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Feature Article

Adapting Pressure ‘Injury’ Prevention Programs for Use in the Outpatient Clinic

Wound care facilities can borrow specific inpatient strategies when caring for patients who’ve been recently discharged from the hospital. This article will focus on the pediatric population.

Pressure ulcers, now referred to as pressure “injuries” by the National Pressure Ulcer Advisory Panel (NPUAP), are defined as a “localized injury to the skin and/or underlying tissue, usually over a bony prominence, or related to a medical or other device” and are considered generally preventable.1 Pressure “injuries” are costly and may require a stay in the hospital. Additionally, patients may develop serious problems such as infection and scarring. Many healthcare systems have evidence-based practices in place that focus on prevention of pressure injuries.2 Although published studies have discussed effective prevention programs for inpatient settings (eg, hospitals, long-term care facilities), few describe their application to the outpatient setting, such as the wound care clinic.3 Additionally, around-the-clock assessment and interventions for pressure injury prevention are prevalent in the hospital setting. However, clinicians in the outpatient setting have limited time to assess for risk and may only have access to limited resources to help these patients. Preventing pressure injuries begins with an accurate assessment of and treating of at-risk patients. Wound clinic providers should focus on identifying vulnerable patients and individualizing interventions for those at greatest risk for pressure injuries.4 This article will discuss strategies that outpatient wound care clinicians can consider when providing care to patients who are at risk for further pressure injury based on successes experienced at a hospital-based outpatient department. A particular focus will be placed on the care of the pediatric population. 

‘Championing’ for Skin Care 

At Children’s Hospital of Wisconsin in Milwaukee, a pressure ulcer prevention (PUP) program was initiated in 2009 in the facility’s pediatric ICU (PICU) in response to a concomitant increase in the incidence of pressure injuries as the number and complexity of patients who were at risk for skin breakdown increased throughout the hospital. After the success experienced in the PICU, a comprehensive program was created to improve patient outcomes hospital-wide. While this program of care was initially launched for inpatient settings, it’s adaptable to outpatient settings, including wound care clinics, in the opinion of the authors. Based on a clinical nurse champion model that identifies at least one nurse on every inpatient unit as a “skin champion” and a member of the hospital’s PUP team, the goal of the program is to promote improvements in skin care through proper assessment and treatment protocols that should be implemented into any care setting. Additionally, as members of the PUP team the nurses who participate in this initiative receive monthly educational in-services from the facility’s wound and skin care clinical nurse specialist on topics including proper skin assessment, pressure injury staging and assessment, and interventions for prevention and treatment of pressure injuries. These nurses also serve as resources for the clinical staff members on their respective units. Their time and education is supported through the quality and safety department within the hospital. The use of this model of unit-specific skin champions and the hospital-wide PUP team resulted in a 40% decrease in deep tissue, Stage III, Stage IV, and unstageable pressure ulcers, as well as a significant improvement in nurses’ knowledge of wound care. This hospital-wide team continues to refine its approach to decreasing pressure injuries and providing the best, safest care while continuing to measure outcomes. A measureable outcome goal continues to decrease pressure injuries and maintain sustainability of practice.

The skin champion model is guided by principles developed to identify the responsibility, accountability, and authority for the team. Skin champion responsibilities include identifying interventions for patient risk areas related to mobility/activity, moisture, and friction/shear. Bundle elements were incorporated to decrease a patient’s risk, which include moisture management, bed surface, repositioning frequency, skin assessment frequency, and device rotation. These bundle elements have been integrated into the electronic health record. Standardized care plans were created for Stage I and Stage II pressure injuries and diaper dermatitis, which were individualized to each patient. Specific strategies involve the collaboration of the skin champion and the clinical nurse performing skin assessments, weekly face-to-face meetings, and peer evaluation of documentation. Signs on the inpatient room door, labeled “Know More By The Door,” were created to serve as reminders for staff members to assist in pressure injury reduction. Bedside “huddles” are called if there is a concern about a skin injury. Patient care plans are reviewed on at least a daily basis to address new pressure injuries and monthly meetings are held with all skin champions. 

Protocol for the Outpatient Setting

Providers in outpatient settings may have more opportunities for patient follow up, which should mean an increased opportunity for education and reinforcing needed interventions to prevent skin breakdown.5 Using the basis of the discussed program as a guideline, each clinic visit should start with a thorough patient history, including a discussion with the caregiver, if applicable. This can help the clinician understand the patients’ daily routines and nutrition habits, which, in turn, can help identify risk factors. A full head-to-toe skin assessment should follow the thorough history. A comprehensive history and assessment are critical to the plan of care during the patient’s first visit and a comparable history and assessment should be given during subsequent visits. 

The aforementioned bundle elements can also be adapted and used to discuss risk and individualized pressure injury-prevention interventions with patients. The quality of a patient’s skin may reveal a difference when comparing the skin in the inpatient setting and the outpatient setting. Skin may be less stressed once the patient is discharged from the hospital, but risks can also change. For example, a patient may have spent most of his/her time in bed while in the hospital, but is now spending more time sitting upright in a chair, which places increased pressure on different bony prominences, especially if the chair does not have a pressure-redistribution surface. 

Patients living with chronic medical conditions may be seen frequently in the outpatient setting, but when they’ve required an inpatient stay for an acute medical condition the focus area may change. For instance, when patients are inpatients, their skin is said to be more “stressed.” Areas that may not be of concern while the patient is at home (eg, sacrum, occiput) may become focus areas of risk as an inpatient. Also, if patients are living with chronic wounds, the wounds may be stable or improving at home, but can worsen, or healing can slow down, while in the hospital.

