Caring for Pressure Injuries in the ICU

caring for pressure ulcers in the icu

Every day, the Intensive Care Unit (ICU) of every busy hospital around the world receives new patients with severe conditions that require comprehensive treatment and monitoring. The units are usually staffed with a higher number of medical professionals on duty at any given time than other ward. The staff is particularly well trained to treat people with critical illnesses.

It's a unit that saves lives each day because of the essential treatment it provides. It's also one of the most common settings for pressure injuries.

The problem is that many of the illnesses that bring people to the ICU also pose a challenge to skin integrity. And many of the drugs they receive as treatment often make skin more vulnerable to rupture as well.

The combination has proven to be an enormous challenge to ICUs, even with all of the extra attention devoted to each patient.

"ICUs have the highest rates of PIs in Australian hospitals," said Fiona Coyer, professor of Critical Care and Clinical Support Services, Royal Brisbane & Women’s Hospital (RBWH). "We used to have a 50% PI rate, according to a study from 2008, but we’ve reduced that to 30% following interventions in critical care nursing."

The steps the Australian ICU took to reduce the incidence rate can be applied to reduce PIs everywhere, but especially in ICUs across the world.

Converting Theory into Practice

The strategy implemented at Prof. Coyer's hospital showed improvement week over week. "We felt that the very high incidence rate was due to lack of translation from theory into practice," she said. "We attempted to address that to improve skin integrity for this vulnerable population."

Strategy implementation made a point of taking time to discover the challenges and advantages to placing an emphasis on PI prevention in the ICU setting and then identify the people who were most likely to implement the strategy.

"We looked at key adopters of the strategies, like the ICU RNs, used focus groups to assess awareness and knowledge, and evaluated the practice environment," Prof. Coyer commented. "We then established an expert clinical liaision group because we need champions to drive the uptake of these strategies."

The strategy included:

1. Turn Audit – Turning patients regularly helps blood flow through the body and prevents skin from staying in one position for too long. At RBWH, patients were turned every 2.5 hours. "Unlike the UK, we have patient care assistants," she said. "The patient care assistant does the manual handling so the nurse can visually inspect the back."

2. Skin Integrity Round - Every week, the clinical nurse consultant in charge of the unit asked an RN to present a patient for the multidisciplinary round. All nurses were invited to attend, along with dieticians, physiotherapists, and occupational therapists.

"This started a system of skin integrity round feedback," Prof. Coyer noted. "The results of the audits were emailed to the RNs each week, improving the flow of information and placing an emphasis on PIs and skin integrity in daily treatment.”

3. Mandatory In-Service on Skin Integrity - Each member of the team received additional training on pressure injury prevention based on the results of the audits that followed each week.

Prof. Coyer said some measures were particularly successful. "We implemented prophylactic dressings, which had an impact especially with the in-service that came along with it."

Turning ICUs into PI Free Zones

Prof. Coyer also said any statistical comparison between different units at hospitals is not useful because every type of unit has its particular qualities. To understand if a strategy is successful, it should be compared to another ICU of a similar size rather than an alternate ward inside the same hospital.

This allows heads of the unit to build realistic benchmarks. It allows them to monitor their own performance in preventing pressure injuries, and learn from others who are facing similar conditions and challenges.

Although conditions do not allow any strategy to lead to the complete eradication of pressure injuries in the intensive care unit, the most successful measures, she said, aim for the greatest impact.

"A zero rate for the ICU is not achievable because patients are admitted with a serious diagnosis, and in higher level ICUs, they often have a lengthy course of treatment during their critical illness," she said.

But this does not diminish the important need for PI prevention strategies, namely identifying patients at very high risk and consistently implementing prevention strategies for these patients.

"Zero is our goal even if it is not always attainable."