Pressure Injury prevention in the ICU

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Tune in to hear the discussion with expert Tracy Nowicki as she takes us through  the challenges faced in the Intensive Care Unit when considering  pressure injury prevention ,specifically  in the COVID-19 environment.

You'll  hear about the key considerations when implementing a PIP protocol and practical tips for clinical practice. The website may contain information and discussion (including the promotion of) methods, procedures or products that may not be available in certain countries or regions, or may be available under various other trade or service marks, names or brands.

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Welcome to Smith and Nephew's Closer to Zero podcast, bi-monthly podcasts with leading experts in wound care hosted by Smith and Nephew helping health care professionals in reducing the human and economic costs of wounds. 00:00:00


Hello, I'm Ruth Timmins and welcome to our podcast today discussing pressure injury prevention in the ICU with our very special guest, Tracy Nowicki from Queensland. Tracy is currently employed within a major metropolitan hospital in Queensland Health as a clinical nurse consultant and a lot of her role includes pressure injury prevention and skin integrity. So, we're really pleased you are able to join us today Tracy. 00:00:14


Thank you. Thanks, Ruth. I'm so excited to be here. 00:00:38


Yes, it's coming up to Stop Pressure Injury day in November, and that's a world international sort of campaign. And we've got a webinar coming up with you on this topic as well. So, if our listeners want some more detail and a really good educational webinar that's coming up on the 18th of November, but we thought today we just have a chance to discuss some of the challenges, perhaps in the ICU when considering pressure injury prevention. So, what would be your thoughts on that Tracy? 00:00:40


OK, so challenges in ICU. Well, that's kind of like we could probably spend two days talking about all the challenges. But just some of the really basic ones are one of the things I found really challenging is there's so many staff, for a 27 bed unit, we've got around about 200 staff. So that's four times what you'd normally see in the wards. I just want to do staff training and standardised practice is a challenge in itself. The other challenge is early mobilisation is getting these people up when they're really quite unwell and then a lot of patients can't be moved because they're hemodynamically so unstable.

The drugs that we use to keep them alive actually have complications as well. Some of these are on inotropes we're using them to keep their body alive by taking the blood out of the extremities and feeding the vital organs and this can cause skin damage. But keeping them alive. So the other challenge is things are changing rapidly and there's a lot of equipment to learn how to use. So it's getting them to use that equipment at a high end. And sometimes these patients, as they become more and more unwell, they become more and more difficult to move. So doing skin inspection is quite a challenge and then trying to get those preventative dressings looking underneath them, that's also challenging because of the difficulties of moving them.

Length of stay. We know that the longer they're in intensive care, statistically speaking, the more risk that could happen to them. And we've now got data to show us that the longer you are mechanically ventilated, the higher the risk of a pressure injury. (1) So, these are not just mechanical ventilation is a risk. We now have data showing that if you're ventilated more than six hours, you've got a higher risk of developing a pressure injury. So that's a challenge. 00:01:13


There are many, many challenges that you've listed and as you say, there’s probably a lot more as well. But what are the specific, perhaps pressure injury risk factors when assessing patients in the ICU Tracy? 00:03:14


So, I think we can’t not mention the whole medical device problem in ICU.(1) So, we know that there's about 68 different types of medical devices. And typically, when we look at our medical device pressure injury data, it's mostly on that 30 to 70% or on the head and neck. And this is all the essential devices for respiratory equipment. So and nasogastric feeds and things like that. So, you can't just take them away. And you can't just loosen them either if you loosen an ET tube, you're going to have a very annoyed doctor.

So trying to protect the skin underneath. You don't always have that choice because the device has to be so tightly secured. You don't always have the choice of loosening the device. You don't always have the choice to be able to take the device off because it's a life sustaining device. So that's a huge risk factor. We know that co-morbidities, these people are really sick. That's why they're in intensive care. The other risk factor that's really interesting now is the timing of the surgery. So, we know that, for example, one that's had a lot of researchers fractured NOFs. So, their outcomes are vastly improved if we can repair that fractured NOF in the first 24 hours as opposed to the next 48 hours.

