Pressure Injury Prevention for Critically Ill Adults

The critically ill adult patient is at increased risk of developing painful pressure injuries (1, 2). For hospitalised patients, independent of their diagnosis, pressure injuries increase length of stay and contribute to increased healthcare costs (3). Of great importance is that pressure injuries significantly impact health-related quality of life for patients (4). The Australian Commission on Safety and Quality in Healthcare have created a national standard to focus healthcare clinicians and organisations on this important preventable adverse event (5).

A multidisciplinary approach is required to identify and prevent pressure injuries, from both intrinsic and extrinsic causes. Predicting and preventing pressure injury will improve the quality of care and reduce the financial impact on the healthcare system.

The Pressure injury prevention for critically ill adults guideline is based on the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury (2011) [Pan Pacific CPG ] (2). The scope of this guideline is prevention of pressure injury in critically ill patients and does not include treatment of pressure injuries. Clinicians should refer to Pan Pacific CPG (2011) for further guidance and clarification of recommendations and pathophysiology of pressure injury.

Pressure injury prevention for critically ill adults

Resources

Health questions at focus of clinical practice

The clinical questions underpinning this guideline include:

  • what is the prevalence and incidence of pressure injuries in the adult intensive care unit?
  • what are the risk factors associated with pressure injuries in the adult intensive care unit?
  • what prevention and interventions are required to reduce pressure injury incidence in the adult intensive care unit?

Scope

This guideline is provided so that acute care facilities can develop local practices to support the accurate identification, assessment and associated interventions to reduce the incidence of pressure injuries in critically ill adults in the intensive care environment (individuals aged older than 18). It does not include recommendations regarding assessment, staging of pressure injuries or their associated management. Clinicians should refer the Pan Pacific CPG (2011) for further details (2).

Target clinicians

This guideline is aimed at clinicians who care for critically ill adults across acute care hospitals in NSW . Specifically, it refers to nursing staff as this clinical practice falls within their scope of practice. Medical officers were consulted and included during consensus development.

For complete details on guideline development processes please refer to the guideline document.

Why is pressure injury prevention important in critically ill adults?

Pressure ulcers or injuries are a common consequence of critical illness and have a significant impact on patient recovery (2, 25). Because many critically ill adults have multiple risk factors eliminating pressure injuries can be difficult. However because the costs to the patient and the healthcare system are significant (3) clinicians and managers must implement programs to reduce the incidence and severity of pressure injuries. This section will briefly describe the:

  • pathophysiology of pressure injury
  • risk factors  for critically ill adults
  • pressure injury incidence and prevalence.

Readers are directed to the Pan Pacific CPG (2011) (2) for a more comprehensive overview.

Pathophysiology of pressure injury

Traditionally, pressure injuries have been attributed to compression of tissue between bony prominences and support surfaces. Current consensus however is that pressure injury development is complex and the result of a number of intrinsic and extrinsic factors. Current research indicates that the important extrinsic factors are pressure, shear and friction forces as well as the micro climate of the skin (6).

When patients are in a bed or chair different mechanical forces will be applied to tissues; these forces include pressure, shear and friction. Pressure injuries occur where these forces impair and/or damage microcirculation leading to tissue hypoxia and necrosis (2, 7).

Direct pressure

A direct pressure injury occurs when tissue is compressed between bone and a hard surface. Where this compression exceeds capillary pressure tissue ischemia and cellular hypoxia will occur and if the pressure is not removed tissue damage and ultimately necrosis can occur (8, 9) (figure 1). Because patient risk factors vary the time to pressure injury may be as little as 30 minutes and up to four hours (10). Prevention of pressure injuries revolves around positioning patients to minimise and if possible relieve this pressure.

 Tissue distortion due to pressure

Figure 1: Tissue distortion due to pressure. Taken from Takahashi et al, 2010 (9). Used with permission.

Bending of the tissue lines in B (figure 1) shows that when external pressure is applied over a bony prominence, compressive, shear (distorting) and tensile (stretching) stresses occur.

Shear injuries

Shear injuries occur because the patient’s position allows the skeleton to slide, distorting tissue and damaging cells. Prevention of shear injury involves positioning the patient so that they are less likely to slide. Areas susceptible to these injuries include the heels and sacrum (2).

Friction injuries

Friction injuries occur because the patient’s skin is dragged across a surface burning the skin and damaging the stratum corneum (2, 7). To prevent these injuries clinicians should protect the skin by lifting patients and using protective dressings.

