Transcript

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Interesting that in terms of microclimate, mobility and medical complexity, we have to look at more comprehensive solutions to be able to address this. The cognitive load that exists on the frontline nurse and frontline assistant to remember all of these factors to make sure the right thing happens to the patient is very tough. And so microclimate, it's the reason why I literally call nurses “skin champions.” I don't call them wound care champions because, and I also don't call it pressure injury prevention. I call it eliminating hospital acquired skin injuries because the minute we say the word “pressure,” the only thing people think about is pressure and the moisture and the shear get forgotten in the process. 

And so microclimate, so having a mattress that meets the S3 criteria of immersion, envelopment, and microclimate, having a slide and glide on the bed that is breathable, that takes care of shear during any movement, and having a wick away pad. On top of that, if a patient has incontinence so that we're addressing moisture, because what happens when you put pressure, moisture, and shear together, the cell deformation and the softening of the tissue, especially in moisture, the tissue becomes very thin and friable, making it easy and more susceptible to shear and pressure. And literally, when I teach frontline nurses, when I taught the staff that I partnered with, if the patient's in a puddle, game over. You could turn them, you could offload them, you could address shear, but if they're sitting in a puddle, it weakens the skin and sets them up. 

So that deals with the microclimate component. It also deals with the mobility component, because when you're moving a patient, you have to make sure you're addressing the shear at all times, including safe patient handling for the staff. 

And the last piece is the medical complexity. So our current risk tool, the Braden, that is frequently used—if you are still using the total Braden score, I ask you to look at the research of driving your interventions based on the subscales so that you are focusing on the individual kind of risk factors that your patient has and then having the right tools in your work environment to be able to address those risk factors. 

Now, my background's critical care, so the medical complexity of this patient population is huge. And it's interesting to note, and this is a little—I don't know if I'd call it a fun fact, but it's a fact that if you're on a mechanical ventilator, you're 23 times higher risk for the development of a pressure injury. Is that because you're on a mechanical ventilator? No, because you're getting oxygenated. It's because it's harder to mobilize the patient and we aren't using the right tools to make sure the mobility happens. 

And one of the biggest pushbacks I get in the critical care environment is this concept of hemodynamic instability with turning. Now, there are patients, don't get me wrong, that are unstable with turning, but it's also how we approach the mobility. Usually, most of the time, a lot of activity occurs before we finally turn the patient so they can rest. They don't have the capability of supplying enough oxygen to meet the demand we just placed on them. And so they're likely going to … have their blood pressure go down. So one of the activities we can do is space our care practices to allow respite time for that patient before we put them through another oxygen demand activity like turning. 

Another, and this comes from the space world, astronauts, is the stretch receptors re-equilibrate at zero gravity, but they have to train the astronaut to tolerate multiple gravitational changes before they're able to shoot them up and take them to 9 Gs in the shooting of the rocket. Otherwise, their blood volume would be in their toes. So if you think about what happens to the patient, they're in the emergency room flat. Well, first they're in the ambulance, then they're in the emergency room flat, then they're in the CAT scan flat, and then they're in the OR flat. And by the time they get up into the intensive care unit, when you try to turn them, they have established this equilibrium in a supine position. So we have to take steps of slowing our turn because inner ear equilibrium plays a role in this as well. And we have to train them gradually. 

So starting off with an immediate 30-degree turn, a complete sacral offload may not work for this patient. So you're doing micro-turns, but you're doing incremental micro-turns so that you're literally training them. All of this is based on whether you have the right evidence-based tools to do the right evidence-based care.