Pressure Injury Prevention and Incontinence Associated Dermatitis – Aged Care Perspectives

Don’t miss this informative podcast with wound expert Fleur Trezise  as she takes us through  the challenges faced in the Aged Care setting when considering  pressure injury prevention (PIP). An overview of the recommendations from the Royal Commission in relation to wound care and PIP is discussed, as well as the role of Incontinence Associated Dermatitis in pressure injury development. Fleur describes some key considerations when implementing a PIP protocol and practical tips and strategies for clinical practice.

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SPEAKER:

Welcome to Smith and Nephews Closer to Zero Podcast, a 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.

RUTH TIMMINS:

Hello and welcome to today's podcast. I'm Ruth Timmins, and today we'll be discussing pressure, injury prevention and the aged care setting with our special guest, Fleur Trezise, who is a nurse practitioner and has worked in the world of wound management for over 25 years. Fleur has a really broad clinical experience in managing, both acute and chronic complex wounds. So, welcome Fleur. It's great to have you with us today.

FLEUR TREZISE:

Thank you very much. I'm really excited to be here.

RUTH TIMMINS:

Yes, so obviously this is a really hot topic isn't it, pressure, injury prevention and so on in the aged care setting in light of the Royal Commission recently in the report and so on. And often it is highlighted as quality indicator isn’t it? You know, could you give us a little overview, perhaps of some of the recommendations from the Royal Commission and the impact?

FLEUR TREZISE:

Absolutely Ruth like, I think, you know, although the I think the time that the commission was happening, I think it was fully traumatic time for those working in the aged care space because ideally and ultimately really good care happens in the aged care space. But of course, there was still, spotlight has shone on some of the deficiencies. And to me, that becomes an opportunity. There is areas where there's not enough funding or there's not enough education around things like wound management, around pressure injury prevention and so forth. So, if what comes out of the Royal Commission means that we get better education and we get better funding in those areas, then to me that's a win that it means that at every level of every organisation, people are aware of pressure injury risk and aware that actually to prevent pressure injuries, it does cost money. And it does mean that you need an educated workforce and an educated community as well, so that everyone becomes part of that team. Now, essentially out of the Commission, there were around about 148 recommendations that came out of the Commission when the paper was published in February 21. Now, only a few of them were around wound care, and they probably didn't go far enough, but I see it as a starting point, I see it is a point where we can continue to agitate and continue to promote the need for it. So, some of the recommendations that did come out of it was really acknowledging that in aged care, there needs to be embedded in that regular clinical review and assessment of individuals to meet the individual clinical need. And that includes pressure risk assessment so that all of our individuals or our residents are being appropriately assessed for their risk. And if they're being appropriately assessed, that means the appropriate prevention strategies are actually implemented as well.

There was a review of the aged care quality standards where a pressure injury, wound management, continence care, etc, came in as mandatory standards where data collection is occurring as well and using more comprehensive indicators for pressure injury and anyone working in the aged care space knows now that they are mandated to collect that quality data on pressure injury incidence that's occurring in their organisations. One of the things that was really interesting and didn't go far enough in the recommendations that there be a review of the certificate-based courses for Cert three and Cert four, and really that it was recommended that wound management is involved as part of their training. Now, anyone working in wound care recommendation is a wrong word there, it should be mandated, anyone dealing with people with wounds needs to be educated, so that's a really important one as well. And of course, better funding and better training to ensure that those delivering the care have the training to be able to do it properly. So, they are the big things that came out.

RUTH TIMMINS:

Well, thanks for that overview, and you know, there are many challenges aren’t there in the aged care setting and you know, what are the particular challenges in implementing pressure injury prevention in that setting?

FLEUR TREZISE:

That some of those challenges, again, there's a myriad of people that are attending to the care of the resident. And one of the big things is they're working really tightly as a team, I think is really important because you may well be having someone that is attending to the personal hygiene, someone else that is attending to some repositioning, someone else who's actually doing wound care. And now if we don't have good communication strategies in place or we have again, that lack of education where we're not recognising a problem until it's too late, then I think they're the sorts of challenges that sometimes the care can or can be seen to be a little bit disjointed. Or perhaps the communication can be a little bit disjointed as well. And of course, understaffing, that's always going to be a challenge if we don't have enough feet on the floor, how can we really deliver that high-quality care that our residents and our aged people actually deserve?

