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How do hospital-acquired pressure injuries (HAPIs) occur in the ICU and why is the ABCDEF bundle such a powerful tool to prevent HAPIs? How do HAPIs impact healthcare costs, staff workload, patient quality of life, and overall survival? Wound Care Karen joins us in this episode to explore the crisis of hospital-acquired pressure injuries in the ICU.

Episode Transcription

Kali Dayton 0:00
Hi, Karen, welcome to the podcast. I am so excited to have you on. Can you introduce yourself to our listeners?

Wound Care Karen 0:08
Well, thank you so much, Kali. Now one thing you might not know about me is I’m a Leo. And we love to talk about ourselves. So you don’t have to ask me twice. My name is Karen Weidlich. And I’ve been a registered nurse since 1994. I had started out in long-term care, and then I transitioned to acute care. I was doing ortho neuro on a, in a trauma hospital. And then in 2003, I transitioned into wound care. And I just fell in love with it. I definitely found my niche for sure.

So I’ve been doing that ever since. I’m currently a clinical nurse manager of an outpatient wound care department. And I am double board certified. I have my CHRN, which is a certified hyperbaric registered nurse. And I have my CWS, which means I’m a certified wound specialist. So I just love it. My passion is wound care, as you will know.

So a couple years ago, I realized that I was doing the same patient teaching that I’ve been doing since day one. There’s so many myths and misunderstandings out there regarding wound care. So that was the impetus for me to start a social media campaign, just about wound care, awareness. And at first my audience was patients and their loved ones at home. And so I did funny videos on Wootten on YouTube, and Facebook. And then as I got more feedback, then I started doing to do some for nurses also, and then sometimes a mix for patients and nurses. So I created this educational campaign, so to speak.

My business name is Wound Care Karen. So I’ve expanded from YouTube and Facebook and Instagram. I’m still learning Tik Tok. And then a couple of years ago, also I added podcasting to it. And so folks can see me on all those platforms. Again, my business aim is wound care, Karen.

Kali Dayton 2:17
So you are an expert master in this field. You’ve done this for a long time. When did you hear about awaken walk in ICOs? And why was that important to you?

Wound Care Karen 2:31
Well, it’s almost embarrassing to say because I had never even heard of the concept. Until April of this year 2023. I was listening, my favorite podcast, good nurse, bad nurse. And she had you on as a guest. And that’s when you talked about this concept of the awakened walking ICU. And at first I thought, okay, maybe I didn’t hear the podcast correctly. So I actually listened to it again. And then I went on your website and learn more, and then I started listening your podcast and it just I was just gobsmacked because Oh, my gosh, it was just such a game changer for me. Because as a wound care nurse, my most difficult patients or the patients with the worst Pressure injuries are from extended stays in ICUs. I mean, hands down, they beat them all.

Kali Dayton 3:26
Even if they come from compared to those that come from nursing homes, or are at home but require full time caregiving. Always worse in the ICU.

Wound Care Karen 3:35
Just just numbers wise. Yes, comparatively.

Kali Dayton 3:39
Ok, the volume of patients that develop pressure injuries? Interesting. That’s really, that’s actually not what I expected. I knew that they were bad in the ICU, but I assumed that they were worse in other settings, where care, I would perceive care to be worse. Right. More risk factors in the end.

Wound Care Karen 3:56
Yeah, don’t get me wrong. Yes. I mean, there are bad pressure injuries that occur in in in homes and in skilled nursing facilities, etc. But I think you’ve touched on something there. I think it’s all the other factors that go into an extended ICU stay for sure. And when I heard about, that, you’re actually able to get sedated patient that you will take them off sedation, and you’re actually able to get intubated patients up and walking. That’s why I was so excited. And I’m like, Oh my gosh, I have to help her shout this from the rooftops.

Kali Dayton 4:32
Absolutely. So I was at an ATI, big nursing conference, critical care nursing. And I was in a class for a quality improvement. And everyone had their phones that were connected to a program that puts up these responses onto a projector and the question was asked to all these critical care nurses, nurse managers. Let’s walk through the process of quality improvement, what is something that your teams need to work on? And this isn’t 2021 Three, we’re still you know, muddling through COVID. And the vast majority of responses were happies, hospital acquired Pressure injuries, which made my heart hurt because I did a previous episode with one of our wound care nurses from this Awake and Walking ICU.

And the pressure injury rate in the ICU was less than 1%. So I was astonished to see that most people are really fixated on HAPIs. And it is a big problem when you have studied patients. So the next question was, “What kind of interventions would you implement to improve this?”

And there were all these great responses about turning alarms, turning teams, mattresses, things like that, which I think are fine. But there was not one proposal about early mobility, or sedation cessation, or waking trials, or the A to F, but nothing about mobility was mentioned. Yeah, it just broke my heart. I thought we had this huge problem going on in our facilities.