And that includes also the risk of pressure injuries. And I know in the hospital that I work in, we make sure that we get them straight on to hover mats or lateral transfer devices. So, we're not shear and frictioning their skin. We make sure before they go to theatre, they got those preventative dressings on. We know that the earlier we get people moving, the earlier we feed them. It reduces their risk factors and sometimes in intensive care, you don't have choices with that. Sometimes the patient's too unwell to go to theatre. So the timing of surgery has a big impact on the risk of pressure injuries.

The number of comorbidities will influence whether they'll go into intensive care, but it'll also influence whether they are likely to develop a pressure injury. And then there are all sorts of things, I really like the American paper on avoidable versus unavoidable, and it looks into septic shock. So there's a lot of patients in intensive care with septic shock, and we think of the impact that shock has on the body. But we're now starting to look at pressure injuries at a microcellular level. And what I found absolutely fascinating when we're talking about the impact of this infection on the person, they're actually saying that these bad bugs are actually eating the food and the oxygen that we would use for the skin to survive and the body to survive.

So, we've got this competitive like it's kind of like the bad cop and good cop where these bad guys are coming in and stealing all these essential things that we need to survive. So, I found that whole competitive microorganism behaviour really, really interesting. And one of the other ways we keep people alive is by fluid resuscitation. But that fluid resuscitation but that could also cause fluid shift. And then you get that hypoalbuminemia which then creates more fluid shifts. And then when you've got a oedematous limbs, they're heavier, they're at high risk of pressure injury. They're cold because they're poorly perfused. And these will increase the risk of pressure injuries. And then the other risk factors that we're now seeing, which is the new modern intensive care is the introduction of ECMO.

Where you've got external cardiac and ventilation through mechanical means. So basically you put garden hoses into their femoral and you artificially pump blood and oxygen through their body. And to do this means the patient is really, really sick and people now survive where they would have died. We first saw this when H1N1 came in and ECMO was now becoming a standard practice. Now there's a lot of medical devices with these people. Some of these people are so hemodynamically unstable you can't even lift their head to brush their teeth, let alone do a full body turn. And then the other thing that we're seeing in intensive care that we're just starting to understand is skin failure.

So, while we we've got a lot of knowledge on organ failure around our kidneys, heart, lung, brain. We haven't really understood skin and skin fails as these other organs start to fail as well. So it's probably a talk for another day. But to understand skin failure, it comes into acute, chronic and end-stage. So often in intensive care, we get patients that are already in chronic skin failure and then because of their episode of while they're in intensive care. They then exacerbate into acute skin failure and then may end up going into end-stage skin failure. So that is a really, really interesting phenomenon where the skin is our largest organ of all is dying like the rest of the body, but we tend to think of it as a pressure injury.

When it's actually not, it's a skin dying as the organ itself is failing. And that is just the tip of the iceberg of talking about risk factors. If you look at the webinar, if you get to watch the webinar that we also do. I also mention about proning. So, proning for some people is new, and some people are a little bit more experienced. There's a lot of things to think about when you're proning a patient to prevent pressure injuries. 00:03:29


So you mentioned proning there, Tracy, and we know that's been quite a common way to nurse patients in the ICU hasn't it with COVID? So, it's going to bring in how has COVID affected the ICU approach to pressure injury prevention? What do you say? 00:09:17


OK. So, you would really need to watch the webinar that we do on COVID and intensive care to really understand this fully. But the interesting thing when we think about COVID, we hear a lot about clotting. And now that we're starting to understand COVID, we understand that these thromboembolic episodes are actually causing a hyper- coagulation under the skin right at the epidermis and dermis level. (2)So there's like these little micro clots. So while they're happening in the lungs, they're actually happening in the skin as well. So these little clots are flying off under the skin and you see this. It's almost like a lace where it kind of bleeds with these little embolisms, all under the skin. 00:09:38