RUTH TIMMINS:

It's a really good point there isn't and you know, like you say, education and training is a very key part, isn't it? So, hopefully, through the webinar that you've got Fleur as well, that can also help to support some of these challenges in the education space at least. We'd encourage our listeners to check out that webinar with Fleur. So, with pressure injury prevention particularly in aged care, Fleur you know IAD or incontinence associated dermatitis is often a big challenge as well isn't it? So, what role does that play in the development of pressure injuries and prevention strategies?

FLEUR TREZISE:

Absolutely, well, as we know you’re thinking about what are the risk factors that are there and what are the causation for pressure injury. And we know immobility is a is a big one and we know that we're, you know, we're getting really good at our repositioning and our support services. But what if we are then challenged with incontinence? So, not only do we have a client that is gonna get a pressure-related injury, but if we're not good at managing or if we haven't come on board and manage their incontinence and we end up with that dermatitis as well.

The big thing is that if we're not recognising it, that it is actually IAD and we’re thinking, it's a pressure injury, we are doing all the right stuff about pressure and things aren't getting better, it's because we haven't addressed the cause. So, what is what I really focus on with people is if they are both at risk of pressure and have continence issues, you need to deal with both and you need to work out what the problem is. So, not every injury is, as I say in the webinar, and if you read in the literature that looks like a stage two on the bottom is a stage two pressure injury. If, for example, we have a linear lesion in the natal cleft, it's a moisture-related injury. And for such a long time, I've worked with people and we've gone through and corrected and said, well, actually, now, this is moisture, not pressure and they look at me surprised and they go, Oh, I always just thought it was always a pressure injury because that's what we've been taught. And so now there's so much more in the literature about the association of the moisture-related issues we just need to, and every time we speak about pressure injury prevention, we need to also incorporate and ask about what are the issues to do with incontinence? What are the issues to do with moisture, and are we addressing them appropriately? Do they have good quality incontinence aids in place? Are we you know, using zinc, for example, and using so much zinc on their bottoms that we're blocking the ability for a continence aid  to actually work properly. Are we using gentle products or are we using products are actually damaging to the skin? All of those sorts of questions. And as you know, you've got a range of products in place that address this that are gentle, that actually help in terms of moisturising and soothing and healing. It's important that I think we all have a look at what products we’re using and does it meet the need of the client as well.

RUTH TIMMINS:

And you know, you mentioned there are some people, you know, it's hard to distinguish between IAD and PI sometimes say, you know, what's the best way to distinguish between the two? Would you say.

FLEUR TREZISE:

Do you know that that's a really good question? Often, like if you're thinking about a pressure injury, most likely most often will be over your bony prominence. And if it's not on a bony prominence, ask yourself, is this really a pressure-related injury? It could well be a shear injury absolutely. If they are incontinent, have a high suspicion that it's an IAD. If they're not incontinent, take that suspicion out is one way. You've got, if you've got depth or any rolling of wound edges, it's most likely to be a pressure injury. Again, as I mentioned earlier, if it's a linear lesion, it's probably more likely to be an IAD. Now you can have them both together, so you do need to be a bit of a detective and work out. But if you think it's IAD and you've put in IAD strategies such as the creams, the lotions, the protection and it heals it was IAD. If you put in pressure injury strategies and it improves, there was pressure. You know, again, link it to your clinical interventions that you're putting in place as well. And or if it's a combination of both, you've got to be able to recognise that combination.

RUTH TIMMINS:

It's really good advice. And there are some resources attached to the podcast and some charts to give some visual assistance as well with distinguishing between IAD and PI as well, so check those resources out. And the other thing Fleur, the importance of early identification, of the risk of heel pressure injuries and what are your thoughts on that?