As I’m consulting with teams, one of my first gap analysis questions is what are your happy rates, and it is astonishing to see how high they can be. And obviously, there’s a lot of work that can go into preventing them. But that’s the key is that it is so much work to prevent them when you have patients sedated and immobilized. So tell me from your perspective, and what you know, what are some of the main causes of hospital acquired pressure injuries in the ICU?

Wound Care Karen 6:24
Yeah, to me, there’s two major major causes that come from Hobbes in the ICU or cause it. The first one is the immobility hands down, humans were not built to just lay in one place for any extended amount of time we were built literally to be up and walking, actually. And the second one is malnutrition. And they go hand in hand. So even if someone is, is up and walking, but they have poor nutrition, they’re at very high risk of getting a pressure injury.

Even if they’re come completely immobile, but they have excellent nutrition, they’re gonna get a pressure injury. So So those two go very hand in hand. And I think most nurses do understand how pressure injuries develop, I think they understand, you know, it’s usually from a bony prominence, it’s laying on the same surface for too long. But I don’t think that they realize how short of a time, but that may be for someone. And now the data, it varies. I’ve seen different sources, they say it can occur within one to four hours to five air hours. But that’s an average.

And so that’s why so many nursing protocols, say turn the patient every two hours or turn them every one hour, it’s because they’re working on that average, right. But that’s a range. And if you take your sickest patients, which they’re in the ICU, right, then guess what end of the range, they’re going to be, they’re going to be at that one hour range, or perhaps even a half hour, they might develop an ulcer, that’s might be all it takes. Because of all the other comorbidities, the malnutrition, poor circulation, do you have them on? pressors? Are you proning them?

I mean, just all the other things, the fluid overload, you know, think of those patients that when you touch them, they’re already wet and clammy. All of that, it just stands to reason that they are very high risk of developing tissue injury, probably within the one hour range of immobility. Right. So there are sickest, most Yeah, yes. sickest, most vulnerable patients. And, and you and I touched upon this when you were a guest on my podcast, because I want to clarify something because sometimes patients or even their loved ones asked me, Well, why don’t why don’t I get a pressure sore at night because I sleep for seven hours in the same position and I don’t move for seven hours. And I beg to differ with them. Because as we talked about, when patients are sedated in the ICU, they’re not sleeping.

Please don’t make that mistake, right. It’s not a restful natural sleep like you and I get every night. So you know, when you and I sleep at night, it’s a natural restful sleep and our body has autonomic reflexes which are just naturally moving us all the time. We don’t realize it we it’s kind of like your heart beating. You don’t have to think about it to make it happen. But it’s it’s making you bend your knee a little bit it makes makes you move your elbow a little bit tiny little movements throughout the night that you aren’t even aware of. Even if you wake up in the same major position that you were in when you fell asleep. Trust me throughout that night. 6,7,8 hours however long you sleep. Your body has made little micro movements. all the time, in a way to prevent, that’s why people don’t get pressure ulcers, you know, in their own homes at night while they’re sleeping.

Whereas the artificially sedated patient, those autonomic reflexes are turned off, they’re the body’s not moving for them without them thinking about it, and then add artificial paralysis to it, right, so that they can’t even move their body, even if they weren’t sedated. If they’re paralyzed, they literally cannot make that movement and take that pressure off that area. So there are fancy beds there, they’re amazing beds and mattresses are made, some beds are so fancy, they’ll even turn the patient, you know, shift them a couple of degrees, and you can set them to every 15 minutes, half hour, hour, whatever you think. But, but again, it’s not the cure, the cure is mobility.

Right? Again, like you said, all these little tools we have, are just trying to sometimes I feel like we’re Sisyphus, just trying to push that little rock up the hill, you know, it’s it’s just too much to bear sometimes. So, you know, fancy beds and mattresses, they have their place, but they are not a replacement for early mobility, hands down, for sure.

Kali Dayton 11:25
And I think you’re always going to have exceptions, which patients have to be sedated. And that’s where the tools like ternal arms may come into play. But it is concerned that we would standardize that for everybody. And I think it’s a lot of work. I think it’s a lot of work to turn someone every hour, two hours. You know, when you have these large adult bodies, we have our feeling lifts, but I am seeing that that’s very variable in facilities. Not everyone has access to that not every room has that. So we’re putting a lot on our teams to turn these patients every two hours, but their lives may depend on it if they’re sedated.

Wound Care Karen 12:01
Absolutely.

Kali Dayton 12:02
But how much work could we avoid? How much harm could we avoid, if we just allowed them to wake up and mobilize and help them preserve the ability to shift themselves to turn themselves and patients are more comfortable when they get can get into the position that they prefer? It’s really hard and they lose the ability to lift a finger get they want to get off, but now they can feel you know, now they’re de sedated. And they can feel that pressure needs to be relieved. Now they’re too weak to relieve that pressure. I mean, that’s gotta be torture, right? Like it’s, it’s on your nose that you can’t scratch.

