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How do Hospital Acquired Pressure Injuries (HAPI) impact patient outcomes and quality of life? How can they be better prevented? Cami, our wound care specialist, shares with us penetrating insight into the reality of rotting in the ICU.

Episode Transcription

Kali Dayton 0:28
Today, we’re going to talk about hospital acquired pressure injuries (HAPIs). I was contacted by a listener that mentioned that her wonderful ICU was trying to improve their HAPI scores. I had no idea what a “HAPI” score was. So had to look it up there hospital acquired Pressure injuries.

This made me so curious because I feel like the only time I really see pressure ulcers are when patients have develop them prior to arrival, I really had to think about it and realized they can’t really happen when patients are awake, strong, moving, walking, changing from chair to Bed Chair during the day, and showering. I was fortunate to snag Cami, our wound care nurse specialist to teach me more about how Pressure injuries impact patient outcomes and quality of life. What she had to share blew my mind.

Cami, thank you so much for sharing your expertise with us. I was talking to a nurse, another listener of the podcast and she said that she was interested in some of the principles we were talking about in the process of care because her team is working on decreasing their hospital acquired pressure injury rate, “HAPI”, and I had to look it up because I didn’t know what it was. And I realized that that is a hospital acquired pressure injury. And I think the reason I didn’t know what that was, is because we don’t really deal with it here. So will you tell us from wound care side about where you’ve come from what you’ve seen and what you see now, right?

Cami – Wound Care Nurse Expert 2:01
Hospital acquired Pressure injuries have been known by other names or the past many years. So layman’s terms, a lot of people refer to him as to “Deubitus Pressure Injuries”, “Decubitus Ulcers”, or “bed sores” is a layman term. But now the current terminology is “pressure injury”.

So it’s been an ongoing battle for years, hundreds of years as people have, you know, tried to recover from illness. But more so as we’ve been able to save more lives, have we discovered that these happen on patients after they’ve had some sort of, you know, life event where they’ve been critically ill. And about 2000 And… I would say six or seven… CMS defined them as a “never-event”. So then we went, “Okay, our culture has to change because we’ve always thought these happen when our patients are critically ill.” And now we had to do that shift of saying, “well, CMS is saying, ‘we’re not going to pay for the stays if these happen.’ ”

And a lot of us in the wound care profession at that time thought, “well, how can you say that because these are ‘unpreventable’.” So we really had to have a culture shift in our thought of, “How are we going to stop these because we know that this is going to be a large impact for you know, our hospitals and our systems if we don’t prevent them.”

So I started out with my certification as a certified wound and ostomy nurse. So CWLCNs. That decided, okay, “we’re going to get aggressive with this.” And they started working through different products to try and prevent pressure injuries from happening in hospitals. And they found that even just by using a foam dressing, from the very beginning and putting them over bony prominences, they were able to significantly reduce rates, which was a very different way of treating things than we were before then just turning them and putting them on a different surface. So from there, it just kind of trickled on to where, hey, there’s probably more options, you know, to help improve these rates. And so it’s really been a driving factor for wound care to help reduce those rates.

Kali Dayton 4:14
Yeah, and what are some of the other contributing factors with other barriers? I mean, you’ve worked in different ICUs, what are the differences you see between those ICUs?

Cami – Wound Care Nurse Expert 4:24
I think the big thing is nursing education. So the best thing that we’ve found here, and actually my experience to the other hospital is educating our bedside nurses. Getting them invested and knowing that this really tows the line with them taking full responsibility for their skin. Your patient’s health of their skin, and owning it. I’ve been really impressed here, where nurses, they own every patient and their skin as their own. And they’re invested in keeping that skin healthy.

So it starts out with educating your bedside nurses and saying, “okay, as soon as I get that admission, one of the first top priorities, besides all the other critical things I need to do, is doing a head to toe, head to toe assessment of their skin.” Accounting for what they see. And no matter how minor, you know, considering that as a potential problem, and then documenting it. We encourage our nurses, you know, document what you see if you’re not sure, then reach out to us as a specialist, and then we’ll help you, you know, label it appropriately.

But if they don’t document what they see, then if it isn’t characterized in that first 24 hours, then it becomes owned by us as a facility. So and then we’re responsible and claim have to claim that if it ends up being a pressure injury, so that’s probably one of the biggest barriers in hospitals is just getting that buy in from the bedside nursing, and also administration to give us the amount of staff it takes to educate nurses, and, and also the physicians that this is important. And we need to take the extra time to educate and get that buy in from the bedside nursing.

