideline, you need to be aware that it exists. And that's why these podcasts and the webinars, we need to take this document and try to bring it alive and see action. So, we need to be aware of it and we need to want to engage with it either as an individual or small teams or organisations. You know, we need to connect with it. And I think the other thing too that you can take away from the guidelines is that they did a systematic review of the literature and then looked at the congruence of that against the conceptual framework that they use for susceptibility for pressure injury. So, it is one of the nicest kind of summaries at the moment of new information, and Ruth, nothing stays the same forever. And if we were all practicing relating to pressure injuries as we were back in the 80s, what a disaster that would be. Yet, sometimes we have organisations and healthcare professionals that are working with knowledge of the past. So, I think these are a great way to update, up-skill, and really challenge ourselves. Did I know that? Great, I do now. OK, now what are we gonna do with that information?
So, Wendy, you've been working in this area for a number of years obviously and seen a lot of things. So, you know, what inspires you in this area?
Oh, look, it’s definitely seeing change in knowledge and change in practice that has a direct, positive impact of those in care. So, when you see the light switch on with a healthcare professional, or it might be, you know, the everyday clinician on the ground, or it might be one of the clinical leads or managers, or it might be quality teams or organisations as a whole, you know? Sometimes you can even engage with boards and CEOs that say, you know, we want to do this. We want to be leaders. We want to do this better. I think just seeing that change, it has to be inspirational. And I also, Ruth, I really love when people are trying to move forward, trying to do things better and then something falls off the wagon or something happens and it's not great, but they just say, right, what can we learn from that? How can we make sure it doesn't happen again, you know? That whole quality and safety. So, it's not easy. Preventing pressure injuries and managing them is not easy. And I think when you see people striving to keep, to deliver the best care they can, I just get so inspired by that, yes.
Thanks, Wendy. So, what would be your three take home messages for our listeners today?
I think just considering that any setting with any population that is requiring care from us in a health environment, in an age environment, primary health care, it doesn't matter where these folk are. The human body is not created or designed to be able to withstand these external forces or these forces of the human body's weight against surfaces. So, I guess just knowing that pressure injury is something that happens in our industry, like in the webinar, Ruth, and we talked about the aviation industry. Unfortunately, air crashes and investigations are part of their industry. Well, pressure injury is what can happen to people in our care, and sometimes we're unable to modify their risk factors. Other times we are, but we should at least see the risk. I think the second thing is knowing those really high risk groups. Then, there's no surprises, Ruth. I think you just... There's no surprises here. And if the aged are found throughout every environment that we now provide care in, then let's just see them at risk and let's just act. And then I guess the third thing is that individual nature of it. You know how we looked at the framework, and it is this concept of someone's tolerance and susceptibility? Well, that's what pressure injury is, it's individualised. And we for too long have dumped them all into the same bucket, given them the same care plan and expected the same result. And that's not what happens, so I think seeing the individual nature of it and recognising the impact of end of life, choosing to not move positions, acute illness, medications, chronic diseases, you know? It's going to be different for this person than it is for that person and for this. So, I think this problem isn't going to go away, Ruth. And they would be my three take homes, I think. And there are demands on us to remain diligent and committed and, I think, on high alert. So, yeah, that's what I'd say.
Thank you so much, Wendy. It's been really great to catch up with you and I'm sure your insights have given us all some inspiration and knowing that we can make a difference in pressure injury prevention and management. So, thank you to you again, and to our listeners for joining today. Be sure to tune in for our next podcast.
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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
MWoundCare. BEd. RN. Plast Cert. MACN. FWA
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.