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- [00:02]
Sue Crehan
Talking all things wound care. This is the Pressure Effect brought to you by Smith and Nephew.
- [00:14]
Dr. Lee Ruzzi
Welcome to the Pressure Effect from Smith and Nephew. I'm your host, Dr. Lee Ruzzi. Today we're sharing a special bonus episode. Our topic for today is prophylactic dressing use to reduce pressure injury. Joining us to discuss this subject is is wound care nurse consultant Sue Crehan, msnrn, cwn. In addition to her present consultant work, sue has developed a wonderful program some years ago at Virginia Commonwealth University in Richmond, Virginia for inpatient wound care. So sue has been in this world for a long time and I am pleased to count her among my friends. Today we'll discuss best practices for using prophylactic dressings, the differences between types of multilayer foam dressings, and new research coming down the pipeline. Sue, welcome to the show.
- [01:16]
Sue Crehan
Oh, thank you, Lee. It's a pleasure to be here with you today.
- [01:19]
Dr. Lee Ruzzi
So pressure injuries are still on the rise in today's healthcare environment, placing not only a quality of life burden on the patients, but also a really significant financial burden on the healthcare institutions across the country. Do you have a little bit of insight for us on ways that the bedside clinician can address this ongoing problem?
- [01:46]
Sue Crehan
Leigh, you're 100% right in the fact that for whatever reason, pressure injuries is one of the hospital acquired conditions that has been very difficult for clinicians to wrap their arms around in order to reduce the incidence of hospital acquired pressure injuries. And unfortunately there have been financial penalties that have been set against hospitals whose performance with not being able to decrease their pressure injury rates and falling into the bottom quartile of hospitals reporting to CMS. They are being charged with penalties up to 1% of their Medicare dollars being withheld when they're unable to successfully bring down hospital acquired conditions. All of them, but specifically hospital acquired pressure injuries. The reason it's tough for the bedside nurse to actually make the difference that they really want to make is that out of all the hospital acquired conditions, I think pressure injuries is the most complex. It's complex because every patient brings to us their own set of comorbidities, their own list of drugs, their own health status, be it poor, their own body structures. And every single person is different, of course. And to be able to avoid hospital acquired pressure ulcers from occurring, the nurse has to implement some evidence based bedside practices. But the way these practices work on one individual may need to be tweaked for the individual in the bedside next to that patient. And so it's not only a matter of just one size fits all it's where you have to be able to give and take. You have to be able to constantly being, assessing and reassessing the patient in order to successfully provide the care that they need to eliminate or avoid them developing a pressure injury. Some of the other hospital acquired conditions are very easy to reduce because it's just a matter of following a checklist. And pressure injuries just seems to be much more complicated than that. And I think that's been the challenge around the country, Lee, is that there's so many nuances to how you reduce pressure injuries or avoid pressure injuries that it's just, it's a conundrum.
- [04:35]
Dr. Lee Ruzzi
Well, you know, you use the word nuances and that is so true. That's exactly the word that was floating around in my mind while you were just sharing those thoughts with us. As you said, it's not like line sepsis or catheter acquired urinary tract infections where it's a fairly discrete, isolated problem. There are so many variances in what sort of factors play into an individual's risk for the development of pressure injury. So what are your thoughts about best practices? Not necessarily at the bedside level, but. But at the organizational level.
- [05:14]
Sue Crehan
I'm so glad you asked that, because that's like one of the topics that burns inside of me because I realized quite a few years ago that pressure injuries are not just a nursing issue for many, historically speaking, for many years, nurses were blamed for pressure injuries when they occurred. Everyone pointed to the nurse and saying, we missed something or we didn't implement something. And while that may partially be true, the bigger picture of pressure injury prevention is that it is a hospital concern. It needs to be dealt with on an organizational level, on a macro level, on a meso level, and on a micro level. And by that I mean organizationally, macro level, meso level, on each individual unit with staff there, and then micro level, including the patient and the family. So that's how I like to kind of break it down in my head. But that macro level, that organizational piece, is that senior leadership within hospital systems must be keenly aware of pressure injury data. And actually, I like them to actually know what a pressure injury is and how they develop and what causes them. So it's not only them knowing the data, but also knowing something about the problem, understanding a little bit about the problem. So they need to be, senior leadership needs to be engaged. And an effective program, an effective pressure injury prevention program has someone in the C suites that is their advocate and.
