4 strategies that can help nurses in hospitals, despite increased workloads
By Peyton Root
April 24, 2023
Pressure ulcer prevention is often the last priority of an emergency department (ED), where patients first enter the acute health-care system. Although skin integrity is a low priority when considering life-threatening conditions, it is an issue that has gained importance as the time spent in the ED increases across the nation. We must quickly address the risk of skin breakdown in the ED to mediate the long- and short-term consequences of pressure injuries (PIs) (Han et al., 2020).
Examining Ontario, the average time admitted patients spent in the ED increased from 13.8 hours in 2015-2016 to 16.2 hours in 2018-2019 (Health Quality Ontario, 2022). In 2014-2015, the median length of stay in the ED for high-acuity patients not admitted was 3.5 hours (Health Quality Ontario, 2022). Recent data shows that in July 2022, high-urgency patients not admitted to the hospital spent on median 4.7 hours in the ED and admitted patients waited an average of 20.7 hours (Health Quality Ontario, 2022).
This is not only a provincial issue but a national one as well. The Canadian Institute for Health Information reported that across Canada, the ED length of stay for people admitted to hospital in 2016-2017 rose 11 per cent from the year before and almost 17 per cent from five years prior (CIHI, 2022). For nine out of 10 admitted patients in Canada, the ED length of stay in 2021-2022 was 40.7 hours versus 33.5 hours in 2020-2021 (CIHI, 2022). This represents patients waiting in chairs and on stretchers — surfaces that are intended for short-term use — for increasingly extended periods. This is significant as research has shown that staying in the ED for over 12 hours is an independent risk factor for PIs within a week after admission (Han et al., 2020).
Older patients with mobility issues and multiple co-morbidities commonly arrive at the ED by ambulance. Despite an increased risk of developing PIs, these patients frequently await care spaces for long periods on ambulance stretchers, which are relatively rigid and narrow (Fullbrook, Miles, & Coyer, 2019). Interface pressure (i.e., the pressure exerted by the compression system over the skin’s surface) is significantly increased on ambulance stretchers, especially when braking and turning, which are likely to cause capillary occlusion and tissue distortion (Parnham, 1999). A study in two Australian hospitals found that pressure-relieving interventions were rare during ambulance transport and the first hour in the ED, even with high-risk patients (Fullbrook et al., 2019).
ED stretchers are generally thinner because they are meant for short stays and easy patient transfers. In contrast, hospital beds are thicker and wider, intended for patient comfort and longer stays (Modsel, 2022). As the wait time and patient volume increase, the time patients spend on ambulance and ED stretchers also increases, creating a risk of PI development. Irreversible PIs can develop in as little as two hours of immobility or being cared for on the wrong type of mattress (Kirman, 2022). Additionally, patients are often left in cervical collars and on spinal boards for extended periods as they wait for care spaces, further increasing the risk of skin breakdown. In healthy adults, lying on a rigid backboard for just 30 minutes can result in sacral tissue hypoxia (Berg et al., 2010).
PIs have a significant impact on patients as well as the health-care system as a whole. Because of this, we must prioritize health promotion and prevention to help decrease the burden in EDs. A study conducted in Seoul, Korea, demonstrated that developing PIs increased the risk of in-hospital mortality, readmission, ED visits after discharge, extended hospitalization, extended intensive care unit stay, and increased health-care costs (Han, Jin, Jin, Lee, & Lee, 2019).
4 strategies that can help nurses reduce and prevent pressure injuries
The implementation of attitude change, assessment, prevention and engagement can effectively reduce PI development within the ED as wait times increase (Santamaria, Creehan, Fletcher, Alves, & Gefen, 2019).
A study done in a UK ED describes how the nurses did not view pressure ulcer care as important and deemed it not part of their role (Faulkner, Dowse, Pope, & Kingdon-Wells, 2015). This attitude led to a delay in early PI prevention as it was left to the admitting ward to address (Faulkner et al., 2015). To effectively promote change, there must be a shift in the attitude of the interprofessional ED team that PI care begins on arrival at the ED and continues until transfer or discharge. To create this attitude change, it is imperative that ED nurses complete thorough training and education on the importance of PIs and the long-term effects of skin breakdown. Although we must address life-threatening conditions first, PIs are linked to increased length of hospital stay, which correlates to poor outcomes and increased risk of stroke and sepsis (Bauer, Rock, Nazzal, Jones, & Weikai, 2016). All members of the interprofessional team are responsible for skin breakdown prevention to promote skin integrity in the short and long term.
