Medical device pressure ulcers in long term care settings - Is your organisation ready for Tissue Viability Updates?
Medical Device Related Pressure Ulcers can be defined as:
“Devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure ulcer generally closely conforms to the pattern or shape of the device.” EPUAP, NPUAP, and Pan Pacific Pressure Ulcer Alliance. ‘Prevention and Treatment of Pressure Ulcers’ (2015) Clinical Practice Guidelines.
The updated Tissue Viability guidelines in June 2018 state “A pressure ulcer that has developed due to the presence of a medical device should be referred to as a ‘medical device related pressure ulcer’ or MDRPU.”
They also recommend The National Pressure Ulcer Advisory Panel’s (NPUAP) 2015 definition of device-related pressure ulcers should be used: “Pressure ulcers that result from the use of devices designed and applied for diagnostic or therapeutic purposes.”
These tend to be viewed as a hospital acquired issue due to the amount of patients who are acutely unwell and are often restricted to bed and likely to be supported by multiple medical devices while an inpatient.
However, it is becoming increasingly common that patients are reliant of these devices in a home or long term care setting such as their own home, residential and nursing care and hospices.
How many of your residents have a catheter in situ or require oxygen? Many patients may be discharged with a splint in place or with anti embolism stockings on. On occasions instructions of how to prevent device pressure are not provided from the referring organisation.
How many phone calls did I receive as a community TVN, asking when a home could take someone’s ‘Ted’ stockings off post discharge? In some cases the resident was fully mobile.
The difficulty is that these devices are paramount for the persons medical needs, so we are unable to simply take the device away. There are some device solutions on the market looking at padding or offloading the pressure from the affected area, but are not as straight forward due to the complications of the anatomical areas and keeping the pressure relief in place.
Solutions are sometimes found in-house and working with the patient and where possible with their families who may have some innovative ideas. For example, patients will know which side they sleep on, or if they have found a self-solution to keep the device in place, working with the patient to make this work may increase the compliance rate of the device use. Having said that these are not always recommended! Anyone that has been in the nursing profession for a while will know of some of these homemade devices and will still send a shiver down their spine! Incorporating allied health professionals such as occupational therapists or physiotherapists may bring up some fantastic solutions too which you were not aware of.
Examples of MDPUs may include:
Endotracheal tubes/commercial endotracheal tube holders.
Face masks for non-invasive positive pressure ventilation.
Faecal containment devices.
Pulse oximetry probes.
Radial artery catheters.
Sequential compression devices.
Splints and braces.
J.Black et al (2010)
As health providers it is paramount that anyone with a medical device has a pressure ulcer prevention plan that incorporates the care and management of the skin.
Anyone with an acquired MDRPU, will still need to be reported in terms of the category of the ulcer e.g. Category 3 or 4 depending on the depth on tissue loss. Where reasonable steps haven’t been taken to assess and prevent within the SSKIN or prevention care plan could potentially be investigated as omission of care.
Ways of mitigating this risk can be done via an in-house analysis or audit of current practices including: staff behavior, value and understanding of current medical device practices. Identifying teams’ skills gap can be a good start to improvement planning. For those working in quality or governance where quality improvement (QI) plan has been prepared, involving all staff is paramount to gain ‘buy in’ to improvement proposals. It is quite often the case that the best idea can come from the most unexpected place or staff member so incorporating a ground up approach to change is becoming an increasingly understood change model for sustainability of QI.
https://improvement.nhs.uk/resources/pressure-ulcers-revised-definition-and-measurement-framework/ (Accessed 4th December 2018).
Joyce M Black, Janet E Cuddigan, Maralyn A Walko, L Alan Didier, Maria J Lander, Maureen R Kelpe (2010) ‘Medical device related pressure ulcers in hospitalized patients’ InternationalWoundJournal (7) 5.