Kali Dayton 6:11
So yeah, and I see that because the only time I really see Pressure injuries are when they come from other facility that feels like that’s the only time I’m really made aware that they’ve occurred on patients. And it is so important to document where they came from, because that’s a huge liability. And it’s I mean, it’s, it’s a sign of abuse, neglect, things that no one wants to do to patients. So when this other ICU reached out and said, we’re trying to decrease our HAPIs rates, I had to grab you, when I saw you. You came to see a patient just yesterday that had come in with a very severe decubitis ulcer, and it was really upsetting for the staff, because we’re not used to seeing those. You treat so many things in our ICU. But pressure ulcers aren’t that common unless they come with it? But especially they’re not really caused here?

Cami – Wound Care Nurse Expert 7:01
What is very rare actually to have it

Kali Dayton 7:04
How rare is that? Like? What do you what have you seen in critical care, especially.

Cami – Wound Care Nurse Expert 7:08
So nationally, it’s really hard to benchmark nationally because there’s so many factors that go into the way they collect their data. But we usually do a big study with Hill rom where we can kind of bench with other Hill rom studies. So nationally, you can see a rate anywhere between six to 8% to 30% of our patients acquire hospital acquired Pressure injuries, which I mean, that’s a staggering rate.

Kali Dayton 7:33
30%???

Cami – Wound Care Nurse Expert 7:35
Yeah. Yeah,

Kali Dayton 7:36
Wow.

Cami – Wound Care Nurse Expert 7:36
Especially when you get into the extended the skilled nursing facilities. But within our hospital system, our rates are significantly lower, we kind of vary between 0.6% to at worst a 2%. So significantly lower than in national. And then here at this hospital with this “Awake and Walking ICU”, it’s been, we’re been really proud to have a 0% for the last two years, which is almost pretty unheard of.

So we’ve had a lot of people reach out. So yes, it’s something that here, I think that our staff takes for granted, because we’ve already developed this culture of, hey, we have, we’re already doing these things. So they already kind of become just natural for us to own, to offload patients to turn patients, to assess patients. So that culture is established. Yeah. Right. So it just seems like it’s a rare thing.

But in other hospitals, it’s an ongoing battle constantly. And it feels like you know, you’re spinning your wheels, because you feel like a lot of staff are saying, “Well, we’re doing a lot of these things”, but they’re not consistently doing everything they need to do. And so you get those holes, and then you’re going to get the pressure injuries. So I mean..

Kali Dayton 8:44
and the more you have patience, as a whole and immobilized, sedated, not moving, then you really have to be so diligent about turning. I I know that our nurses turn our patients, but on very rare occasions do they really have to. So most of our patients are awake sitting in a chair during the day, moving, they can shift themselves in the chair, they can shift themselves in the bed. I mean, most people aren’t going to lay in the same spot.

Cami – Wound Care Nurse Expert 9:10
You’d be surprised…

Kali Dayton 9:11
Really? Even when they’re awake and strong?

Cami – Wound Care Nurse Expert 9:13
Yep, you’d be surprised at how many so one thing we’ve done since I started here was we made sure surfaces were of a good quality meaning our beds. Not only that our chairs, so even you and I if we’re just enough sedated or altered, we may not sense that I need to shift myself or if we have neuropathy, or we’ve been sedated for procedures. So our normal or normal triggers to help us reposition are kind of altered.

So we want to kind of catch that by making sure bed surfaces and our chair surfaces are, you know, redistributed that pressure by offloading. So we’ve made sure beds already are redistributing. We’re using things to help turn our patients so that it’s easier for nurse not to have to go grab Another nurse, yeah, right? Because we’re stressed all the time, using a taps, turn a position system so that the nurse can do that independently.

Using cushions in the chair that offload, we also use heel elevation devices to help offload Pressure injuries from happening two legs in heels. Those are 100% proven to be effective in reducing well causing zero injuries. So yeah, I mean, just those simple things and instituting those and having nurses just know that, okay, this patient isn’t, you know, up and about which most of our ICU patients still have at risk, Braden rates, and so they just grabbed them for right from the beginning of Institute those so

Kali Dayton 10:43
yeah, I do see that it may. So someone becomes encephalopathic, or maybe hyperoctive delirious or things like that during kind of altered mental status. You’re right, they, I guess that’s a nurse practitioner. I’m not so involved in all those little details, but they do. They just, they just grabbed the things. It’s always preventative, prophylactic interventions to prevent those things.