Wound Care Karen 12:35
Absolutely. And we all have a favorite sleeping position, right? I sleep on it my same side every night. And to not be able to to do that, or to not be able to even communicate that, you know, and here we are trying to turn them on the right side, but their left side sleepers normally. And so even even if they do get some sleep to sleep in the ICU, it’s probably not a restful restoring sleep, like the body was made to have.

Kali Dayton 13:02
And I like to ask patients, how do you like to sleep I’ve had many patients sleep on their side. We had we heard from in a previous episode, a nurse that was intubated, and she slept on her side with a young girl in her hand, she’s able to succeed her own mouth during the night. I mean, there’s so much more we can do. And the amazing impact that can make on preventing herpes. Yes. So how how, like, tell us why it’s so important to prevent them. I think sometimes we get this very narrow insight into someone’s life, just in those few weeks that they’re in the ICU. So why are we so obsessed with herpes? How does Pressure injuries, impact even just their course during the hospital admission?

Wound Care Karen 13:44
Right? There’s so many factors. Unfortunately, you know, developing a pressure injury, it just complicates and usually extends the stay. It adds so many burdens, it adds first of all, it adds a burden to your metabolic needs, right? Because now your body needs more nutrition to heal that wound, right. So now we’re adding that need, it adds a burden to your fluid balance because now you have wounds, you know, we’re really just bags of fluid, right? So but now you have a hole in your bag and your fluid is draining out of it.

So now you have to resuscitate by giving that patient more fluids, right. It adds a risk of infection. And that by might be simply you know, localized like cellulitis, or it could even go systemic, like sepsis. So then you’re adding an antibiotic, which then disrupts the body’s natural microbiome, right, which then leads to diarrhea, which then leads to more fluid loss. And now a hygiene burden. I mean, it’s just, I mean, when you when you think about it, it’s just the snake eating its tail. It just goes on and on and on and on all these little burdens that and that’s a single pressure injury. What if you have more than one? Right? What if you have a sacral? And he’ll you know, it just it just adds up. It’s like dominoes real common.

Kali Dayton 15:09
Do you know how common it is? To have more than one? I mean, if one is caused by certain variables, is it common to have multiple happen because of those same variables?

Wound Care Karen 15:20
Prior to COVID, I would have said, No, that’s really unusual to have more than one pressure off. So many of my answers have changed ever, after COVID COVID was such a blip on our radar, people were so much more sick. And their metabolic rates were just through the roof. And we were pruning them. Right, right. So so because of COVID, and specifically, with COVID, that’s when we started seeing patients with multiple pressure injuries. And so we saw patients who had sacral and facial injuries, I mean, that’s just that had been unheard of before COVID. We saw a lot of patients with buttock and heel injuries. And again, I think it just spoke to the the severity of the illness than the malnutrition was always again, the longer their stay, the worse their injuries. I mean, it was just that was just parallel, you know, it’s so easy to tell.

Kali Dayton 16:24
And we learned a lot about nutrition during COVID. Right, we had a lot of amazing nutrition research come out showing that obese patients especially were hypermetabolic, during with COVID. So there is I think some persistent misinformation, misunderstandings that I’m still seeing at the bedside where we have obese patients, we assume that they’re going to metabolize their adipose first. And so there’s like this false sense of security that we can address nutrition down down the road, that maybe it’s time for them to go on a diet, while they’re in the ICU, when really they’re gonna lose their muscle first. And when they’re sick.

I mean, we just looked at COVID. But this is happening during sepsis and other conditions in which obese patients are hypermetabolic. And need, especially need more nutrition. So I would invite the listeners to explore more about that in episode 64 and 111 of the podcast, because this is all intertwined so I don’t want to go without really touching on nutrition, but it’s there. It’s its own topic. It’s vast, but it absolutely circles back to pressure injuries that result from malnutrition. I agree. And

Wound Care Karen 17:33
Just to speak to that, even as an outpatient again, I run an outpatient wound care department, and many of our patients, as you can imagine, are either obese or morbidly obese. And I would venture to say 98% of those are malnourished. So again, I know again, goes against, you know, the initial Oh, they’re they’re well fed, right? No, they’re not. They’re actually malnourished, they have the wrong the wrong type of nutrition in their body. Yeah, absolutely.

Kali Dayton 18:06
And then it’s gonna make mobility harder when they lose that muscle first, they’re going to be less likely to mobilize promptly and it just, it’s exponential problem. Oh, absolutely.

Wound Care Karen 18:15
Because then they’re at higher risk of falls, then they fall and break a bone and then add, you know, an or if to the mix, it just goes on and on.

Kali Dayton 18:23
But so when patients develop Pressure injuries in the ICU, how does that set them up for the rest of the ICU? And where were they likely to go after the ICU?

Wound Care Karen 18:49
Right? This is it’s so impactful. So most of the time, the wound, a pressure injury, that a patient develops in the ICU, requires extra care and support afterwards. And many times this prevents the patient from going home. Very often, they have to go to either a long term acute care to LTACH facilities, or a skilled nursing facility. And so then this can add weeks or sometimes months on to their already extended hospitalization. And I just, I can’t even imagine that, can you imagine being away from your home from what you know, for four weeks, sometimes months on end? I mean, it’s just so impactful.