FLEUR TREZISE:

Ruth, that's a really... And if you... In the webinar that I do and hopefully, those listening to the podcast will also do that by going to a bit of detail about some of the transcripts from the Aged Care Commission and some of the things that was cited was that it took a period of time before a problem was recognised, or it took a period of time before a resident was referred on to a specialist, for example. And these were to do with pressure injuries and heel pressure injuries. Now in the aged care setting, you've got a lot of people that may have diabetes, you've got a lot of people that may also have peripheral vascular disease or a combination of both and you add that to immobility, you add perhaps some nutrition that's not optimised, you add maybe agitation and shear and friction forces to that. You've got someone at an extreme risk of pressure injuries occurring on the heels and the feet. So, one of the things that I always encourage anyone that I'm working with in the aged care space is a) know the underlying co-morbidities of your clients. And that's not just the registered nurse that's dealing with the patient. The care workers as well, as well that are engaged should have an understanding that if Mrs Smith has diabetes and poor circulation in her feet, I have to take special care of those feet. I have to make sure that pressure isn't on the heels or against the bed board or whatever it might be so that we can reduce the risk of injury because if you think about the sequelae and what can occur, if we end up with a significant pressure injury on the heels of that patient is amputation. And you don't want to end up in that space if you can avoid it. Sometimes it's completely unavoidable if you have an ischaemic event. But if it's due to the fact we didn't relieve pressure, it's not a good outcome. So, I'm quite passionate about heels and offloading.

RUTH TIMMINS:

Yes, I. And that's really some really great advice there. And the importance of early referral Fleur, you know, if there are signs of deterioration you know could you give us some insights into that, please?

FLEUR TREZISE:

Again and again, that can be challenging but one of the things early referral again is I think it goes back to that early being proactive in treatment also that if you see something that is either deteriorating or at risk of deterioration and it's not being met and you think it's not being managed as well as it could be or despite best evidence treatment, it's still going backwards. Someone else should be casting an eye over it. It might be simply that a determination is made that no, this is a palliative wound and we're moving down a palliative care framework, and everyone then knows that, the resident knows that, the family knows that, the staff know that and you're putting protocols and strategies in place that meet that end outcome. Or it might be that that client, actually, they could be reperfused. So, we end up getting a vascular consult they get their pipes unblocked, they get blood supply back to that foot and we don't have a problem. So it's really that early identification or we might be bi-... Again we can go on and on. It might be needing to use an anti-microbial dressing early rather than later. It might need some debridement if there's a wound that's there and you don't have those specialised skills in your organisation, find someone that does. Now, one of the things of although COVID has been a horrific thing, you know, across the globe. One of the good things that have come out of that is telehealth. Now, you know, we know sometimes to get referrals and consults can be challenging and difficult, but we've got telehealth now.

There are lots of places you can refer a wound to that it can be across, you know, a webinar can be, you know, a telehealth consult. So, I think those doors have opened and I think those opportunities are open and I think we should all make use of them.

RUTH TIMMINS:

Thanks for those thoughts Fleur. That's really interesting that, yeah, the telehealth aspect is really the technology we could really tap into that now, can't we?

FLEUR TREZISE:

Oh, absolutely.

RUTH TIMMINS:

Yeah. And so, just perhaps to round off, we could talk all day on this topic anyway.

FLEUR TREZISE:

We could.

RUTH TIMMINS:

Yeah, you know, what are some of the main considerations for implementing pressure injury protocols to those in the aged care setting? You know, some of the main, I guess, strategies or things that can actually be done to improve outcomes?

FLEUR TREZISE:

