It’s estimated that 95% of all pressure injuries are preventable so how can aged care facilities best support their care workers and nurses to look after residents’ skin?
Wound clinical nurse specialist and president of the New Zealand Wound Care Society, Mandy Pagan, ran a six month pilot programme last year with staff at two Invercargill aged care facilities to see what improvements could be made to prevent and manage skin-related issues and wounds.
Her research found skin and wound care education, combined with meaningful procedures and guidelines for staff, could significantly improve knowledge and outcomes for residents.
“Nurses and care workers work incredibly hard in a very challenging environment,” she says. “Their aroha and devotion is wonderful. But residents are now coming into aged care more dependent than ever before. They have higher rates of cognitive impairment, incontinence, immobility – all of which increase the risk of pressure injuries.”
Having an agreed in-house skin care regime is the first step, Mandy says. Wall posters which identify what types of barrier creams should be used to prevent incontinence-associated dermatitis, and what other moisturising products to use (how often and when), will provide a clear guideline for staff to follow.
“Soap, for example, will strip and dry the skin of an older person so you want to use a soap substitute instead. A good skin regime will improve skin elasticity and moisture to provide more protection and resilience to tearing.”
Care workers must also be trained to look for warning signs of pressure injuries developing. “We want them to identify when the skin is red or purple but still intact. A stage one pressure injury is red skin that doesn’t blanch which means when you push it, it stays red. When pressure is removed off a stage one pressure injury it will resolve; if not it will deteriorate, forming a wound.
“Purple skin, related to pressure, looks like a bruise which may resolve but can also break down into a wound. We want them to report those back to the nurses.”
Pressure injuries cause pain, reduce a person’s quality of life and are a financial burden to manage, Mandy says. “Some will never heal in this compromised population which is devastating for residents, their family/whanau and staff. We must focus on prevention!”
Having a shared communication ‘red skin alert’ chart for residents is one way to make sure those early warning signs are communicated between care workers, nurses and their night shift colleagues and acted upon in a timely manner.
Mandy points out that equipment such as bed-cradles, catheters, splints, plaster casts or even tight footwear can also cause pressure injuries and should be repositioned regularly or removed if necessary. And just because a resident has an alternating air mattress, doesn’t mean they don’t need to be regularly turned.
“Staff need to consider the intensity and duration of pressure. Residents who are sitting upright in a chair have a higher concentration of pressure than someone who is reclined or lying down. They still need those small positional changes throughout the day which can be challenging if the resident has contractures or they’re cognitively impaired.”
Some staff will be well-informed on pressure area care, while others will have very limited knowledge or training. “It’s important to know what your gaps in practice are and education must be tailored to the needs of your care workers. Some staff will still try and massage reddened areas which is a big no-no. The damage is already done and you’re just going to cause more damage.”
During her pilot programme, Mandy discovered short on-site tutorials with supporting guidelines (developed with nurse and care worker input), were the most effective education method. Aged care facilities are staff and time-poor so education must be relevant and implemented to improve care. She also developed a series of one page pictorial ‘hot tips’ that were given to staff once a week to communicate key messages.
“This prevented conflicts of information from occurring, which can be difficult when there’s a hierarchy between nurses and care workers. When you do bring something new in, it must be communicated in some form across all staff so they understand what it means and how to do it. Care workers certainly felt more empowered by having standard guidelines to support their practice.”
The NZ Wound Care Society, in partnership with ACC, HQSC and MOH, has promoted international ‘Stop Pressure Injury’ day for many years, with the acronym SSKIN used to explain basic pressure injury prevention principles. But despite facilities displaying SSKIN posters, Mandy discovered the majority of nursing and care worker staff did not know what SSKIN stood for.
“It stands for Surface (making sure residents are on the correct supportive surface), Skin inspections (looking for skin discolouration and pain), Keep moving (to keep the pressure off and let the blood flow back to that area), Incontinence (keeping skin clean, dry and protected) and Nutrition (because food and fluids are important for healthy skin and wellbeing).”
From a governance perspective, there’s also a great deal more that can be done to support staff working at the coalface.
Pressure care equipment should be on a regular maintenance programme and items such as high specification standard bed mattresses, air alternating mattresses, seat cushions and heel devices should be on a regular audit and replacement programme.
During the Invercargill pilot, eight air mattresses were found to have punctured air-cells and weren’t operating to provide the pressure relief that staff and residents assumed they were.
“To check air-alternating mattresses are working, put them on static so all the air cells are up and touch each one to make sure they’re inflated,” Mandy says. “Regular cleaning is another area that should be addressed. Often equipment isn’t cleaned unless it’s visibly soiled. But it may be with the resident until transfer or end of life. I recommend waterproof coverings are cleaned at least weekly with a neutral detergent as part of best infection control practice.”
A good range of pressure relief and positioning devices are required in aged care facilities because one size doesn’t fit all residents. “Having access to small bean bags or cushions between knees so bones don’t touch each other, that sort of thing, is really important.”
Effective leadership and being open to change is another crucial component. “If people attend education but then come back to a facility where they can’t implement the great ideas they’ve learned, it’s a waste. It’s important we develop nurse and care worker champions in the workplace to lead these changes.”
In her role with the Southern DHB, Mandy oversees the treatment of the most complex wounds which can come from the community, hospitals or occur in residential aged care settings.
“There is a national drive with fantastic work occurring in partnership with ACC to prevent pressure injuries occurring. Let’s be proactive; prevention does cost but is cheaper than treating a pressure injury. We need good equipment, standard skin care regimes, meaningful staff training and to ensure we are all working and communicating effectively together. Prevention is key.”
Mandy says the third edition of the International Clinical Practice Guideline for the Prevention and Treatment of Pressure Ulcers/Injuries will be released this month.
The NZ Wound Care Society also offers corporate membership and can provide support and educational resources for your staff. Visit www.nzwcs.org.nz for more information.