Kali Dayton 19:39
The longer you’re stuck in the hospital, the less you’re going to move, the more risk you are developing delirium and hospital acquired infections. I mean, it just it’s like this ball and chain you get oppression free and you’re stuck and you’re gonna be vulnerable to all the other insults. Well, even

Wound Care Karen 19:54
worse, it’s like a snowball. Yes, yes. Where it just adds up and adds up and adds up and by the end, you’re left with this Huge what how do you overcome that it’s so much harder to bounce back, after having developed a pressure injury in the ICU, you’re lucky to be alive, don’t get me wrong, it’s great that your life was saved. Because you know, most for ICU patients, they’re, you know, they’re one foot in the grave, you’re very lucky to be alive. But believe me, it’s having a wound is such a burden to patients. It really, really is.

Kali Dayton 20:28
It’s pretty amazing to look at these patients then rewind, and look back to what happened upon arrival to the ICU or upon intubation. What started this. And then the question was that an avoidable when we have so very few real indications for sedation? Are we unnecessarily setting patients up for this and our teams and our clinicians, for all the extra work and burden that happens, and also to be deprived of see them have good outcomes successfully walking out of the ICU and really going home? What kind of emotional burden This is add to teams when patients develop Pressure injuries?

Wound Care Karen 21:11
Right, right, that’s got that’s got to be hard, just knowing going to work every day and struggling with that. And you’re right, knowing that the patient whose life you saved, is also still going to have a very long road ahead of them, because of their delirium, their pressure, injuries, their acute kidney injuries that they still need to recover from when they leave your unit. Yeah, for sure. Big, big difference.

Kali Dayton 21:35
And I don’t think many of us really understand what that journey looks like after I mean, you do outpatient? What is it like for the survivors that finally do make it out of the hospital, but still have pressure injuries to heal?

Wound Care Karen 21:48
Right? So wounds can take months, and sometimes years to heal. And sometimes people are very shocked to hear that. But I have a perfect example. I’m we’re seeing a patient. He’s in his early 40s. And he barely survived COVID He was on multi system failure. But he did he survived. Now he has, you know, end stage renal, he has other problems that he sustained, again, during his extended stay while recovering from COVID. But he developed such a horrible sacral pressure injury that has required now three surgeries, because of course the bone got infected and surgery, and then Oh, we didn’t get it all.

And he has required, you know, three different surgeries. He’s had to quit work. His spouse had to quit work to help take care of him. Yeah, he maxed out all of his insurance benefits, his his skilled nursing days, and then eventually even his home health days. So much so that now you know, his spouse has to take care of him. She’s now his nurse, and his his driver, his you know, she’s his full time caregiver. And this was a young healthy man, just going about day to day living his life without any pre COVID conditions. That’s how impactful it is.

Now that that’s an extended case, I understand. But he’s not the only case. Right? He you know, he’s not an outlier. We see this a lot. So patients go home with a wound. And and again, the burden on everyday living if they have if they had a job before the illness. They’re either still on you know, disability, or sometimes again, they just call it quits. I don’t I don’t see my ever being able to go back. It impacts their spouses, their families, sometimes children end up having to be caregivers, you know, oh, well, dad, dad’s in a wheelchair. So now I have to reach things from the cupboard for him or I need to help him in the bathroom. And you know, it’s just so impactful. It impacts every aspect of your living every hour of your day.

Kali Dayton 24:11
And when this is happening in congruent with hospital acquired weakness or ICU acquired weakness, I mean, how do you really heal from a pressure injury until you’re mobile enough to really stay off of that spot?

Wound Care Karen 24:26
Exactly. So what does it take to heal an injury, right? It literally takes a village, it takes a lot. It’s it’s so many factors first, if you have a pressure injury, the very first thing you have to make sure is that you are aren’t still getting pressure at that site. And that may sound easy, but what if your pressure injury was on your sacrum? Well, every time you sit, you’re, you’re either worsening your wound, or it’s at very least stable. It’s you’re not going to Yellow wound if you’re sitting on it, literally.

So if you have a sitting type wound, and that’s either on the sacrum, or on the issue rooms, so like, you know, think when you’re when you’re at the bleachers at a football stadium and you sit on the right, the hard bleachers you feel it on your issue comes. If you have wounds there that then you can’t sit. And so those patients very often we have to put them on bed rest. Can you imagine being at home on bed rest? It’s It’s so, so difficult. So that what you do.

Kali Dayton 25:31
Then you especially get weak, and you’re especially dependent, and then you are at higher risk of developing other Pressure injuries, abs I mean, where does it how do you get out of there?

