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Ann Marie Dunk RN BHthSc(Nurs) MNurs(Research) Adjunct Associate Professor, University of Canberra Clinical Nurse Consultant, Tissue Viability Unit, Canberra Hospital, ACT Health Wounds and Wellbeing Combined Celebrating the Anzac Spirit AWMA(ACT) Conference Hotel Realm, Canberra, 6th & 7th November, 2015 Outline Link between pressure injury development and importance of understanding microclimate Quality improvement and cultural practice change Lessons learnt Past and Present Increased skin moisture especially associated with incontinence has long been recognised as an important risk factor for pressure injury development In more recent times clinicans have a suite of multiple aids to assist with continence management Traditional out of date devices and aids often go unnoticed in practice The value of skin status and skin assessment is overlooked in a busy clinical environment Definition Pressure injury is a localized injury to the skin and/or underlying tissue usually over a bony prominence, resulting from sustained pressure including pressure associated with shear International prevention and treatment of pressure injuries, 2014 Well recognised there are interactions between many intrinsic and extrinsic factors in a person that if focused on in clinical practice can prevent pressure injury development eg; microclimate Risk factors in pressure injury development Skin moisture Excessive moisture impacts the susceptibility and tolerance of the skin by affective the barrier and mechanical properties of the tissue and physiology and repair Body temperature Body temperature impacts upon the susceptibility and tolerance of the skin by affecting physiology and repair, transport and thermal properties What is microclimate? Temperature of the skin or the soft tissues Humidity or skin surface moisture at the interface between the skin and the support surface Temperature Raised skin temperature increase metabolic demand Increases the susceptibility to the ischemic effects of pressure and shear 1○C increase in body temperature increases metabolic demand by 10% Skin, subcutaneous tissue and muscle perfusion are at risk of ischemia Strength of the stratum corneum changes: At 35 ○C the mechanical strength of the stratum corneum is 25% of that at 30 ○C Humidity Moisture weakens the linkages between the collagen fibres in the dermis and softens the stratum corneum Excessive moisture and high relative humidity of the skin leads to macerated or incontinence associated dermatitis (urine/faeces) Increases the exposure of underlying blood vessels then heightens the impact of pressure and shear stresses on these vessels Changes the smoothness of the skin surface increasing the likely hood of damage from shear and friction Humidity of 100% the stratum corneum is 25 times weaker than at 50% relative humidity Can both be measured Skin surface temperature Can be measured at the skin/support surface interface with patient still in contact with the surface or after moving our of the contact with surface Relative humidity Relates to the amount of water vapour in the air at a specific air temperature to the maximum amount of water vapour that body of air would hold at that temperature In clinical practice assessment of moisture is subjective eg Braden scale Microclimate barriers High levels of core temperature with patient when sweating and perspiration and ambient humidity is high therefore evaporation is poor at skin surface Layers of incontinence management devices and products Low exposure to air and contact with another surface Eg clothing, support surfaces, dressing and incontinence pads and devices 20th Century . 21st Century . Practice challenge – 16 months Pre practice change Evidence poor Cultural change in practice draw sheet Limited information regard re‐ usage Uncertainty product performance – regular laundering Poor practices conflicting with policy Cost consideration Total usage 260,000 annually Approx 710 per day ‐ $1,420 Approx purchase @ $40 unit x 710 = $28,400 one day Post practice change Evidence strong No lift policy Multidisplinary input Extensive dissemination Environmental disposal Impact of current mattress technology Added microclimate management system Heighten awareness of pi prevention, skin integrity and importance of microclimate Improve governance Approx 710 per day ‐ $1,143 Lessons learnt Effective needs to be hospital wide approach Practice change does not happen overnight – 16 months Often a hidden culture changes Tertiary teaching hospital over 672 beds – speciality areas have special needs Transferring better evidence in clinical practice can reduce costs eg moisturisers Continual educational resources and practice tips that are multidisplinary; eg repositioning Collaboration with industry can lead to improved and tailored products Further research and quality activities are need to full understand microclimate effects on the development of pressure injury References • National Safety and Quality Health Service Standards: http://www.safetyandquality.gov.au/publications/national-safety-andquality-health-service-standards/ September 2015 • International reviw. Pressure ulcer prevention, pressure, shear friction and microclimate in context. A consensus document. London: Wounds International, 2010. • National pressure ulcer advisory panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure injuries: Clinical Practice Guideline. Emily Haesler (Ed). Cambridge Media: Perth Australia.2014 • Clarke M, Romanelli M, Reger SI, Ranganathan VK, Black J, Dealey C • Microclimate in context. Wounds International, 2010 I Thank you [email protected]
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