Current guidelines for preventing pressure ulcers are outdated and existing risk assessment tools are “like flipping a coin”, an international expert says.
Netherlands-based Dick Schilstra, a trained tissue viability nurse who now specialises in medical devices for pressure care as Group Product Manager at TSS Invacare, was in Sydney this month to address a conference about developments in pressure wound care.
Mr Schilstra says current practices and risk assessments are outdated, lack reliability and often do more harm than good.
“There’s a lot of knowlege among healthcare staff about pressure ulcers but quite often it’s outdated knowledge,” he told Community Care Review after speaking at the ATSA Independent Living Expo on May 9.
“As health care workers we like to check boxes and get an answer that says ‘this patient is not at risk’.
“But there are 92 different risk assessment tools for the same problem and they all have a scientific reliability of round about 30-50 per cent, so it’s just like flipping a coin.”
What is a pressure wound?
A pressure wound is localised injury to the skin or tissue resulting from sustained pressure or pressure combined with shear, or friction.
Sustained pressure on a body part – frequently the heels, sacrum, shoulder blades or elbows – blocks blood flow and oxygen to tissue, interfering with waste removal and resulting in a chemical imbalance.
External factors like pressure, shear, moisture and “microclimate” contribute to the formation of pressure ulcers, as well as intrinsic factors like frailty, mental capacity and nutrition.
Pressure ulcers are categorised into four stages, ranging from a red mark to a wound that goes down to the bone.
In Australia pressure wounds cost $285 million a year, Mr Schilstra said. “There’s a very big financial cost to this problem,” he told the conference.
It is important for carers to assess a person’s risk of developing a pressure ulcer, Mr Schilstra says, but they shouldn’t just rely on a risk assessment tool.
It is important to use clinical judgement taking in individual circumstances as well, he says.
While there is a choice of 92 different risk assessment tools, the type of tool used tends to depend on geography. In Australia and the UK the Waterlow Pressure Risk Assessment Chart is most common, while in other parts of the world the Norton Scale or Braden Risk Assessment Tool is more common.
But Mr Schilstra says the problem of pressure ulcers is too complex to capture in a single risk assessment tool.
“There are so many influencing factors,” he says.
“The main causation of pressure ulcers are pressure and shear. But if a patient is old, or has diabetes, for example that’s a different profile than a patient that has asthma and is in a bed and has difficulty breathing.
“That patient has a very different type of risk profile which is not captured within risk assessment tools.”
Repositionining is also vital in avoiding pressure ulcers, but it’s done in the wrong way it can make the problem worse, Mr Schilstra says.
He says there have been some significant research developments, but these have not been adopted in practices.
For example, recent research showing that tissue deformation can quickly cause skin damage has implications for repositioning techniques, which if done incorrectly can result in tissue deformation.
“Quite often nurses ‘grab’ a patient in way that causes tissue deformation and that’s a recipe for disaster if you’re not doing it right,” he says.
Mr Schilstra says home healthcare workers face specific challenges when it comes to pressure wounds. This includes having less time to spend with patients, who often also have limited finances to ensure they are getting the best beds and mattresses given the wide range of therapeutic options.
“For home care nurses it’s very important to involve the patient and the family because they are always there,” he says.
“For home nursing staff its very important to keep their knowledge up to date so they can instruct the patient’s family on techniques like correct positioning.
“There’s a lot of team work and the team involves the patient and their family.”