And so why is that so important? I think a lot of this podcast is about the long term outcomes, the big picture. And so of course, a pressure injury is a sign of poor care. But what does that mean to a patient? What does it what does it take to heal a pressure injury that occurred in the ICU? And how does it impact their quality of life?

Cami – Wound Care Nurse Expert 11:25
The latest data that I saw was that a stage for hospital acquired pressure injury, and that still alone, just can cost right under $130,000 to treat. So significant amount, right? And a stage for depending on the other underlying medical problems that the patient has, I mean, can take upwards of a year or two this to heal. So you that doesn’t even encompass all of that time and costs, so affects not only the patient’s quality of life, but their families quality of life, because now they’re following up with when clinics and home care, or being admitted to skilled nursing facilities, and having to go to those appointments multiple times a week to help get this wound to heal. Not only that, their their risk of death is four and a half times greater than another individual that has exactly the same risk factors, but not a pressure injury. So that’s…

Kali Dayton 12:28
and what amount of time do you know four and a half times greater rate of mortality…

Cami – Wound Care Nurse Expert 12:32
Within a year.

Kali Dayton 12:33
Within the first year after discharge? woah…. I like have to wrap my brain around it. So $130,000 to treat a stage four pressure ulcer, your mortality rate is four times higher.

Cami – Wound Care Nurse Expert 12:46
Yeah, so 60,000 people die annually of a pressure injury.

Kali Dayton 12:51
I had no idea. Cami, I had no idea. That’s crazy.

Cami – Wound Care Nurse Expert 12:54
And also the second secondary complication, when related bacteremia can increase the mortality rate to 55%?

Kali Dayton 13:04
Oh, yeah, yeah, you just send them right back into septic shock.

Cami – Wound Care Nurse Expert 13:07
Correct.

Kali Dayton 13:08
And I guess when I when I think about these patients that are coming out of the ICU after being heavily sedated, they’re very weak, they’re going to SNFs because they can’t care for themselves anymore. They have pressure injuries that occurred during that time that they were in a medically-induced coma. But in the SNF, they’re so short staffed, they’re continuing to be immobile, continuing to lay in bed. So how obviously, how can I heal when they’re still stuck in bed because they’re so weak?

Cami – Wound Care Nurse Expert 13:39
Right. They can’t heal if the SNFs continue the things that we’re doing here by repositioning, get them moving, making sure they have adequate nutrition, that there have a good wound care staff that’s helping to make sure that is the wound that evolves and changes that they’re being treated appropriately or that they’re going to a wound clinic, which is really important to help get those ones to closure.

It’s certainly possible. We do it all the time. But it does require a high level of coordination and commitment to get these wounds to heal and education for the staff, you know, down to the CNA level, especially that- I’ve got to take care of this patient. I can’t just leave them sitting in their chair for you know, more than an hour or two. I need to be turning them and repositioning them and making sure their briefs are changed or pillows or under their heels. So it’s a big Yeah, really. When we get a patient with a pressure injury. We’re signing them up for a long battle. Yep.

Kali Dayton 14:39
I really took SNFs for granted, it is not just pill passing. Not at all I mean, we make these messes in the ICU. We allow people to become so debilitated and and rot. – Is that a bad word to use? Is that bad for me. Do you say that patients when they’re in medically induced coma is that they “rot”? I mean their muscles atrophy but their skin literally rots.

And then we sit into SNFs that are already in this hard positions. We know, nurses know – we know what it’s really like for them. And they work so hard and they try so hard. But you these are these are vulnerable, fragile people. And I just hadn’t really thought of pressure ulcers being such a huge risk factor for death.

And now it’s COVID. I’m hearing of these survivors come out coming out of the hospitals and some of these overloaded areas. Young people in their late 40s or 50s, that are coming out with pressure ulcers from from being hospitalized for COVID. I know a lot of that is because it’s such a difficult situation. I know if a unit would have had 13 patients to one nurse, there’s no way you can turn them every two hours.

But yet, I look at some of our patients right now. They’re two to one. But still, if we had them totally sedated, it would change their outcomes entirely. And so I just asked a patient who was intubated sitting on her chair suctioning in her mouth, and I was explaining to her she’ll be on the podcast later as asking her she told on the podcast I had explained to her, “Hey, if you’re in probably any other hospital right now, with your ventilator settings, you would be sedated.”

