Introduction

Pressure injuries are among the most serious health and patient safety concerns that health care facilities deal with on a daily basis, according to The Joint Commission.¹ The number of patients affected annually is 2.5 million. Hospital-acquired pressure injuries (HAPIs) cost the US health care system between $9.1 and $11.6 billion per year.² Aside from having a significant influence on patients' quality of life, HAPIs are associated with substantial treatment expenses, which are incurred not only by the patient but also by the health care industry.

Each year, more than 17,000 pressure injury lawsuits are filed by or on behalf of individuals with these injuries. Pressure injury is the second most common type of claim after wrongful death, and it is more common than claims for falls or emotional distress combined.² According to the Agency for Healthcare Research and Quality in 2014, the cost of health care for an individual patient and pressure injury ranged from $20,900 to $151,700.² Among patients referred to the hospital from a nursing home, 26.2% have present on admission (POA) pressure injuries, compared with 4.8% of patients admitted from another living arrangement.²

Despite a wide range of prevention methods, HAPIs persist, particularly in the intensive care unit. In critical care units, rates of such injuries have been recorded to range from 2.8% to 53.4%, whereas rates in medical-surgical units have been reported to range from 2.0% to 8.3%.³ According to the Centers for Medicare & Medicaid Services (CMS), “present on admission” means that the pressure injury was present at the moment the order for inpatient admission was placed. Pressure injuries that develop during outpatient contact, such as in the emergency department, during observation, or during outpatient surgery, are included in the definition of the POA term.

Admission to the hospital from a nursing home has been identified as a significant risk factor for pressure injuries because these patients are usually older and hence have a higher prevalence and risk of pressure injuries. This demographic group is more prone than the general population to have chronic diseases that impede their mobility. As a result, common risk factors, such as limited mobility and incontinence, suggest that nursing home residents have a higher prevalence of pressure injuries when compared with people who live in a community setting.⁴ The Joint Commission, which is a global leader in quality improvement, believes the growth of stage 3 and 4 pressure injuries to be a concern.¹

This is a medical emergency that occurs while a patient is in the hospital or in a health care facility. In 2008, the CMS declared that it would no longer pay for any additional costs associated with HAPIs (then referred to as pressure ulcers).¹ A higher risk of pressure injury exists among high-risk populations, such as the older adults and people with chronic diseases, as a result of the use of medical devices, as well as the presence of hemodynamic instability and the use of drugs such as vasoactive agents. A head-to-toe skin examination must be performed on all patients on admission by health care personnel to prevent POA pressure injuries from being falsely reported as HAPIs.¹

Prevention Methods in Reducing HAPIs

Several studies have found that collaboration among health care professionals can reduce the frequency of pressure injuries.⁵ In addition, the methods described in the following subsections have been found useful to prevent HAPIs.

Prevention for the at-Risk Patient

Preventing and identifying pressure injuries as soon as they occur are critical to achieve better outcomes when treating skin injuries. Identify current pressure injuries and other chronic contributing factors by using a comprehensive risk assessment tool. This tool should incorporate the identification of existing pressure injuries and other chronic contributing factors. Repeat the risk assessment on a regular basis, and make changes to the care plan as necessary in response to the findings of the risk assessment. It's important to remember that individuals who have already experienced one pressure injury are at a higher risk of experiencing another.

Nutritional Management

Every patient should undergo a risk assessment using a credible screening instrument. Patients in hospitals are at the greatest risk of malnutrition, according to the World Health Organization. Patients who are at risk for pressure damage should always be referred to a trained dietitian or nutritionist for further evaluation. Weight and oral, enteral, and parenteral intake should be monitored on a regular basis to identify and correct nutritional deficits. In patients who have nutritional deficits, extra nutritional supplements such as a high-potency multivitamin, arginine drink boxes or powders, and protein supplements (puddings, ice cream, powders, and meals) may be recommended to aid in wound healing as needed.

Skin Care

The importance of good skin care cannot be overstated in the maintenance and management of skin health and integrity. Moreover, good skin care is important in the monitoring and assessment of skin. On admission, as well as on a daily basis, examine and evaluate the skin from head to toe. Particular attention should be paid to pressure points and the skin underlying any medical devices. When evaluating skin, always take skin tones into consideration; pressure injuries on darker skin tones will not appear the same as pressure injuries on lighter skin tones. Take your time and use good lighting. When it comes to protecting the pH of the skin and preventing maceration, consistent incontinence care is essential.

Body Positioning and Mobility

Patients should not be placed on bony prominences or on any pressure injury that has occurred or is currently occurring, according to nursing guidelines. Immobility is a significant risk factor for the development of pressure injuries, but other factors to consider include age, poor health, paralysis, sedation, and coma. Use wedges, pillows, positioners, protectors, and foams to support body positioning. Every two hours, as needed or as tolerated, turning and repositioning are recommended. Consider the use of pressure redistribution support surfaces and high-end wheelchair cushions to alleviate pressure points. Equipment should always be selected in accordance with the patient's body weight, body size, and state of immobility to guarantee that the equipment is appropriate for preventing further pressure and/or shear.

Guided Clinical Workflows

Documentation not only serves as “evidence” of treatment but also functions as a means of reporting wound progress and healing outcomes. It is possible to optimize documentation standards through the use of systematic and customized clinical workflows that help guide the clinician throughout the wound care assessment and documentation processes and provide consistency across the wound care continuum.

Conclusion

Continuous monitoring and leadership support will ensure the greatest possible outcomes for both patients and the overall collaborative spirit in the facility, according to researchers. When it comes to implementation of a pressure injury prevention program, effective communication among team members is essential. As a result of increased staff education, personnel will be better able to detect and document POA pressure injuries and thus reduce the likelihood that these injuries will be wrongly classified as HAPIs.

References

1. The Joint Commission. Quick safety 25: preventing pressure injuries. Accessed December 16, 2021. https://www.jointcommission.org/resources/news-and-multimedia/newslette…
2. Preventing pressure ulcers in hospitals. Rockville, MD: Agency for Healthcare Research and Quality; 2014. Accessed December 16, 2021. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressure…
3. Pittman J, Beeson T, Dillon J, Yang Z, Cuddigan J. Hospital-acquired pressure injuries in critical and progressive care: avoidable versus unavoidable. Am J Crit Care. 2019;28(5):338–350. doi:10.4037/ajcc2019264
4. Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Adv Wound Care. 1999;12(1):22-30.
5. Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Accessed December 16, 2021. https://www.ncbi.nlm.nih.gov/books/NBK2650/