- [07:09]
Dr. Lee Ruzzi
Is looking at it in some fashion other than simply dollars Spent for prevention.
- [07:16]
Sue Crehan
Exactly, Lee. Because again, it's not just about the money. It's about human resources, too. Right. So making sure that the staffing levels are appropriate is one big thing. And so senior leadership needs to be involved in monitoring the data, watching the data, also in removing barriers that exist within the health system that may cause nurses not to be able to do the things that they need to do or want to do. So it's removing barriers, it's watching the data, and it's being an advocate for resources.
- [07:57]
Dr. Lee Ruzzi
I'm thinking back to what you said about this has always been thought to be a fault of the nursing and, you know, smiling, thinking about that. You, Florence Nightingale, how many years ago said that, you know, if the patient develops a bed sore, it's the fault of the nursing, not the f of the patient. But I think, you know one thing. And sue, you're probably going to laugh about this a little bit, because this has been one of my soapboxes for a few years. So for the audience, sue and I not only have known each other for a number of years, but we've spent some time on the board of directors of the National Pressure Injury Advisory Panel together. And one of my soapboxes has been that there's another important part of the healthcare team that typically is very poorly informed about pressure injury, both in prevention, treatment, and staging, and that is the provider segment, the physicians, the advanced practice providers, and we've got to get in the game in order for the team to work.
- [09:00]
Sue Crehan
That's 100% right, Lee. And, you know, I think we're in this paradigm shift right now across the nation, where as we embrace this idea that pressure injuries are not just a nursing issue, they're an organizational issue. As that becomes more spoken about and embraced and actually implemented, providers are being pulled in. But sometimes, Lee, honestly, and I love you as a physician, I like all the providers that I ever worked with alongside, but they come kicking and screaming when it comes to pressure injuries. It's like, you know, you just. They don't want to be bothered. It's a. It's not in their wheelhouse of things they are focused on with a patient. You even look, you know, whenever you're doing an HMP and going through all the systems, right? The providers going through all the systems and doing this comprehensive HMP skin, every. It's either labeled as integumentary or just skin or something like that. And every single time you read an hmp, its skin is warm and dry, no rashes like that's. And it just drives me crazy that there's not, there's not the thought process that goes beyond warm and dry and no rashes.
- [10:25]
Dr. Lee Ruzzi
That is so true. I can't remember the last time I saw an H and P by a provider that spelled out a discrete pressure injury. So just a quick anecdote in, in my prior program, we had the same problem within our five hospitals that everybody has around the country. And our chief medical officer, with a big smile on his face told me that he was going to mandate that every departmental meeting in the coming months until they got through all the specialties was going to have to listen to me talk with them for a half an hour about pressure injuries.
- [11:08]
Sue Crehan
Pressure injuries.
- [11:09]
Dr. Lee Ruzzi
Talk about kicking and screaming. But again, to your point about senior leadership, it has to come from that level. They're not going to come listen to me because I put up a poster someplace and say, hey, you know, come on over and we'll talk about bed sores. So let's move on a little bit to the 2019 international guidelines of which the NPIAP, the EPUAP and the PPPIA are members. Tell the audience a little bit, just from a 30,000 foot view about whether there are patient specific best practices that are contained in the guideline.
- [11:49]
Sue Crehan
Okay? Absolutely, Leigh. So that our clinical practice guideline for prevention and treatment is actually a 400 plus page document and that is a little overwhelming for a bedside nurse to pick up this book and try to find what it is they're looking for. And so they've the, they've created apps for it now and also, you know, a condensed version which is really great. Your question about are there specific practices, best practices that are contained therein? And the answer to that is absolutely yes. The clinical practice guidelines actually speak to all the best practices at the bedside, regardless of the setting. So there's content in there about ICU patients, about neonates, about pediatrics, about geriatrics, about at home applications for at home nursing home acute care settings. You can draw information about how to care for different patient populations as well, in that there's content in there about the morbidly obese patient, there's content in there about the spinal cord injured patient, about the comatose patient. So it really drills down quite nicely the best practices for various settings and various patient populations. In addition to being clinically applicable, these best practices that are found there, there's also best practices on an organizational level. We've addressed the fact that the organization needs to get on board as a whole. And so those best practices are Also located in the 2019 clinical practice guidelines.