Wound Care Karen 25:39
Yes, yes. So I and I’m not done. Right. So that’s the pressure component. So you might need a special cushion for your chair or your wheelchair, you might need a special mattress or mattress overlay. If it’s on, if you have a wound on your foot, like the back of your heel or the side of your bunion or a little bun, your net, you might need special shoes. It’s just amazing. Then you also need Optimum Nutrition. Now who among us gets Optimum Nutrition, right? And that’s just to live. So folks with wounds need extra protein, and extra vitamin C and zinc and all the components that go with healing? So that takes time and money? And do they

Kali Dayton 26:25
Do you sometimes keep feeding tubes and people to ensure that we get that optimal nutrition? I’m just thinking these people from the ICU, they’re so weak? Do they have the ability to swallow? Do they have the drive they have the cognition to really have that level of intake that they need? Or do we keep them on Intel feeds for longer because of this wound?

Wound Care Karen 26:45
Absolutely. And and in my opinion, I think some folks should probably, sometimes I think we pull the tube too soon. Right? Because so even if they are they think they can eat and no, I want to eat but pleasure foods and everything, it’s probably not 100% of their needs. So let’s you know, let them have their pleasure foods, let them eat that. But let’s do the extra supplements then also in the tubes, for sure. Absolutely. Then another thing so along with pressure relief and nutrition, then you have to see Do they have any other comorbidities?

And then we have to optimize all of those, for example, are they diabetic? Okay, they are. So now we really need to make sure they have good glucose control. Because if you have high blood sugars, your wound is not going to heal your your body’s on fire, it’s on crisis, it’s going to keep your brain and your heart alive, it’s not going to heal that wound on your bottom. So super important. If they’re a cardiac patient, we have to maximize their cardiac efficiency. If they’re a lymphedema patients, so they have a lot of swelling, we have to add compression therapy to keep the swelling out, right.

If they have PAD, peripheral arterial disease, we have to make sure they’ve seen their vascular specialist and that their circulation is optimized, right. So all those things go into wound healing. It’s not just one, it’s not just wound, special dressings. You notice I didn’t even mention dressings, right? Because all these other things are just as important. wound healing is like like spokes on a wheel. And if any one of those spokes are broken, whether it be nutrition, or offloading, or diabetic control, then then the wheel is broken, and that wound is not going to heal. So it takes a village, it takes an entire team.

Kali Dayton 28:40
I’m Yeah, I’m just trying to think of the team and you got obviously home health nurses, you have wound care nurses, you’ve got to have home physical therapists, I mean, if these patients make it home, but this is a lot of monitoring and care, and managing the patients that have developed by some acquired weakness, and they’re so profoundly weak. And then a lot of times the patients that are most vulnerable that develop those the most do they have the kind of family support? Do they have the medical literacy to really re vigilant with these interventions?

Wound Care Karen 29:10
Yeah, and very often not. And so very often those folks do end up in facilities, whether that be long term acute care. And again, that’s if they qualify, and if their insurance covers it, or very often in skilled nursing facilities.

Kali Dayton 29:25
Yeah. And that’s something that that ends up also being hard on the ICUs because you fill up those facilities with their survivors, and then your next round of survivors can’t get there and so you’re stuck either they’re stuck in the ICU in the medical floor. So we might feel like we can put them off to someone else. And that it’s no longer our problem, but it is it is definitely our problem.

Wound Care Karen 29:49
Yes, for sure. It’s like a conveyor belt in a in a factory or facility right if you know, things keep adding up then the whole belt gets slowed down for sure. Yeah,

Kali Dayton 30:00
We saw that so clearly during COVID. And I think our communities are still suffering the effects of that. We still don’t have good outpatient or out, or nursing home resources to support our hospitals.

Wound Care Karen 30:13
In many ways, I think it’s gotten worse. Absolutely, yeah. Because of the I’ll be honest, the mass exodus from nursing, to be honest, so, so many nurses are leaving the field that’s putting a strain on on the entire healthcare system, for sure.

Kali Dayton 30:32
Absolutely, and I think this is, these are all things that we need to consider when we’re deciding whether or not to sedate a patient. Because it may be easy for that moment to get through our one shift. But it’s setting us up even us personally, and not just talking about our teams. But if I as a nurse, and looking for an easy shift today, it’s gonna cuff on some of the grenade is gonna explode on someone later, to decelerate the patient to liberate the patient from sedation and then deal with the delirium.

And that’s, that’s going to be my shift, taking care of the same now LTACH patient that stuck in the ICU for weeks to come. And ICU nurses don’t want to do that. That’s not why they got into the critical care medicine, they really wanted the initial exciting things and the critical illness, but once it becomes more of a chronic illness, we’re kind of turned off, we’re kind of done with it. But when it comes to wounds, there’s no way out, you’ve got to just keep treating them. And if they can’t get to a facility, they’re yours. We made that patient and we get to treat that patient for weeks to months. For sure, yeah. So then what happens if I mean, patients, even if they make it home, they’ve lost their jobs, they their family relationships have been impacted, their even their spouses careers have been impacted their financial.