And her eyes got huge. And she shook her head. And like, like, “Why would I have to be sedated?” I didn’t mean to laugh, but I was like, “I know. It’s I was like you and me, girlfriend? I’m with you. That’s…. I don’t know why you’d have to be sedated. But you would be.” So just even looking at her. She’s been on the ventilator for… six days, maybe? How much more would her risk be increased to have a pressure ulcer?

Cami – Wound Care Nurse Expert 16:34
Significantly. Yeah, I don’t know what the data for that is- with sedation. But you know, where she’s able to be alert enough to help to direct us and say, “You know, I I’m uncomfortable here. I need some help to be repositioned.” You know, so that indicator for her to tell us, you know, “I’m uncomfortable” or whatnot.

But there’s something along the lines of seeing intubated patients, and they tend to be more moist, they tend to be more sweaty, and I’ve noticed that over the years.

Kali Dayton 17:03
uh huh.

Cami – Wound Care Nurse Expert 17:04
And that adds to an increase in risk and pressure injuries by just that retained moisture, we call it the “patient’s microclimate”. So that alone contributes a lot to pressure injuries by having, you know, that increased microclimate next to the patient. So we, we as ostomy nurses, when COVID hit nationally, you know, all kind of rally together, because we knew that we were up for this battle.

And you know, I’ve heard some really terrible things coming out in New York, with young people getting pressure injuries, but not really only that, all of the patients that have been intubated or been really sick. And so here, we became really proactive about making sure we ordered in extra beds and extra offloading boots and dressings and things that we might possibly need. But honestly, it’s new territory for all of us, right? And so we’re just gonna have to be extra diligent as we can to just keep those patients moving turned as much as they can tolerate and creative about offloading those bones, bony prominences with anything we can really find that’s available to help protect. So.

Kali Dayton 18:16
Okay, that just totally blows my mind, because I had this whole long list of “Why not to sedate, and immobilize and leave patients to rot on the ventilator”. And I had been thinking about the functional part of it, the muscular part of it, the cognitive function, the psychological aspect of it, the pulmonary aspect of it, but skin. I just…

Cami – Wound Care Nurse Expert 18:38
The largest organ of the body.

Kali Dayton 18:40
Yes, yeah. And that’s deeply impacted. And now, when you talk about moisture, I’m like, “yeah, when I get a patient up to walk, their gown is stuck to their back. The sheet, or the chuck is stuck to their back.” I mean, they, they’re sweaty, but we’re getting them up. And a lot of times when we can get them when we get them up, we just wash them off with the washcloth really quick. And they feel better, they get to dry out, and then they sit in a chair, and then they get back to the bed, but they’re not on the same sheets, which changes sheets while they’re up. It’s just so innate, that I didn’t even realize the value of that.

Cami – Wound Care Nurse Expert 19:13
Significant value in protecting that patient and their quality of life. Right then, like you said, making them feel better, but helping them down the road to prevent them from, you know, being signed up for something terrible, as far as, you know, quality of life for them and their family but also potentially losing their life because of a pressure injury.

Kali Dayton 19:33
Wow. Well, thank you and your whole specialty for all that you do. I hadn’t thought about wound care’s response to COVID. I mean, that’s how sad had to end up anticipate people coming out of critical care, having rotten parts of their body. It’s just, it’s heartbreaking. But I think the more that critical care realizes what’s possible, the why and the how, hopefully we can make your job easier and bring you less heartache.

Cami – Wound Care Nurse Expert 20:01
It’s all a team effort, thank you.

Kali Dayton 20:03
Thank you Kami, I appreciate it.

 

Transcribed by https://otter.ai

 

References

Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., Golinko, M., Yan, A., Lyder, C., & Vladeck, B. 2010. High cost of stage iv pressure ulcers. Clinical Science, 200 (4). 

Brown, G. (2003). Long-term outcomes of full-thickness pressure ulcers: healing and mortality. Ostomy and Wound Management, 49(10).

Kirman, C. (2020). What is the mortality rate for pressure injuries (pressure ulcers)? Medscape. 

Redelings, M., Sorvillo, F., & Lee, N. (2005). Pressures ulcers: more deadly than we thought? Advanced Skin Wound Care, 18(7). 

 

 

 

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