All of the latest technology is not going to help your patients if their malnourishment is not addressed. This author’s hospital found success with pressure injuries by focusing on the basics and fundamental of care.
The “pressure” is always on for wound care providers to continue decreasing nosocomial injuries. For 30 years, I have witnessed various successful pressure injury/ulcer programs and have seen how education for the clinician and the patient continues to evolve. What works for one institution may not work for another, but the consistent formula is still input = output when it comes to this time-committed clinical effort.
The central questions that I must pose to all those reading this is: Are we becoming dependent on costly advanced technology while forgetting to rely on what the basics of our education tell us to do for our patients? Are we diluting the root cause of success and pacifying the problem? Are we masquerading around with expensive “solutions” that don’t accomplish what we really intend to accomplish because we are not following certain processes? We must remember that in order to know how to best improve a wound, we must fully understand why it exists.
To facilitate a quality-improvement process at our hospital, Natchitoches Regional Medical Center, we were tasked with decreasing the incidence of pressure injuries. It is understood that pressure injuries continue to be a major challenge for hospitals, as there are numerous extrinsic and intrinsic factors that predispose patients to these injuries. Additionally, patients have an increased number of comorbidities. Healthcare costs increase exponentially based on age, patient acuity, and the number of chronic conditions or comorbidities. We reviewed available research, guidelines, and recommendations regarding programs to reduce and effectively treat pressure injuries.
Instead of using advanced technologies, we decided to concentrate on the basics and fundamentals of care regarding prevention and treatment of pressure injuries. Our comprehensive program included the use of validated risk-assessment tools, skin assessment, providing staff with needed education and tools, triggering consultations based on risk assessment, rapid root-cause analysis, leadership presence, personal accountability, and a team approach.
As I write this, I am proud to say that our goal of reducing pressure injuries was surpassed—and adequate nutrition and hydration was the one common factor that affected our population in a positive fashion. Consider some available research first:
• 30–50% of admitted patients are malnourished.1
• Up to 69% of admitted patients will undergo a nutritional decline.2
• 44% of patients do not have a nutritional screening and 72% are documented as “malnourished” with no interventions.
• Malnutrition is associated with adverse clinical outcomes.3
• Malnutrition increases the length of stay, leads to muscle wasting, infections, falls, and pressure injuries.3
• Patient healthcare dollars are spent on patients with four or more comorbidities. The risk of pressure injuries increases with each comorbidity.4
• Malnutrition can impact pressure injury development and healing.
• Implementation of nutritional interventions, along with good hydration, reduces pressure injuries.
• Studies have suggested associations between dehydration and cardiovascular, respiratory, renal, and gastrointestinal disorders.5
With the available literature and research found, we focused our program on prompt identification of patients who were malnourished and those at risk for breakdowns, as we could pinpoint patients as they were being admitted. This was followed by prompt deployment of skin-care preventive measures and supplementations. We did not need to rely on new technology or standardizing the use of prophylactic dressings. This comprehensive plan appeared to move slowly, but its implementation was felt by many departments across the organization including therapy for early mobilization of patients. As we updated our validated risk assessments, we utilized a trigger mechanism for patients found at risk for malnutrition, at risk for pressure injuries, and/or patients with any type of wounds.
Our incidence of pressure injuries significantly decreased consistently over time based on prompt identification of patients at risk for developing pressure injuries, recognizing patients who were malnourished, and patients with existing wounds while promoting rehydration of patients. It is our belief that patients being admitted to the hospital are sicker, malnourished, and possibly dehydrated, so recognizing them up front and addressing these risk factors impacted our numbers, as described in the literature. When identified malnourished patients properly there are increased healthcare dollars available to assist with care.
The outcomes were positive, but in a period of more than five years that we trended, our success was not with the utilization of expensive technology or dressings, but with identifying those patients at risk and intervening promptly, providing adequate nutrition and hydration along with personal accountability. Our pressure injury trend began a downward spiral when our triggered dietary and wound care consults took a sharp increase. Coincidentally, dehydration was being addressed simultaneously.
Care for the Continuum
Of course, a focus on nutrition and hydration doesn’t do much good if other facilities that the patient visits aren’t following suit. It is becoming more noticeable that wound care clinicians must advocate for adequate nutrition for patients across the continuum.
Implementing “hydration hours” at every setting is a helpful way to decrease pressure injuries as well as other complications, such as urinary tract infections. Patients are routinely admitted to facilities with factors that place them at higher risk for dehydration. Dehydration lowers blood volume and decreases blood pressure. Blood volume is needed in our capillaries as it delivers oxygen and nutrients to the skin and cells that are needed for proper function. Could this be contributing to a skin hypoperfusion type of injury in our critical ill patients?
Reliance on Research
The amount of research, guidelines, and technology available for pressure injuries is impressive, but will only help your facility if you implement evidence-based guidelines that are readily available to us concentrating on the fundamentals of care. A comprehensive prevention program that promptly targets and addresses extrinsic and intrinsic risk factors such as nutrition and hydration can be quite helpful in lowering pressure injuries across the continuum.
Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches.
1. Robinson MK, Trujillo EB, Mogensen KM, et al. Improving nutritional screening of hospitalized patients: the role of prealbumin. JPEN J Parenter Enteral Nutr. 2003;27(6):389–395.
2. Amaral TF, Matos LC, Tavares MM, et al. The economic impact of disease-related malnutrition at hospital admission. Clin Nutr. 2007;26(6):778–84.
3. De Van Der Schueren M, Elia M, Gramlich L, et al. Clinical and economic outcomes of nutrition interventions across the continuum of care. Ann NY Acad Sci. 2014; 1321:20-40.
4. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269–2276.
5. El-Sharkawy AM, Sahota O, Lobo DN. Acute and chronic effects of hydration status on health. Nutr Rev. 2015 Sep;73(Suppl 2):97–109.
6. Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure ulcers in adults: prediction and prevention. Clinical Practice Guideline No 3. Rockville, MD: Agency for Health Care Policy and Research; 1992. AHCPR Publication No 92-0047.
7. Langemo DK, Olson B, Hunter S, et al. Incidence of pressure sores in acute care, rehabilitation, extended care, home health, and hospice in one locale. Decubitus. 1989;4(3):25–26, 28–30.
8. 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
9. Black J, Baharestani M, Mylene, M, et al. From the NPUAP: National Pressure Ulcer Advisory Panel’s Updated Pressure Ulcer Staging System. Adv Skin Wound Care. 2007 May; 20(5):269–274.
10. Mace S. Technology tackles the pressure ulcer. Health Leaders. May 2013.