A shared collaboration between the inpatient medical team as well as the outpatient team can best serve the patient for decreased pressure injury risk. Collaboration of all team members, including nursing, medical staff, rehabilitation, dietary, physical and occupational therapy, case managers, and social workers, can help provide patients with enough resources to decrease risk of pressure injuries. The following information discusses specific areas to address when working to decrease a patient’s pressure injury risk:

Assessment of skin and pressure injury risk

In the hospital, the patient should be assessed at least daily for pressure injury risk. Likewise, the patient should be assessed for pressure injury risk at each clinic visit. If a patient is identified as “at risk,” a full skin assessment should be completed at each clinic visit. Patients and caregivers should be taught to assess for areas of erythema on the skin that do not resolve within 30 minutes. If there are areas of concern, patients and caregivers should have a resource person to call to discuss these concerns. A skin champion in a clinic would be a team member who could address these issues and offer interventions. Education also becomes a key component of pressure injury prevention. Offering patients and caregivers literature on prevention of skin breakdown helps engage patients in their care and allows them to participate in the full skin assessment during a clinic visit. Door signs that include tip sheets on pressure injury prevention and other care protocols can serve as important reminders. Signs can also serve a purpose in waiting rooms and common clinic areas where they can be easily viewed by patients and family members. 

Moisture management

Patients and caregivers should be taught the importance of keeping skin dry and cleansing the skin properly as soon as possible after incontinence. Patients should be taught to use absorbent products, if incontinent, or external collection devices, if applicable.1 Education can also be provided on the importance of moisturizing dry skin and application of a moisture barrier to any skin at risk of moisture exposure. 

Repositioning

Patients and caregivers can be taught to use pillows, towels, and blankets to help offload pressure to bony prominences.1 Positioning devices such as wedges or fluidized positioners that may have been utilized in the inpatient setting could be sent home with patients. Those at risk should be taught to reposition or turn at least every two hours while in bed and at least every hour while in a chair. If they’re able, patients can be taught to use their arms to lift themselves up in a chair or move their chair back or forward, if electronic. If applicable, physical or occupational therapists can be consulted to help teach proper transfer techniques to avoid shear and friction associated with dragging the skin across the bed or chair when repositioning or transferring.1

Bed and chair surface 

If the patient is confined to a wheelchair, the surface of this chair can be assessed during a clinic visit. Patients should be assessed for the need of a pressure-redistribution surface in the home. Other members of the team, such as a case manager or social worker, can assist to help determine whether the patient’s home has the ability to fit this type of surface as well as whether or not financial resources are needed. 

Device rotation

Medical devices pose some of the biggest risks for pressure injuries, especially if the device is unable to be moved or repositioned.5 Patients and caregivers should be educated on the risks associated with medical devices (eg, oxygen tubing, Foley catheter tubing, pulse oximeters, splints/braces), including padding and repositioning of these devices and appropriate skin assessment.  

Resources in the community

Another differing characteristic of wound care clinics compared to the inpatient setting is accessibility of resources. In the inpatient setting, supplies are usually accessible from the materials department. However, wound care clinicians must be able to help the patient with resource allocation of supplies, especially if they are not covered by insurance. It’s important that clinicians know the accessibility of community resources for cost effectiveness of obtaining supplies, as well as alternatives or creative solutions for supplies that can assist in reducing pressure injury risk.3 For example, the clinician may recommend using an inexpensive tube sock to help hold a dressing in place instead of mesh gauze that may not be accessible or financially affordable for the patient. 

Conclusion

Inpatient and outpatient settings alike are central to preventing pressure injuries and ultimately affecting patient outcomes. Providers in outpatient settings may have more opportunity for follow up, which should mean an increased opportunity for education and reinforcing needed interventions to prevent skin breakdown. Although aspects of each setting may differ, programs that focus on preventing pressure injuries are essential to achieving the best outcomes and preventing patient harm. 

Rebekah Barrette is the wound and skin care clinical nurse specialist at Children’s Hospital of Wisconsin. Melissa R. Bennetts is a doctor of nursing who’s certified as an acute care pediatric nurse practitioner working in critical care for the Medical College of Wisconsin at Children’s Hospital. Both clinicians also serve as co-leaders of the pressure ulcer prevention team at Children’s Hospital.

References

1. National Pressure Ulcer Advisory Panel (NPUAP) Announces a Change in Terminology from Pressure Ulcer to Pressure Injury and Updates the Stages of Pressure Injury. NPUAP. Accessed online: www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury

2. Creehan S, Cuddigan J, Gonzales D, et al. The VCU pressure ulcer summit-developing centers of pressure ulcer prevention excellence: a framework for sustainability. J Wound Ostomy Continence Nurs. 2016;43(2):121-8. 

3. Bergquist-Beringer S, Daley CM. Adapting pressure ulcer prevention for use in home health care. J Wound Ostomy Continence Nurs. 2011;38(2):145-54. 

4. Rodriguez M. Appropriate treatment of pediatric pressure ulcers among the special needs population in the outpatient clinic: an introduction. TWC. 2016;10(5):12-14.

5. Pittman J, Beeson T, Kitterman J, Lancaster S, Shelly A. Medical device-related hospital-acquired pressure ulcers: development of an evidence-based position statement. J Wound Ostomy Continence Nurs. 2015;42(2):151-4; quiz E1-2.

Feature Article
Rebekah Barrette, MS, RN, PCNS-BC, WCC & Melissa R. Bennetts, DNP, RN, CPNP-AC
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