So, you'll see some really good images if you watch the webinar on how COVID actually changes the skin and they actually call it the greatest mimicker, it could present as vesicles, urticaria livedo which is almost like a little bleed under the skin. There's lots of ways that COVID would manifest in the skin, but we haven't really seen a lot of that, but there's a lot of research leading to that. 00:10:23

We really need to understand the skin changes because people may be calling it a suspected deep tissue when actually there's no pressure loading in those areas. So, it's basically clotting under the skin. And again, COVID has affected the intensive care because we've had to get good at proning, we've had to get good at using PPE and we've had to get good at setting up intensive cares in non purpose built areas. So when we were first getting ready, you might have a 30-bed intensive care unit, but I think the government was hoping that you could provide a 90-bed intensive care unit.

So, there was a lot of scramble buying and trying. And you might not have the equipment that you were familiar with. We just had to get what we could get. And from an example, you might be familiar with an AIRVO high flow oxygen device. Now I've heard that Victoria bought 5,000 of them and there was only 100 a week coming into the country. So that's sort of just one example trying to get intensive care beds and things. So you've probably got a lot of different models that you weren't used to. The other thing is having to have these people up in the upright position when we try to prevent pressure injuries. The guidelines are very clear on having patients at no higher head of bed than 30, but that's impossible on someone that's dying of respiratory failure or struggling with respiratory failure.

So in summary, it's about understanding the skin changes that COVID can have, understanding that the strategies that we had for avoiding pressure injuries may not be possible in a highly stressed, overrun intensive care. The Americans wrote a paper on that. So they used to talk about avoidable versus unavoidable pressure injuries. But in a COVID environment, the facility may not have enough resources, and that includes trained staff, the right equipment. And we may not be on a turn as much as we like, and the patient is so unwell that they may not be able to be turned. So, I'm sorry, Ruth, that I can't give you a really clear dot-pointed answers because this thing is moving really fast. It's a crazy, complicated topic. It's fascinatingly interesting. And I have to say, particularly for you in New South Wales and Victoria, you've done an amazing job of setting up and preparing. And if you look at our death rate, I think we've done a phenomenal job of keeping our patients and our society safe. So, that's a little bit off the side. So, I'm getting off-topic. 00:10:55


That's fascinating. But you're right, there's been a lot of different approaches, I guess because we've had that sort of new phenomenon of the COVID and how it affects people. But we've also seen some of these awful images of the staff with these facial pressure injuries and skin problems from the PPE. So on that sort of subject. What are your thoughts and considerations for the staff for PPE protecting themselves? 00:13:43


OK, so that's a really good question. Thanks, Ruth. I'm really pleased that we can talk about the staff wellness as well. Initially there was a lot of talk around fit checking with N95s and then we've moved into mandating fit testing. So, we went from having two types of N95 masks to having nine types of N95s. And then we're also bringing in these PAPRs, these purified air these big helmets and things like that.

So, it's very interesting that there's been some studies done, and I have to say it's the boys with the biggest problem on the pressure injuries from PPE. And the research has shown it's because they're not as diligent with their skin hygiene as the girls can be. So the first thing they say is make sure you're hydrated because a lot of the staff aren't able to go out and particularly when you've got all this PPE, on you can't go out and have a drink when you like. And even I've seen overseas where they can't even go the toilet. Some were actually wearing incontinence pads because they're in those overall cover all things. And so people aren't drinking enough.

So number one of protecting skin is hydration. They're actually saying that you need to cleanse and protect your skin, moisturise skin at least two hours before you come to work. And then it's about that moisturising and then identifying. You see those really fair-skinned Caucasians like you can really see the skin breakdown really quickly. So, in the webinar, I actually talk about all types of PPE, not just masks. So, you've got your hand gel, your hand wash. I even saw people reacting to gloves when we were using gloves more often. We've had allergic reactions to the disposable gowns so it can depend on the chemicals and things like that.

