In November, the Australian Commission on Safety and Quality in Health Care (ACSQHC) released a new edition of the National Safety and Quality Health Services Standards (NSQHSS). The ACSQHC has presented the new edition as less siloed and more integrated, with a greater emphasis on clinical leadership.
The standards have been consolidated and streamlined, and in this edition pressure injury is positioned as one component of a comprehensive care standard. In the first edition there were 22 actions required to prevent and manage pressure injury, while the second edition contains 3 actions.
Wounds Australia is concerned that this will impact on patient outcomes and in the post below, CEO Anne Buck discusses why she is calling for a more comprehensive and evidence-based approach to reducing the incidence of hospital acquired pressure injury.
Why preventing pressure injury matters
Anne Buck writes:
“A pressure injury is a localised injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from sustained pressure (including pressure associated with sheer).”
They often develop on the heels, sacrum and hips. Pressure Injury is a common hospital-acquired complication, affecting between 9.5 to 17.6% of people in hospital at any point in time. Importantly, surveys have consistently identified around 70% of people in health care settings are at risk of developing a pressure injury. Pressure injuries are preventable, but pressure injuries and complications arising from PI can lead to death.
Pressure injury has a significant impact on the individual, affecting their quality of life, mood, sleep, causing pain and discomfort, social isolation and embarrassment. Patients have described the experience as being the worst thing that could happen to them, as isolating, and frustrating. They experience anxiety that their wound won’t heal and the length of treatment.
Pressure Injury is costly, with one recent study estimated the cost of treating pressure injury to be $983 million per annum. However, this study identified a paucity of data and emphasized that it was a conservative estimate. The Independent Hospital Pricing Authority estimates a 13.9% cost-of-care for a patient who develops a hospital acquired pressure injury.
The NSW Clinical Excellence Commission’s Pressure Injury Prevention Project illustrates a hospital acquired pressure injury’s impact on the individual, their family and the health system with a detailed patient journey.
Impact of the changes in the NSQHSS
Preventing hospital acquired pressure injury is a work in progress. The NSQHS Standards are an extremely important tool to deliver better outcomes for patients. Published data on the prevalence of pressure injury and the impact of Standard 8 is limited, but there are some promising signs, such as data from the NSW Clinical Excellence Commission.
Pressure injury requires strong championing in the health service, with many steps in patient journey where pressure injury prevention and management can fail. Wounds Australia is concerned that with pressure injury being consolidated and streamlined into a standard on comprehensive care, this will mean:
- Screening and risk assessment for pressure injury will be integrated into comprehensive care screening that covers falls, nutrition and hydration, cognitive impairment and confusion, mental health, and aggression and violence. This is worrying when the latest survey in NSW, shows that despite Standard 8, only 60% of patients received a comprehensive risk assessment including a skin assessment and a validated tool within 8 hours of presentation to the hospital.
- Monitoring and quality improvement activities specifically to prevent pressure injury will be integrated with other comprehensive care monitoring. With already limited data on pressure injury, how will we be able to measure the impact of pressure injury?
At the same time that the Commission has made this change, the Independent Hospital Pricing Authority has announced that funding will be withdrawn for hospital acquired complications, including pressure injury. Croakey has previously reported that this funding approach is unlikely to improve safety and quality in health care as a stand-alone strategy. The Commonwealth has missed an opportunity to apply multiple policy levers to safety and quality in health care
Naturally many voices have urged the Commission to embed their issue into the standards – because they work to promote action and improve outcomes. But for the 70% of patients at risk of pressure injury, these changes are a premature step. The concern is that by consolidating and streamlining a number of risk areas into one standard, this will have a dilution effect: fewer actions across multiple ‘comprehensive care’ areas will spread the efforts too thin.
How do health services prevent pressure injury?
Preventing pressure injury and reducing the impact of pressure injury is achievable through following the internationally acknowledged Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. The Guidelines provide comprehensive guidance on the actions needed to prevent pressure injury.
A key recommendation is that a risk assessment for pressure injury be conducted within 8 hours of admission. The Guidelines also provide recommendations on assessment and classification of the pressure injury (which become important for funding purposes) and cover all aspects of treatment.
Implementing these Guidelines require a whole-of-organisation focus, from policies to, leadership from management and education. Where hospitals have been successful in reducing their PI prevalence, they have attributed the success to this approach.
What is Wounds Australia calling for?
Lowering the rate of hospital acquired pressure injury requires leadership to implement clinical practice guidelines across all parts of the hospital – from emergency to outpatients, from the data systems to the procurement system. Education for patients, their families and carers, support staff as well as clinicians is needed.
Pressure Injury and wound care is a complex area and for some patients, they will also need access to specialist staff who can provide advice on complex PI and wound management.
Ultimately Wounds Australia wants to make sure patients experience safe and quality care, and to work with the Commission to this end. While the Standards have changed, we need to ensure hospitals and health services don’t reduce their efforts in preventing pressure injury. There are other tools that can drive safe and quality health care, particularly the accreditation processes. We hope that these tools are strong enough to maintain the ground on pressure injury.
“Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. The Guidelines provide comprehensive guidance on the actions needed to prevent pressure injury.”
These guidelines do not provide the clinician with the pathological cause of pressure injuries/ulcers in the decubitus zones of the body.
As wounds which are necrosis based, the important background to understanding these wounds is in a knowledge of the histological structure of the skin/subcutaneous tissue complex and the Angiosome Concept, which describes the modern understanding of the blood supply to the skin.
When these are comprehended, the mechanical effects of vascular injury (i.e. pressure, shear and friction) over the architecture of the blood vessels which supply the cells that form the skin/subcutaneous tissue complex, and particularly the capillaries in the dermal and sub-dermal tissues, can be explained. This is the basis of why offloading and interface dressings (i.e. Mepiplex) can work to minimise the degree of compressive forces caused by pressure over bony processes.