Two-person skin assessment builds a foundation for pressure injury prevention.
- Pressure injury (PI) care bundles help to reduce variations in care and improve outcomes.
- PI care bundles should include risk assessment, support surface selection, patient turning, incontinence management, and nutrition.
By Catherine Spader, RN
An interview with Debra Crawford, BA, ADN, RN, CWOCN, CFCN. Crawford is the team and wound, ostomy, continence (WOC) nurse at Mercy Health Saint Mary’s Campus in Grand Rapids, Michigan.
Intensive care unit (ICU) nurses face many challenges when caring for their patients and must sometimes focus on immediate life-saving interventions. Unfortunately, protecting the skin can get bumped down the priority list and lead to serious problems later.
“The skin is the largest organ in the body and deserves a lot of attention,” says Crawford. “When it breaks down, patients are prone to infection—and people can die from infection—so we can’t forget it.”
Another concern is that the Centers for Medicare and Medicaid Services (CMS) doesn’t reimburse for the treatment of hospital-acquired stage 3 and 4 pressure injuries (PIs). “In the ICU, we can no longer save a patient’s life today and worry about the skin tomorrow,” Crawford says.
The process: Two sets of eyes are better than one
PI prevention in the ICU at Mercy Health Saint Mary’s Campus begins the moment a patient is admitted. All patients receive a two-person nursing assessment that includes examining the entire skin. The assessment is repeated when a patient is transferred to another unit, and anytime a patient has been off a unit for more than 2 hours.
Risks are also evaluated and documented. Factors that make ICU patients especially vulnerable to PI include:
- some critical-care drugs, such as vasopressors, which can cause ischemia and tissue necrosis
- decreased level of consciousness
- lack of mobility and difficulty turning
- use of multiple medical devices that can cause pressure on the skin, such as respiratory devices and automatic blood pressure cuffs
- hemodynamic instability that’s worsened with physical movement
- history of surgery lasting longer than 3 hours
- need to leave the ICU for long periods, such as for dialysis or imaging procedures
- poor nutritional status before admission and possibly during hospitalization.
After each assessment, ICU nurses flag at-risk patients and those with skin changes in the electronic health record for a consult with a WOC nurse. “Sometimes it turns out to be nothing of concern, like a mole,” Crawford says, “but I would rather the nurses be vigilant than let anything questionable go.”
The review: Diving deep
Despite the ICU’s best efforts, not all PIs are avoidable, according to Crawford. Unfortunately, no CMS criteria exist to determine if a PI was preventable. When a PI occurs at Mercy Health Saint Mary’s Campus, a collaborative team performs an intensive deep-dive review to determine if it was preventable. The team includes:
- clinical nurse specialists and leaders
- department manager and other hospital leadership
- WOC nurses
- unit skin champions
- risk-management representative.
The review process includes the Indiana University Health Pressure Ulcer Prevention Inventory, which is an objective tool that determines if a PI could have been prevented. It includes these elements:
- Braden Scale for Predicting Pressure Sore Risk
- documented staff assessments
- whether appropriate interventions were performed based on the assessments.
“The Indiana University Health Pressure Ulcer Prevention Inventory minimizes subjectivity in judging whether our staff is doing a thorough job,” Crawford says. “We don’t encounter any surprises, and we’ve found that some PIs were unavoidable.”
SCALE: Skin changes at life’s end
The review process also may include assessing the patient for skin changes at life’s end (SCALE), which considers physiologic changes that occur during the dying process that may affect the skin and soft tissue. These changes may be unavoidable and occur regardless of interventions that meet or exceed the standard of care. This assessment may be appropriate when a patient is declining rapidly or is transferred to hospice care while in the hospital.
The key: Staff nurses
ICU staff nurses play a vital role in the deep-dive review process. They present their insight about the patient using the situation, background, assessment, and recommendation (SBAR) technique, which facilitates brief, organized, and clear communication about the patient.
“Not every detail gets documented in the chart,” Crawford says, “SBAR allows nurses to provide the real-world view, and their perspective of the patient and the situation.”
The team then presents the facts from the documentation, and they determine what can be done to prevent similar incidents in the future. Their findings are shared in written, photographic, and verbal form with leadership and all units.
Prevention: Build a foundation
Crawford believes that an effective review process and PI-prevention program is built on the foundation of the two-person skin assessment upon admission. “If you do your due diligence in the beginning, then you can say with certainty where the injury occurred, and investigate and address how it could have been prevented,” she says.
Catherine Spader is a medical and healthcare writer and editor in Littleton, Colorado.