Wound Care Karen 31:54
And that’s if their marriage survives, you know, very often this puts a strain on relationships. And we’ve seen it many a time that the marriage itself does not survive. Having a wound just places a huge burden on the quality of life. And sometimes it’s a pain, literally pain from the wounds. Imagine having that kind of pain all the time. That can lead to depression, which itself leads to, you know, down a rabbit hole. The smell, if I can be honest, I’ve never smelled, I’ve never smelled a one that smelled good, right. I mean, the the odor, sometimes from the wound dressings, it’s so embarrassing to patients.

So then they isolate themselves. I know several patients who don’t go to church, they won’t go to restaurants, they don’t invite their family and friends over, because they’re so conscious of the smell of their wound. So we do work with them to try to find their like charcoal dressings or special dressings, or just you know, increasing the frequency of dressing change. But that itself, it can just be so embarrassing. It limits your activity. Like I said, if if you have a wound on your buttock, and you can’t sit well, but that severely limits your activity.

Or if you have a wound on your foot, and you can’t play golf, like you used to, I mean, it just it limits everything you used to do before the hobbies you used to do you enjoyed whether that was walking gardening, even just like I said, going to church, it limits that. So many people have to either take time off work or quit their jobs because of their wounds. It is so super impactful. And and not all families survive.

Like I said very often, the the marriage does not survive something like that. And again, it very often places a burden on children, regardless of their age, we take care of patients who you know, have minor children who take an active role in their parents chronic illness, out of need out of necessity. And I understand it and I’m not saying it’s a wrong thing. But that’s how impactful a wound can be to a family. And sometimes there’s the things we don’t think about. But I see it. It’s happens day after day after day. Wow, no, it’s

Kali Dayton 34:19
I think the ICU are thinking I’m treating I’m treating pneumonia in sepsis, but really, we’re treating a family. We’re treating the patient the moment but we’re treating their future as well. I mean, that’s that’s high pressure. That’s a big deal. But I think those are insights that we don’t really get because I think sometimes for me, at least it’s out of sight out of mind, but then I think I assume that outpatient resources will help them get back on their feet and it’ll take few days, weeks months, but they’re going to get back to it.

Wound Care Karen 34:50
It’s almost never as fast as we hope. I’ll be honest and very often the patient’s very first question when they come to meet us During their evaluation is, you know, when will I be healed? Doc? How long will this take? You know, and that’s that’s a hard guess for us, it really is, especially that first visit, because we don’t know the patient at all, we don’t even know their capacity to heal. And like I said, there’s so many other factors, their nutrition, their diabetes, their cardiac status, their circulation status.

So that’s very often a question we don’t answer on the first visit, after a couple of visits in, then we have actually some data, you know, hey, it’s week three, and you’re 40% healed, you know, then then we have some more data points we can play off of. But yeah, it’s a guessing game as far as how long it’ll take a patient to heal. Occasionally, we’ll get a surprise and someone will be healed in a week or two. And, and that’s amazing, and we celebrate with them. But those are outliers that that very rarely happens. We’re normally looking at weeks to months.

Kali Dayton 35:59
Wow. And the ICU sometimes. I mean, oftentimes we’re saying well, we’re, we just gotta get them to survive. All we can focus on is survival. And I think that’s a mentality that inspires us to sedate patients. It’s like, we gotta get control of everything else. So let’s just say them, and then we’ll work on the mobility and other things later when they’ve survived. But how do pressure injuries impact mortality?

Wound Care Karen 36:23
Right? Oh, my gosh. So I can’t I don’t think I can overstate this. But having a pressure injury, just even just one, it totally increases the chance of mortality in in so many ways. Let me explain why. One of the most obvious, of course, is the risk of infection, right? That’s what we’re always worried about. Once you have a little nick any kind of hole in the skin, you know, they’re at risk for infection, which of course, in an ill person in someone with comorbidities can easily lead to sepsis. So very scary.

You know, sepsis is, is just so dangerous. I’m sure you and I both know, many, many patients who did not survive sepsis. So having a wound is such an increased tax on the body. When you mix it with other comorbidities, sometimes you just can’t recover. Like a otherwise healthy person would, for example, if an otherwise healthy active person would drop down with a heart attack, their chance of survival is actually quite quite good, you know, if caught early enough, and with all the interventions, but if that same person, let’s say they gotten out of the ICU three months earlier, and they still have a pressure injury, now they dropped down, have a heart attack, they’re going to have a harder time rebounding from that heart attack, again, because of the increased metabolic demands from their wound.

Right? So again, it’s like I said, it’s, it’s like the snowball effect, it really just adds up to the burden on the body. Our bodies are amazing. And we’re our bodies are always healing ourselves and trying to achieve homeostasis. So most patients with wounds, the body wants to heal it it wants to try. But when we tax it so much with so many other problems, like immobility and fluid overload, malnutrition, and now we’re adding wounds to it. We’re hurting their kidneys because it what we’re giving to them, when we tax it with so many other things, it’s really hard for a body to bounce back from that. So that just adds to the mortality rate for sure.