Micro climate

Ensuring a favourable microclimate is now seen as an integral component of pressure injury prevention (11). The microclimate includes the skin surface or tissue temperature and the humidity or skin surface moisture at the body-support surface interface (30). Risk factors that contribute to increased skin moisture include perspiration, incontinence or wound/fistula drainage. Excess skin moisture and relative high humidity can add to skin damage due to pressure, shear and friction. Treatment options include:

  1. management of incontinence
  2. use of barrier creams
  3. temperature control
  4. air-fluidised mattresses (2, 11).

Pressure injury risk factors

Figure 3: Factors associated with pressure injuries (adapted from Pan Pacific CPG (2011)(2))

Risk factors for critically ill adults

The evidence base for determining pressure injury risk factors among critically ill adults is mixed with few high quality studies. In most studies it is difficult to separate the effects of critical illness and treatment from pre-existing risk factors (see table 1). It is clear however that most, if not all, critically ill adults will be at significant risk of developing a pressure injury, especially patients where delivery of oxygen to peripheral tissues is limited. Clinicians should ensure that clinical practices that restrict patient movement, such as spinal immobilisation, should be removed as quickly as possible.

Table 1 Risk factors associated with pressure injury development in critically ill adults

Level of Risk Risk Factor
Highly significant
  • Age (12-17)
  • Length of stay* (12-14, 17-20)
  • Heart failure (13, 16, 17, 21)
  • Serum albumin / Nutrition (15, 17, 22, 23)
  • Incontinence (17, 22, 24)
  • BMI <18 (14, 18, 24)
  • Immobility/less repositioning (21, 23)
  • Infection* (12, 20)
  • Spinal cord injury (14, 17, 25)
Probably significant
  • BMI >35 (13, 25)
  • Vasopressors (13, 14, 21)
Possibly a risk
  • Emergency admission (23)
* interaction with critical illness

For more details please refer to Appendix 3 Risk factors for critically ill adults.

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations.

Pressure injuries incidence and prevalence

The current evidence addressing the epidemiology of pressure injuries in the critically ill adult patient is limited by the poor quality of the literature, with a moderate to high level of bias associated with most studies. Pressure injuries are most prevalent in the lower half of the body including the areas over the sacrum, coccyx, buttocks and lower heels (13, 21, 22, 26). Pressure is concentrated wherever weight-bearing points come in contact with surfaces and it is reported that there is an increased prevalence with bony as opposed to non-bony pressure areas (27). However due to the conjecture on how pressure injuries begin we need to be mindful of more than just bony prominences, especially in the ICU where several invasive adjuncts may be used.

Prevalence of pressure injuries in the critically ill adult in the literature ranged from 4% to 53.4%. The incidence ranged from 12.4% to 18.7% There is a greater incidence of pressure injuries Grade 1–2 than Grade 3–4 (13, 21-23, 28). However, more recently, with the advent of the classification in 2009 (EUPAP) of the suspected deep tissue injury and unstageable pressure injury, two of the more recent studies (13, 27) do report a higher and increasing incidence of these classifications of pressure injuries.

Sacral pressure injury

Figure 2: Sacral pressure injury in elderly patient post spinal immobilisation. Image use by permission (29).

Upper lip pressure injury secondary to commercial ETT holder

Figure 3: Upper lip pressure injury secondary to commercial endotracheal tube holder.

Practice recommendations

SectionRecommendationGrading
Patients and carers
1. Patients, families and careers are informed of the risks, prevention strategies and management of pressure injuries. Development of the pressure injury management plan is to occur in partnership with the patient, family and carers if appropriate.  Consensus
Standard 8            
Assessment
2. Use a pressure injury risk assessment scale in conjunction with a comprehensive visual assessment to determine the patient’s risk of pressure injury and to inform the development of a prevention plan. Consensus
3. The Braden scale is the recommended validated and reliable tool for assessing pressure injury risk in critically ill adults. (30, 31) B
4.

Inspect all of the skin and devices attached to the patient within two hours of admission, at each repositioning and each shift change to identify indications of pressure injury including:

  • for fair skin races – erythema and for darker pigmented skin – persistent blue or purple hue
  • blanching response
  • localised heat
  • oedema
  • induration
  • skin breakdown. ( 2)
C
5.