- [13:45]
Dr. Lee Ruzzi
And I think another interesting FE is that each of the recommendations comes with it a level of evidence, and so that, you know, provides some comfort. Is this supported by randomized controlled trials or meta analyses? Or is this best practice advice based on expert opinion? It's, you know, it's a very open and transparent guideline, and we can look forward to the next guideline coming out in 2025. Sue, tell us a little bit about your experience with prophylactic dressing use in the prevention of pressure injury.
- [14:26]
Sue Crehan
Oh, yeah. So with my work at VCU Virginia Commonwealth University, we realized my team. So I was the manager for a team of wound care nurses, and we decided that we wanted to be ahead of the curve. We wanted to be proactive in our organization and develop a comprehensive pressure injury prevention program. And what we did to start off with. I am going to answer your question, Lee, but just a little bit of background here. What we did to start off with is one day I sat the team down and I said, okay, guys, we're going to be a think tank here. And what would it take for VCU to become a pressure injury prevention utopia, like, the best place ever for pressure injury prevention? And we just started listing all the things that would have to change, all the things that we would need to do and all the equipment and resources that we would need. We came up with, oh, my gosh, gobs and gobs of things that we realized we needed to work on. And we divided those things into different categories. We divided them into process, things in the hospital's process that would need to change, products that would need to change, education that would need to happen. Just a, you know, just a boatload of things. And we created a timeline, and every single thing that we wrote down, we ultimately addressed throughout the year, throughout the years took us a long time to get through everything. But the end result of that was that we had a comprehensive program that touched all 41 of our inpatient units. It included staff from providers to care partners, to transportation people to people in the emergency room, to the operating room. It also included every single ancillary department that a patient would go through. We gave education to our endoscopy suite, to our cardiac cath lab to interventional anywhere that the patient would go and would be cared for by staff members. Those staff members knew about pressure injury prevention and knew they had to participate and provide care regardless of where the patient was in the health system during that time of checking off and changing everything that needed to change at VCU and working as change agents for the organization advocating for patients to receive pressure injury prevention care. One of the clinicians that worked with me was working in our cardiac surgery intensive care unit and was seeing deep tissue injuries were a real problem there, not only from our heart transplant patients, but just really sick cardiac patients and trauma patients also. This individual worked in our surgery trauma intensive care unit as the wound care team representative. And we saw, actually it was Todd Brindle, that many people may be listening to the broadcast, may know. Todd and I chatted and he had this brainstorm of an idea. We had in our storeroom a five layer foam dressing that was super effective in managing moisture. And he's realizing that you see these deep tissue injuries developing on these trauma patients 48 hours after they get into our health system or whatever, maybe a little longer down, down the line. And he wanted to start, instead of just using these dressings for exudate management, he wanted to use them to see if it could cushion the sacrum because they're thick and pliable. And you thought, if there's a way we could put an interface between the support surface and the skin, the epidermal dermal layer of the skin, if there was something we could put in there to protect it, would that work? And just on a whim, we did a quality improvement project in that unit and found that, you know, after, I think it was 120 plus patients that we did this quality improvement project on, found that the pressure injuries in the control group, where the control group just received like standard skin care versus the intervention group that received the standard ICU skin bundle, in addition to the use of this prophylactic five layer foam dressing, we found a significant difference between the two and no pressure. Well, we had two pressure injuries in the intervention group and we had eight in the control group. And the two that happened in the intervention group were very minor stage two pressure injuries. And the ones that happened in the control group were deep tissue injuries and full thickness problems. So this was pretty exciting. And you know, he thought, oh my gosh. And so Todd started sharing that across the country and sharing his results. And ever since that, we added to our process, added to our protocol, added to the skin bundles. We had an ICU skin bundle, we had a med surg skin bundle, we had a pediatric skin bundle, et cetera, et cetera. But in each of those skin bundles we added with patients that are at risk and qualify for this skin bundle, then the addition of a five layer foam dressing on the sacrum at that Time we were only working with the sacrum. A few years later, maybe two years later, we also added the heels and started using prophylactic dressings also on the heels. But the results that we saw significantly reduced our overall hospital rates tremendously. So we had to prove the point or make a case for the hospital purchasing prophylactic dressings. Five layer foam dressings that weren't going to be used for treatment, they were going to be used simply for prevention. And so we had a voice at the value analysis table, went to value analysis, we took data, we took patient cases with us, and we took information that was coming out in the literature from other academic medical centers around the country. And we took all that information to the value analysis committee, made a case for why we were requesting to increase the amount of dressings that were being available on the shelves on all the units, and saw we were able to demonstrate the financial benefit because we know the cost of pressure injuries. And you take the cost of pressure injuries and the cost of addressing and multiply all that out, it creates a very clear case that prevention is cheaper than treatment. And so we were successful there and just rolled with it. And that's still a practice today. And here we are 10 years later and it's still in practice maybe 12 years later. Gosh, time flies.