Kali Dayton 38:43
And care. I’m just thinking medications like propofol is a mitochondrial toxin. I don’t know if we have any clear research on how that impacts wound healing. But it’s got to impact cellular regeneration. Absolutely. And but if we’re continuing to give proper fall, we’re continuing to be toxic to the mitochondria. Are we causing and or exacerbating these wounds and mobility aside just from disrupting or, or killing the mitochondria?

Wound Care Karen 39:14
Right to me. I mean, theoretically, that just makes sense. It can’t be good for wounds if you already have them. And you’re right. It may even predispose someone to wounds for sure. immobility aside. Yeah, that’s horrific. And same thing with with pressors. You know, so much of that. The circulation gets shunted, of course, to the heart and brain again, keeping them alive. I get it. But But very often, we get ICU patients with you know, black fingers and toes. And again, I get it, they’re alive, but now. Now the patient is left dealing with those wounds and it usually leads to limb loss, hopefully just a digit or partial digit, but very often it leads to further amp mutation is, of course, always at risk for infection the whole time.

Kali Dayton 40:05
Not that sedation is the culprit of all evil. But we saw during COVID, that a lot of sedation or a lot of vasopressors, were being given to compensate for the sedation that was being given. And they were walking ICU during COVID, less than half their patients rough estimate, had central lines, because they were human and chemically stable because they were off sedation. So it’s, it’s all it just affects everything. And sometimes, oftentimes, the dispute is, well, we can’t move our patients because we don’t have enough people, because we don’t have enough resources. So how do we how can we use hospital acquired Pressure injuries to advocate for those resources? What’s the financial cost of pressure injuries on our system?

Wound Care Karen 40:51
So I tried to research this, and it’s like going down a rabbit hole that no one wants to go down. And so essentially, whatever in your mind, you think the cost is? Go ahead and triple that or quadruple that. I mean, it’s just crazy. So just as a baseline, the Agency for Healthcare Research and Quality, the HRC Q, right, they estimate that pressure injuries cost the United States $11 billion per year. And that’s billion with a B, which just blows my mind.

Now, sometimes those numbers don’t mean anything to me, I’m like, Well, what does that mean to my patient? So then I look, I drill it down. And I personally look at the patients that I know. Average, after hospital costs, I’m not, I’m not counting the hospital costs. So once they leave the hospital, and they become an outpatient, and they come to me, depending on the stage of the pressure injury, or the severity, or again, how many of them they have, the cost can run from 1000s to 10s of 1000s, to sometimes even over $100,000. Because sometimes injuries are so severe, they need surgeries, or sometimes multiple surgeries, like we’ve talked about.

And advanced wound care techniques such as negative pressure wound therapy, that is costly, it is so very expensive. Now it’s a game changer. And I swear by it, I love negative pressure wound therapy, that is extremely costly. Sometimes patients need hyperbaric oxygen, again, I’m certified in I swear by it, but also very, very costly. These are advanced wound healing techniques that, again, have high healing rates, but the cost comes with them. And we’re talking again, 10s of 1000s, sometimes upwards of over $100,000 per patient ease. And

Kali Dayton 42:55
best on one on one study showed looked at the cost of claims against hospitals, not just direct patient care costs. But if survivors because Prachanda rates are declared as an never event, right, this should never happen. Yes. So if it happens, like there’s some grounds for malpractice, so the average claim costs a hospital $200,000

Wound Care Karen 43:20
Oh, I think that’s probably low balling it. Yes. I totally agree. Totally agree.

Kali Dayton 43:25
And that helps direct costs. So if pressure injuries happen, then hospitals are liable. They, they have to cover the cost of treating that patient and any kind of complications and the whole everything that happens from then on out is on the hospital, essentially. Right? So Medicare and Medicaid insurances say that happened because your poor care, we’re not covering it. And then on top of it, they get to cover the legal fees, yes, happens. So it’s, they should be very vigilant about making sure they never happen. And the main key is to keep patients awake and mobile.

Wound Care Karen 43:59
I totally agree 1,000%. And in those costs that I talked about, you know, the upwards of 100,000. Again, that’s just for costs of like services. That’s not the cost of supplies. Very often, I have a few patients who their insurance does not cover the cost of home health. And I have a few patients who their medical insurance does not cover the cost of their medical supplies. So all of those items, if they’re able to are out of pocket for them, which blows my mind, which they’re not as you know, as most people know, the cost of medical supplies is so expensive. So a couple of years ago, I was pursuing my undergraduate degree, my Bachelor’s, and as part of my capstone project, I developed a resource sheet to give to those kinds of patients and it had some resources on it. For example, here’s some local pharmacies and DMEs that might might work with you.