The skin and mucosa impacted by invasive medical devices (including but not limited to nasogastric tubes, tracheal tubes, urinary catheter, faecal management devices, nasopharyngeal airway and intravascular devices) should be inspected:

  • at the beginning of the shift
  • each time the patient is repositioned or adjusted
  • where applicable when dressings are changed.
Consensus
IIMS
6. Documentation of pressure injury risk assessment scale and visual inspection should occur at a minimum of once each shift. Consensus
7.

All patients are to be regularly assessed for pain, especially in relation to repositioning and in the presence of pressure injuries. If the patient has a pressure injury this should include wound pain assessment. (2)

C
Interventions
8. Implement preventive strategies to protect the patient’s skin as soon as possible following admission or identification of high risk. Consensus
Interventions: Nutrition
9. Conduct nutritional screening and assessment using validated screening and assessment tools appropriate to the population and clinical setting.2 B
10. Ensure individual caloric requirements are met for patients at risk of pressure injury.2 B
Interventions: Support surfaces
11. As a minimum use a high specification reactive (constant low pressure) support foam mattress on beds and trolleys for patients at risk of pressure injuries. No one specific high specification reactive (constant low pressure) support foam mattress is better than another. (2) A
12. Those patients classified as high risk or very high risk of pressure injury should be placed on an active (alternating pressure) support mattress. (2) A
13. Any device used to prevent heel pressure injuries should be selected and fitted appropriately to ensure pressure is adequately offloaded and hyperextension of the Achilles tendon is avoided. Consensus
14. When seated in a chair or wheelchair patients at risk of pressure injury should be placed on the appropriate reactive or active cushion.(2) C
Interventions: Repositioning
15. Unless contraindicated at-risk patients should be repositioned at least every two hours (2, 21, 23, 28, 32, 33) even if on an active or reactive support surface. (2) C
16.

When deciding on the frequency of repositioning and choice of patient position, the clinician should consider:

  • risk or presence of pressure injury
  • skin response
  • comfort/pain
  • cognition
  • ability to move
  • medical condition
  • support surface used. (2, 32, 34, 35)
Consensus
17. Reposition patients to reduce duration and magnitude of pressure over vulnerable areas, including under medical devices, bony prominences and heels. (2, 32, 34) A
18. As a minimum, position patients using 30° lateral inclination alternating from side to side or a 30° inclined recumbent position. (2, 32, 34) C
19. Patients in seated positions should ideally have pressure relief every 30-60 minutes. For specific patient groups (for example patients with spinal cord injuries) this may need to be more frequent. (2, 12)  
Infection prevention
20. Clinicians should undertake a risk assessment to identity the risk of contamination and mucosal or conjunctival splash injuries during pressure injury prevention and management activities. Personal protective equipment including impervious gown or apron; goggles/mask or face shield and gloves must be worn according to this risk assessment. (36) NSW Infection Control Policy PD_2007_036
21. Clinicians must adhere to the Five Moments of Hand Hygiene. (37) NSW Hand Hygiene Policy PD2010_058
22. To reduce the risk of microbial transmission equipment utilised for each patient must be cleaned as per the Australian Guidelines for Prevention of Infection in Healthcare prior to and following use. (38) Australian Guidelines for Prevention of Infection in Healthcare
Workplace health and safety
23. Staff undertaking pressure injury prevention and management activities are to undertake a risk assessment of the intended activity/ies to protect the health and safety of the patient and all staff involved. (39) NSW Work Health and Safety Act 2011
Governance, audit and education
 24. Governance structures and systems are to be in place within each ICU/HDU to support the prevention and management of pressure injuries. (40) Standard 8
 25.

As soon as possible after discovery pressure Injuries are to be reported and entered into the appropriate risk management tool as per the NSW Health Pressure Injury Prevention policy. (40)

NSW Health policy

Standard 8

 26. Equipment and devices are available to implement effective prevention strategies for patients at risk and to manage the patients with existing pressure injuries. (40) Standard 8
 27.

Auditing of pressure injury prevention strategies, including:

  • clinical documentation (i.e. completion of risk assessment tools)
  • implementation of evidence-based pressure injury prevention strategies
  • rate of occurrence of pressure injuries
  • appropriate referral to wound management and allied health
  • quality improvement and education strategies are to be undertaken on a regular basis. (40)
Standard 8
NSW Health Policy
 28.  Education in the prevention, assessment and management of pressure injury should be provided to all health professionals.  C
The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that changes these recommendations.

Grading of recommendations

Grade of recommendation Description
A Body of evidence can be trusted to guide evidence
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation/s but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Consensus Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (41)

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