Yeah, and again, a really good question. I think in the aged care setting, you've got a framework to work with in terms of the Department of Health, the mandated guidelines. There's information that's there. You've got the guidelines to help you know what strategies you should be implementing. You need to have buy-in from every level of the organisation. If you don't have executive  fully on board, it will always become challenging. If you don't have access to equipment and there's an expectation that your residents need to be on certain sorts of equipment. You really do need to agitate for it. You can't solve a problem if your mattresses are not up to scratch, you will continue to have a problem. So, it really is having a read and understanding the guidelines, making sure you know, when I put the ASSKING framework up earlier in the webinar, again, go to the  webinar, assess your clients know what the problem is. Know what their level of mobility is, get them to keep moving, know what support services you need for that particular individual in that area, optimise nutrition. Use prophylactic dressings, if that's appropriate. So, I guess the thing that's coming out of this answer, Ruth, is it's a bundle, it's a package. It's not just one thing that will solve the problem, it's it's a whole of prevention that will potentially solve the problem. And it's not just doing stuff, it's knowing stuff as well. And I think another thing for me that's so important is that engagement of family because again, we talk about being short-staffed, sometimes not enough people. If I have family that I know, they're happy to go in and say, you know, Dad, come on, let's just wiggle about a bit, let's move a little bit, then everyone's on board. It's a team and that's it shouldn't be seen as  it's just a nurse's job or it's just a care workers job, or it's just a consultant's job. It's all of our jobs and that, to me, is a big key to prevention as well.

RUTH TIMMINS:

Yeah, that is so true, it’s a holistic approach and patient-centred approach and resident centred approach. And as you say, involving the whole team and the families in it.

FLEUR TREZISE:

Absolutely, yeah.

RUTH TIMMINS:

Really true, say what would be your takeaway message or messages today for our listeners then Fleur?

FLEUR TREZISE:

Yeah, a good question. If I think if you're working somewhere anything, we don't have everything we need agitate for it, I think now talk to your organisation, get the guidelines, look at your policy, be really aware, be passionate about it. It really does matter. You know, in some presentations that I do, I talk about my grandmother who died with stage four pressure injury back in the 80s and that I, you know, in on reflection, that's what made me become a nurse. You know, the people that get pressure injuries, someone loves them. It's someone's mum, someone's dad and whatever. And I think the important thing is as a caring professional, you know, we're in this space. We wanna make that end of life or that we want to make it a special and as comfortable as we can. And if you've got a pressure injury, it's not special and it's not comfortable. So, I just every time we go and speak to someone that's in our care, every time we walk past them think, are we doing everything we can to stop pressure injury from occurring? Yes. Just be vigilant.

RUTH TIMMINS:

Yeah, thank you so much for your passion today, Fleur. That's really inspirational. Hopefully, there's been some real take-home messages there for our listeners? So, thanks once again and thanks to our listeners for joining us today. Don't forget to check out the webinar with Fleur and also the podcast resources attached. So thanks again, by for now.

FLEUR TREZISE:

Thanks so much.

SPEAKER:

A single pressure injury in residential aged care is likely to cost you over $16,761 to treat. (1) Incontinence associated dermatitis contributes to pressure injury risk. Protect your residents with the pressure skin care range guarding intact and damaged skin from irritation caused by incontinence and other bodily fluids. It's easy to apply, use and remove and is pH balanced. There is a new way to help strengthen your pressure injury prevention protocols. (2) Find the perfect fit for pressure injury prevention. Contact your local Smith and Nephew representative or email us at profEd.ANZ@smith-nephew.com The information presented in this podcast is for educational purposes only. It is not intended to serve as medical advice. Products listed, outline of care are examples only. Product selection and management should always be based on comprehensive clinical assessment. For detailed product information including the 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.

References:

1 Wilson L, Kapp S, Santamaria N. The direct cost of pressure injuries in an Australian residential aged care setting. Int Wound J. 2019;16:64–70.

2 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.

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Speakers

Fleur Trezise

RN MN (NP)

Nurse Practitioner Wound Management

Director at Wound Solutions Australia

Fleur Trezise was endorsed as a Nurse Practitioner in 2013 and has worked in wound management for over 25 years. She has broad clinical experience in managing both acute and chronic and complex wounds. Fleur is currently working for the Department of Veterans Affairs as a Nursing Advisor for wound management and has recently established her own business, Wound Solutions Australia; providing wound related education, consultation and clinical support to both the public and private sector.

Fleur is a long-term AWMA/Wounds Australia member and has advised on State and National wound bodies, serving as a member on a number of committees/boards relating to wound management and pressure injury prevention. She has presented at local, national and international conferences and provides wound related education to medical, nursing and allied health disciplines. She is passionate about working with people living with wounds to improve their quality of life and enabling others to deliver quality, evidence based wound management.

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