- [22:38]
Dr. Lee Ruzzi
So there, folks, you have it. And you know, I had an opportunity to spend a couple of days with sue and Todd at VCU and I thinking maybe it was 20, 15, 16, something like that. And I remember clearly that I had never seen such a program in place. So they clearly were on the cutting edge of this and have contributed much to what we now know about pressure injury prevention with prophylactic foams. So on that note, sue, what are your thoughts? Are all multi layer foam dressings created equal or are there differences that make them more appropriate for prevention?
- [23:24]
Sue Crehan
Oh, that's a great question too, Lee. And my response to that would be, no, not all multilayer foam dressings are equal. It is actually apples and oranges and watermelons. You know, it's when prophylactic dressings gained their presence and proved their worth in the clinical world. Industry responded to that by creating companies. All, you know, multiple companies got to the drawing board and started manufacturing multi layered dressings. And what we see is that the brand that we used initially at VCU definitely had research that supported how the dressing functioned like the guts of the dressing was put together purposefully in order to take care of several things. And that is helps to redistribute pressure, helps to manage microclimate, helps to reduce shear and helps to absorb friction. And we knew that there were, that it was. What do you want to say? That it was effective and that the design was the reason it was effective. Even though the dressing was originally marketed for treatment, when it got broken down and studied, we realized that the design of the dressing was what made it effective in pressure injury prevention because it addressed those four major contributors to pressure injuries. Pressure, shear, friction and moisture. And then there, there's several. Well, there's another company that also manufactures a stellar five layer foam dressing and the construction of this dressing, A Leave in Life by Smith and Nephew. Just recently we found out that a Leave in Life is effective because there's a new mode of action that was discovered by Ahmed Geffen and his lab in Tel Aviv, Israel. And what Amit recently published about the Alevin Life dressing is that when the dressing is in place, and he studied the dressing on heels, when the dressing is in place, the dressing itself is able to absorb 30 to 45% of the frictional force that never makes it then to the skin and soft tissue, it's absorbed. That energy is absorbed within the dressing itself, therefore limiting the amount of friction that ever reaches the skin and soft tissue. And that's huge because when you can prove that a dressing is able to absorb a form of energy, a form, a mechanical force, that, namely here friction, reducing friction also reduces shear. And we know shear is the huge component that causes tissue damage down at the bone muscle interface, right? It causes cell distortion and that cell distortion, then the cytoskeleton of the cell breaks apart. And when that happens, then the whole metabolic process that goes on within the cell is dist and the cell eventually dies. And that happens very rapidly in individuals where pressure is unrelieved. So if we can minimize the shear and the friction that is exerted against the body by using multilayer foam dressing, we're on the winning team. Other companies, other manufacturers also have been putting on the market what they're calling prophylactic dressings. However, there's no research behind these dressings. They may be multi layer, but the types of materials that are used and how they're layered, one upon the other, whether they're bonded or free, there's so many factors that go into it that I just think we need to caution any clinician or any health system that is interested in getting into the use of prophylactic dressings. Please be careful about your selection and make sure you're choosing a company. I'll highlight Smith And Nephew here, like Smith and Nephew, that has research that's been done specifically on their dressing, and, and it's proven to be effective, and it tells you in the research project or the research study why it's effective. And you cannot take research that's done on one dressing and just kind of borrow it for your. For another company's dressing. It's not apples to apples. It's really apples, oranges, and watermelons. And I say watermelons because some of them are a real disaster. You know, some of them just don't make any sense. The dressings that are on the market that are being labeled as prophylactic, they're not, right?
