(P17) Pressure Injury in the Setting of Transition of Care

Introduction: We present a root cause analysis of a pressure injury in the setting of transition of care, that highlights need for improvement in SBAR (Situation, Background, Assessment, Recommendation) of wound status, to enhance multidisciplinary delivery of timely care and prevention.

Case Description: An elderly male in his late 80’s with moderate dementia, non-ambulatory, Hypertension, Hyperlipidemia, controlled Diabetes Mellitus type 2, chronic obstructive lung disease (not on home oxygen), Osteoarthritis status post right knee replacement, fecal incontinence, Benign Prostatic Hypertrophy, status post prostate resection with chronic indwelling foley, presented with altered mental status. On day 1 of his illness, he was noted to be fatigued. Later that day he became more lethargic and was sent to the hospital. Four days prior to hospitalization, he had been documented with moisture associated skin damage in the nursing home. His blood count revealed WBC of 20.02/mm3 (4.8-10.8), neutrophil predominant, transaminitis, creatinine of 2.87 ng/dL (0.5-1.2), baseline, 1.4, troponin 0.04 ng/mL (0.00-0.01), lactate 3.2 mmol/L (0.5-2.0). The ER physician noted a “questionable stage 4 pressure sacral ulcer”

On day 3 of hospitalization, wound care nurse found an unstageable 7cm x 7cm sacral wound, butterfly shape, with moist black and yellow necrotic tissue, with moderate serosanguinous exudate, malodorous with purple discoloration proximally, with peri-wound erythema. On day 5, surgery team performed sharp excisional debridement followed by electrocautery. Post procedure documentation cited a “stage 2 pressure injury”.

Discussion: A thorough review of the Nursing home (NH) and the affiliated Hospital Electronic Medical Records was performed. Braden scale was used to estimate patient’s risk. A Fish diagram was made with the patient’s risk factors. This led to identification of need for process improvement via educating staff to utilize a common SBAR communication tool.

There were significant discrepancies in the documentation by the ER provider, the wound care nurse and in surgical post debridement documentation. The NH SBAR form was incomplete. Down staging of the pressure injury, a practice not endorsed or recommended, was noted after the debridement. The patient had an estimated Braden score of 10, denoting a high risk for pressure injury.

This case analysis encompassed the Braden Scale and led to standardized in-service training for Nursing Home staff regarding importance of SBAR. A skin integrity lecture series for staff at the Nursing Home and daily wound care rounds occurred. Medical residents doing geriatric rotation at this nursing home are now actively involved in wound rounds.

References:
1. National Pressure Ulcer Advisory Panel. NPUAP. Position on reverse staging of pressure ulcers. Adv Wound Care 1998; 8:32.
2. European Pressure Ulcer Advisory Panel. Guidelines on treatment of pressure ulcers. EPUAP Rev. 1999; 1:31-33