So let's all say it's a big topic in itself when we just think about what you mentioned about seeing these terrible facial injuries from chronically wearing PPE. It's about putting those preventative dressings on early and the literature is very clear. Once that skin is damaged, it's really hard for to repair. And just going on two days off, as soon as you put that PPE back on, it will break down again. So you need to put a thin tape over the bridge of the nose. A lot of people actually experienced the damage on their cheeks.

And whether you need to move into a more advanced dressing. And if you look at that webinar, I've got some good examples of how to put preventative dressings under medical devices. So, the principles are the same as what we've talked about in your previous Smith and Nephew webinars on medical devices it's all about early intervention, early detection and understanding. Don't wait until you're in pain because once there's pain, there's already damage. 00:14:14


And it's really important, isn't it? Because the staff are obviously key and need to be looked after as well. So just looking at the bigger picture in the ICU, then Tracy  to see what would be just a few of the key considerations in implementing a pressure injury prevention protocol, would you say? 00:17:13


So, I've got two really clear messages on this one. And the first one is to always where possible be in preventative management rather than reactive management, not waiting until there's a skin problem, the same as what we just talked about for the staff. Once the skin's damage is very difficult. And the other one I haven't read any literature on this, but I really feel quite strongly about this is trying to get your intensive care unit to link up with theatre. And so whatever they’re doing, whatever the anaesthetic techs are doing and the anaesthetist are doing, ICU is doing that as well.

So you often see it could be a line and then theatre sets up one thing and then ICU goes and take it all down and sets up another thing. And I'll use a simple example of the ET tapes are tied and the prevention under the ET Tapes. It's really important to prepare that skin because we tried all sorts of things, we tried putting like foam under the tapes. And what we found was the drool and  saliva attracts into the fine and causes this moisture-associated skin damage. So what we found is preparing the skin with like a film is really beneficial, but it's not going to work if intensive care is doing it and theatre isn't because that damage will happen really early. So, you need to get all your team together. So, I'm trying to do is have monthly meetings with my key leaders in theatre, recovery and ICU and try and get them to agree that because we've got the one patient we're all caring for, that person's journey is consistent. 00:17:35

So, the first message is prevention. The second is linking ICU and theatre. That's something that doesn't cost you any money. It just means that you're thinking smart. The other thing is looking at what is your standard. So, I would say your standard starting with having a multi-disciplinary team, pressure injury prevention is not a nursing problem. You need to make sure that everybody agrees that the dieticians kind of see everyone in intensive care. And I found the biggest success is when that team works together really closely.

So, for example, three times a week, they all get together and they do a round patient to patient rather than the OT does it this way, the physio does it this way, and the doctor expects it that way. If you all get together and talk and you all agree, what's the best possible outcome for this person. You get real. I've seen pressure injuries reduced dramatically using that method. And one of the other things that I think that we're not good at is using the bed to its full potential. So, I talk about prescribing beds and in intensive care hopefully you've all got really good beds and I'm talking about intensive care beds, not ward beds dressed up to look like intensive care beds.

And using that bed so that you can help the patient to get out of bed using their mobility frame using small body shifts. So, I'm sure all of you at the moment are wiggling because we're only up to about 20 minutes of podcasting and you're all wiggling. That's what a healthy person does. And when the patient is paralysed and sedated, they can't wiggle, so you use the bed to wiggle for them. So, you're just slightly adjusting the head elevation, you're slightly adjusting the knee elevation, and these intensive care beds will actually rotate and turn because you healthy people, you move about every 11.6 minutes. And that's what you need to mimic for your patient. 00:19:14

And then education again, I really want to thank you, Ruth. I love your education sessions. I've learned so much myself from them. I'm so impressed with the calibre and the variety of speakers that you get. And I think the word for education is you don't tick the box that it's done. It's got to be ongoing. And I say to my staff, I want you to be hungry. There's so much to learn. And if you're really smart, you'll retain 10%. So you've got to be added all the time. Listen to the podcast. Watch the webinar. There's never been a greater time for education. This COVID made all this accessible for us before we spend all this money on conferences, and now we can just click a button and we're all together. 00:21:16

I probably think that's pretty well. I'm just talking about education. Don't ever think you've won the battle on staging because worldwide, I mean, I've been to a staging conference in America. There's 460 people talking about staging for two days and at the end of it everybody still couldn't agree on staging. So, staging is a challenge and staging impacts how you diagnose that injury and how you treat that injury and how you respond to that injury. So, it's really important that you've got a team that confirms what you're seeing. So, in my hospital, we'll go and check it, the wound service will check it.