- [29:17]
Dr. Lee Ruzzi
So important to read the data. But when you read the data, make sure you look at who published that data, because some of it gets borrowed, shall we say, and would lead us to believe that it's a class effect, that all foams are appropriate. So make sure in your selection, as sue said, that you choose. You choose one that actually has solid data. So interesting just to tack on. And I. If sue mentioned this, I missed it, but Dr. Amit Geffen is a mechanical engineer at the University of Tel Aviv in Israel, and Dr. Geffen, along with some other folks like Laura Edsburg, who's a present member of the NPIP panel, have really have helped us understand the mechanism of pressure injury from this perspective of mechanical strain and direct cellular death, where maybe a decade or 15 years ago it was thought that all pressure injuries were caused by occlusion of the capillaries. So, you know, it's a big team in a big world. And, you know, some folks that have really nothing to do with medicine in their original training have given us a lot of really valuable information. So, sue, that. That just about wraps up our conversation because you just very eloquently answered the last two questions that I was going to ask you. So there we are. But let me ask you this. Do you have any final thoughts that you'd like to share with our audience about this very large topic before we close?
- [31:01]
Sue Crehan
Well, yeah, Lee, I think it might be worth mentioning that the NPIAP has the Prophylactic Dressing Standard initiative going on. So I want to say maybe two and a half years ago, a group of individuals under the leadership of the NPIAP have been meeting with the purpose in mind to identify what are the characteristics that are required to label a dressing as prophylactic. So they're compiling information for industry and for clinicians that says these are the types of testing that industry should do. On their product. And the results of that testing then will identify whether or not that dressing truly is prophylactic. And I think this is going to be so helpful because it will kind of separate or weed out what is truly clinically effective versus what marketing is just telling us. So the work of the Prophylactic Dressing Standards Initiative is ongoing. And I don't know how much how long it's going to take for them to get their work published because it's still under construction. But I'm very excited about that. I'm very excited that we will have that type of standard so that the clinician doesn't get swayed by a sales rep giving information that may not be actually true and therefore may ultimately harm the patient. You and me and every clinician around the world is the advocate for the patient. None of us want patients to develop pressure injuries regardless of their setting. And we have to have not only the right tools necessary to prevent pressure injuries, which can be even life threatening, but also make sure that we all keep in our heart the fact that the patient needs to be the center of all the decisions that are made about what types of resources we have in our organizations. And the patient needs to be the center and at the heart of everything that we do. So I think that's about it. I was excited to just share a little bit about the standards initiative and then also just a reminder, hey guys, we're all in it for the patient. Keep the patient in your vision when you're making clinical decisions.
- [33:51]
Dr. Lee Ruzzi
I am so glad you brought up the Prophylactic Standards Initiative Group. And a gentleman by the name of Dr. David Brienza from the University of Pittsburgh, who actually is the will be the incoming president of the npiap, has been a big part of that movement and certainly not alone. He's got a number of members on that team and working hard at accomplishing exactly what sue just explained. So, sue, thanks so very much for joining us today. That was a wonderful bunch of information for the audience. Much appreciated.
- [34:29]
Sue Crehan
Thank you. Thank you, Lee. It's been a pleasure. Always.
- [34:38]
Dr. Lee Ruzzi
Well, that's it for this episode of the Pressure Effect. I want to say a big thank you once again to Sue Crehan for joining us today to discuss the use of prophylactic dressings to prevent pressure injuries. If you're enjoying the show, don't forget to subscribe and leave us a rating or review you I'm Dr. Lee Rutzi and I'll see you next time.