Jakes Story

Margo Asimus

Nurse Practitioner-Wound Management

Hunter New England Local Health District

Greater Newcastle Cluster

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Patient History

• 21 year old man

• C4 Tetraplegia

• Dived into the water at Newcastle Beach 16 January 2009

• Previously employed as a chef in Newcastle

• Discharged home from Moorong Spinal Unit (Ryde) 1 September 2009

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Situation • 03:40 hrs on 20/06/10 Jake presented to an

Emergency department with a headache (?Autonomic Dysreflexia & UTI)

• Patient remained in ED for 15 hours. Discharged at 18:02 on 20/06/10

• Carer noticed a mark on his Left buttock the following day, which she described as “like a cigarette burn”

• Over the next few days the pressure injury deteriorated

• Managed at home by lying on his side and restricting sitting in his wheelchair.

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ED Journey timeline

Arrives

ED

1st S/B

CIN T/F Bed TF

ESSU

D/C

HOME

ED ESSU

0338 0532 0800 1700 1802

NO PRESSURE ULCER RISK ASSESSMENT

OR DOCUMENTATION

Approx 4 ½ hours on an Ambulance Trolley

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Unrelieved Pressure • Pressure damage resulted in 3 pressure wounds

– left iliac crest

– left greater trochanter

– left Ilium (Right shoulder pain prevented repositioning)

• Referred to community nursing (CN) for catheter care & wound management.

• Spinal Cord Injury Service (SCIS) contacted 9/8/10 by CN. Concerned about client’s mental health.

• 6 weeks post injury he became withdrawn & not engaging with staff

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9th Aug 2010

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9th Aug 2010

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9th Aug to 12th Aug 2010

• Admission arranged

• ? DVT Right leg

• Wound Management

• Wound debridement of IT and GT pressure wounds

• “There is a chance that some further debridement will be needed in this area in the ward but as this is not sensate this should not be a problem”

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18th Aug 2010

• Review with community nurse

• Maintaining bed rest

• No shower or commode use

• Monitoring temperature

• Requesting admission

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18th Aug 2010

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8th Sept 2010

Hospitalised for wound debridement 2.9.10

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25th - 29th Sept 2010

• Re - admitted to hospital. Febrile, moist cough,

tachycardia, vomiting & haematuria

• Acute renal impairment due to dehydration

• Blocked catheter (over 1 litre seen on U.S.)

• UTI managed

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1st Oct 2010

• Negative Pressure Wound Therapy commenced in community

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3rd Nov 2010

• IT/GT

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30th Nov 2010

• IT

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15th Dec 2010 marked improvement

• IT • GT

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Current Management

• Nurse Practitioner supported CN to manage pressure wounds.

• GT pressure wound healed

• Electrotherapy treatment commenced on IT wound

• Remained on bed rest until wound healed.

• Agreed to engage with psychologist.

• Once wound closure achieved a gradual graded return to sitting over 4-6 week period will commence.

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Impact of pressure injuries for Jake

• Bed rest since 1 July 2010 • High risk of sepsis • Complicated renal failure • Weight loss • High risk of autonomic

dysreflexia • Mental health impact (social

isolation) • Loss of confidence in the

health system • Zero fun factor • Interruption to rehab and work • Reduced independence • Financial strain

Case Study: Patient Costs • Paraplegic of 25 years,

• UTI – sustained hospital acquired stage 3 pressure injury

Administration clerk

• 13 weeks hospitalisation

• $34/hour @ 40 hours/week $17,680

• 2 weeks annual leave $2,720

• 2 weeks @ 3 hours a day $1,700

• 2 weeks @ 5 hours a day $1.020

• Loss of wages $23,120

• Hospitalisation bed days ($1200/day) $109,200

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Organisational Impact

• Reputation

• Patient safety risk

• Cost of care

• Increased services

• Future litigation risk

• Long durations of On Stretcher Time (OST) adversely effects patients,

the damage has been done and it is too late to rescue the ischaemic injury unrelieved pressure causes

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Xsensor Pressue Mapping System

• What is it? - Series of pressure sensors evenly spaced within the mat which measure the

amount of surface pressure between the body and surface being mapped (e.g. pressure relieving cushion, mattress). Measurements transferred from the mat to an image on the laptop.

- Areas of blue indicate low levels of pressure. Areas of red indicate high levels of pressure (220mmHg+)

• How does it work?

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Xsensor Pressue Mapping System

• Points for consideration when evaluating pressure mapping results:

- Pressure mapping measures contact pressure only, and not shear or friction (which is also associated with skin breakdown in a semi reclined position).

- Measurements in mmHg are an indicator only (pressure relieving qualities of the surface being measured are impacted upon slightly by the tension of the mat itself, for example). The maps show the distribution of pressure, and highlight any areas of concern e.g. over bony prominences.

- The following results were of a healthy male of average build on a DHS trolley. Mapping of a patient, such as Jake with vastly reduced muscle mass and adipose tissue would have even more prominent bone structure.

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Pressure Mapping of Sacrum

• Lying Supine

• DHS trolley with standard mattress b) DHS trolley with Repose mattress on top of standard

•

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Pressure Mapping of Sacrum

• Supine with 35 degrees of head elevation a) DHS trolley with standard mattress b) DHS trolley with Repose mattress on top of standard mattress

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Pressure Mapping of Sacrum

• Supine with 55 degrees of head elevation

a) DHS trolley with standard mattress b) DHS trolley with Repose mattress on top of standard mattress

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Pressure Mapping of Sacrum

• Supine with 75 degrees of head elevation

a) DHS trolley with standard mattress b) DHS trolley with Repose mattress on top of standard

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Pressure Mapping of Heels

• Lying supine a) DHS trolley with standard mattress b) DHS trolley with Repose mattress on top of standard

Repose: Community Nurses/Emergency Dept

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Points for further consideration:

• Pressure mapping indicates greater pressures are exerted over

the sacrum when the head of the trolley is raised, regardless of

the type of mattress in situ. Consider lying patient flat if not

contraindicated from a medical point of view.

• Length of time spent on surfaces exerting high amounts of

pressure cause adverse events with major consequences.

• Jake’s story highlights the need for timely pressure care which

must include early assessment and intervention in ED.

DO NO HARM, KEEP OUR PATIENTS SAFE

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Thank you Questions

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