Best practice guidelines dictate that we conduct an initial integumentary assessment as soon as possible to discover any pre-existing skin breakdown or fragility. In addition, multiple assessment tools are available, such as the Braden and Waterlow scales, to assess the risk of PI. Although international guidelines recommend initial PI assessment within eight hours of admission to the ED, recent evidence demonstrates that this is inadequate in high-risk, severely ill patients (Santamaria et al., 2019). Thus, we should conduct a PI assessment within four hours of admission to the ED (Santamaria et al., 2019). Ideally, upon triage, patients should be assessed for the risk of PI development with a standardized tool and placed in appropriate care spots (e.g., chair versus stretcher) (Fullbrook et al., 2019). It is imperative that patients are continually assessed for the risk of skin breakdown and monitored for changes in integumentary status. We should train nurses to identify high-risk patients and promptly communicate these findings within the interprofessional team.
One of the founding principles of nursing is the prevention and promotion of health. Through this principle, nurses can effectively minimize the risk of PI. As wait times increase across Canada, it is more important than ever to prevent PIs, which will have a long-term impact on our health-care system and patients. Examples of various methods to prevent PIs from developing or worsening include the following:
- Remove cervical collars and backboards as soon as spinal precautions are lifted (Santamaria et al., 2019).
- Switch patients from stretchers to hospital beds as soon as they are admitted to the hospital (Long, 2018).
- Develop repositioning schedules to promote position change at least every two hours (Santamaria et al., 2019).
- Place patients at high risk of developing PIs on pressure-distributing mattresses upon entrance to the ED (Long, 2018).
- Improve access to and awareness of pressure off-loading devices in the ED (e.g., positioning wedges, mattress toppers) (Faulkner et al., 2015).
- Consider the application of prophylactic sacral and heel dressings when it is not possible to reposition the patient frequently (Santamaria et al., 2019).
To effectively promote change and prevent and reduce the incidence of PIs in the ED, we must engage the entire interprofessional team and all levels of health management (Santamaria et al., 2019). Using leadership, we can set expectations, guidelines and best practices to remove barriers, encourage collaboration and provide resources while supporting staff to reach goals (Santamaria et al., 2019). Without mid-level support, unit-based programs often lack success; thus, it is imperative that management is supportive of an ED initiative and practice changes (Santamaria et al., 2019). Additionally, other professional groups (e.g., physiotherapists) demonstrate that strong knowledge and a positive attitude toward PI prevention and interprofessional collaboration are proven to create interdependency amongst the team, optimizing patient care and improving staff satisfaction (Clarkson, Worsley, Schoonhoven, & Bader, 2019). Therefore, by sharing the responsibility of PI prevention and reduction with the interprofessional team and leadership, we can successfully combat skin breakdown in the ED.
In 1859, Florence Nightingale wrote, “If he has a bedsore, it’s generally not the fault of the disease, but of the nursing” (p. 6). Despite our best efforts, there are various barriers to effective PI prevention in the ED, including staffing shortages, increased workloads, high patient volumes, and budget and time constraints. Although PI prevention is traditionally seen as a nursing issue, an interprofessional approach is best practice (Clarkson et al., 2019). As the pressure on our health-care system increases, nurses must continue to advocate for patients’ health, engage leadership and develop strategies to promote high standards of basic care. Integrating appropriate assessment and prevention tools will combat the risk of PI development as ED wait times lengthen.
Additionally, creating a culture where PI care begins when patients enter the ED and continues until transfer or discharge promotes patients’ short- and long-term health. Finally, by working together with the interprofessional team and leadership, it is possible to successfully create a change that will benefit patients and our health-care system.
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Peyton Root, RN, works with the London Health Sciences Centre in the emergency department of the Victoria Hospital in London, Ont.