And you know, on a give you some discounts. Here’s, we have a local charity, I live in San Antonio, we have a local charity, who, who refurbished wheelchairs, and crutches and scooters and stuff like that. So I, you know, had that on the resource sheet. We have some free medical clinics and places to get free medicines, I put that on the resource sheet. But that’s how bad it is that I had to make a resource sheet. You know, it’s just the As we’re all aware, sometimes people go into medical debt, right, you know, they have to declare bankruptcy, medical bankruptcy, because of all of their medical bills, nutritional supplements, it’s so easy to say, oh, we’ll go out and get this fancy nutritional protein supplement, but can they afford it?

Most of my patients cannot, you know, so. So we end up just saying, Look, you know, buy some eggs and beans, you know, if that’s what you can afford, that’s excellent source of protein, or even, you know, an instant breakfast drink that’s got just as much protein in it, you know, you don’t need this brand name. So things like that you, it all adds up and in healthcare can nickel and dime you to death. So it’s just an added just an added cost for sure. So

Kali Dayton 46:23
I was just in a financial meeting with a bunch of hospital executives, and I was trying to explain why it’s so expensive when nurses, turnips sedation, to go answer a phone, or to go work with their other patient. I mean, how, how much of it an investment or huge return on investment? Is it to have a sitter at the bedside or mobility tech or some of these kind of low skilled positions, huge investments, if we can avoid, use them to avoid sedation, keep patients mobile, the return on investment is just so profound. But this is not what they’re thinking about when they make a decision as to whether or not to staff their teams in certain way to invest in mobility Tech’s I mean, it’s exact hospital had let go of some physical therapists before I showed up. Oh, Mike, I don’t think they realize how expensive that decision is.

Wound Care Karen 47:15
I agree they can’t see the forest for the trees. Because if you if you cut staffing, so you’re not only not getting that patient up, but I’m going to go out on a limb and say you’re also not turning them every hour, right. So again, you’re just adding to all the cascading injuries that come from immobility. And it’s going to cause extended stays, and it’s going to cost your hospital and then when the patient leaves and realize they probably shouldn’t have developed that stage three pressure ulcer, they’re gonna, you know, find a lawyer, and then they’re going to sue the hospital, you know, and so the, whatever, 60 grand a year that the hospital saved by cutting an FTE, you know, they’re gonna pay it out, quadruple in the end.

Kali Dayton 48:03
And I think the public’s gonna know, more and more. So I mean, pressure injuries are kind of low hanging fruit, right. But I think the public is going to know, and be more aware of the reality of sedation. So if they were wrongfully sedated, and these complications happened, are hospitals going to start being held more accountable for failing to practice the ABCDEF bundle, and are happy is going to be grouped into that discussion to say, and I developed a wound that probably wouldn’t have happened had I not been sedated without an indication for sedation. So we really worry about liabilities. And I don’t think I don’t think clinicians personally should be liable for this. But we worry about liabilities like unplanned extubation, some false that our licenses are on the line, but what if hospitals and even personal clinicians were on the line for these kinds of practices? That ended up increasing mortality and harm.

Wound Care Karen 49:01
I agree, but also, I think the tide is turning, I think we clinicians are starting to be held sometimes criminally liable for what we had normally done in practice, for example, you know, medical errors, etc. And so I wouldn’t be surprised, down the road, seeing someone clinicians whether it be again, nurses, physical therapists, intensivist being held liable, maybe not criminal, but at least civil. For again, not following the ABCDEF bundle for sure.

I’m not sure why that tide is turning and it makes me uncomfortable. But but you know, we also can’t ignore the elephant in the room right where I think we’re all becoming targets. And I encourage everyone to get their own liability license and and protect yourself but again, all All the more reason to advocate for early mobility? Absolutely ever go wrong by being a patient advocate?

Kali Dayton 50:09
Oh, absolutely. And I was in discussion with a group of respiratory therapists, as we were about to embark on working with a team. And the very valid question was asked, Will I lose my license if something happens during mobility? And I should never feel that way. We should never say what I lose my license for practicing evidence based medicine. Wow, that should never be part of the discussion. Unfortunately, it is right now. And so I think that’s a whole nother discussion to be had.

Wound Care Karen 50:36
But that’s a whole nother podcast, isn’t it?

Kali Dayton 50:39
Right. But I was able to say, well, the evidence is vastly in support of ABCDEF bundle. And so I think liability will start to increase with failure to comply with it. Yes. But in the end, it’s the best thing for our patients best thing for our teams. If we’re talking about workload, bed flow, financial, all the different things that make our hospitals run, then we’re going to look at it day one and say how do we prevent pressure injuries from happening?

And what we do today upon admission, is going to greatly determine the trajectory of their lives. So Karen, thank you so much for all you do for the community. I invite everyone to listen to her podcast. I’ll put the link to it in the show notes. Check it out. She’s a obviously a fountain of knowledge and all things wound care, Karen, thank you so much.

Wound Care Karen 51:26
Thank you. Thanks for having me. I really enjoyed it.

Transcribed by https://otter.ai

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