You've got a quality person in intensive care checking it. It's really important that we all agree and we get the egos out of it and we make sure the patient is getting the best possible journey from  us all talking together on something as basic as what do you reckon the stage is? Because particularly in intensive care, you've got diabetic foot ulcers, you've got your venous leg ulcers, versus arterial leg ulcers. You've got your MARSIS and your MARIS you've got all that crazy stuff going on. There's lots of skin damage. So we need to be talking together about what's the best way forward with this. So, that's a pretty well as condensed as I can make an incredibly complex subject. 00:21:59


It is a big topic and it is difficult and the podcast has to get all the information over I know. So thanks for that, Tracy. Just to finish up, then what would be a couple of your key take-home messages today for our listeners? 00:23:17


Don't ever forget the person. They might be paralysed and sedated, but that person comes with a family and that the way you smile, the way you talk to them is remembered for generation after generation. So, I really appreciate the work that you intensive care nurses do, and it's really important that, Australia is doing an amazing job. The grass isn't greener on the other side, the world is looking at how we're getting such great results, and part of it is these opportunities for education.

So, again, the staging needs to be ongoing, education, prevention doing that early, not responding to injury but talking together as a team. And don't ever forget, your most junior member of the team is the patient. Listen to them, when I say the heels are itchy or the bottom sore that means you go looking. And it's very easy in a very complicated intensive care environment to get distracted by  all those other things and everybody's competing to what is the most important. I understand about hemodynamic, stabilising an incredibly potent drugs that you use and all those sorts of things, but trying to keep early skin inspection and risk assessment well documented and communicated amongst your team is absolutely essential for that person's journey.

And in my webinar, I talk about can you imagine surviving COVID and being in intensive care for 40 -60 days and then dying of a pressure injury? And many patients, long after their intensive care visit, will talk, they won't be talking about the near-death experience. They're talking about the chronic pain that they live with from their pressure injuries. 00:23:33


It's so important, isn't it Tracy? And thank you for sharing your knowledge and expertise with us today. And as you said to our listeners, don't forget that there will be resources attached to this podcast and we will be having the full webinar on the 18th of November with Tracy, where she's presenting a lot more information for us on this topic. So, don't forget to join us for then. And we look forward to you logging on and you can watch it on demand as well. So thanks again, Tracy. We've really enjoyed having you our podcast today. So we really appreciate your time. Thank you so much. 00:25:22


Thanks, Ruth. I really I really respect and appreciate what you've done to pull all this together, and it's so fantastic. There's so much activity happening for Stop Pressure Injury  day. It's fantastic. 00:25:57


Yeah, it is, so thank you again and take care bye for now. 00:26:09


Pressure injuries are a costly burden that causes immense patient discomfort and potentially longer hospital stays. Most can be prevented. Enhance your prevention strategy with ALLEVYN™ LIFE   shown to reduce pressure injury development by 71% (3)and reduce costs by 69% compared to standard care.(4) For more information, contact your local Smith and Nephew representative or email us at 00:26:15


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. The detailed product information including indications for use, contraindications, precautions and warnings. Please consult the products the applicable instructions for use prior to use. Helping you get close to zero pressure injury incidence. 00:26:44

References :

1.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

2. Black, J., Cuddigan, J. & the members of the National Pressure Injury Advisory Panel Board of Directors. (2020). Skin manifestations with COVID-19: The purple skin and toes that you are seeing may not be deep tissue pressure injury. An NPIAP White Paper.

3. 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

4. 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

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Tracy Nowicki

Clinical Nurse Consultant

Co-Ordinator Qld Bariatric Interest Group

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.

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