During the present COVID-19 epidemic we anticipated a lot of interest in tissue viability issues and moving and handling care due to the large number of patients admitted into a healthcare system which has been under extreme pressure. However, this does not appear to be the case.
The question is whether tissue care is once again seen as a secondary issue and tissue damage seen as an inevitable outcome.
It is more evident than ever that to “prevent tissue harm“ in both patients and their carers is far more effective than to continually focus on ways to treat it.
I have a vested interest these issues as I run a business that designs, manufactures and sells inbed care systems that protect tissue viability. I am passionate about this topic which stems from my years of practicing as a registered nurse. During my career, I witnessed the pain and suffering of patients who experienced tissue harm – aka pressure sores; pressure ulcers, force related tissue damage etc. This was viewed at the time as unavoidable, especially in an ageing population with a greater risk of frailty.
NB, frailty, obesity and vitamin D deficiencies have also been cited as casual factors in more severe cases of COVID-19. There is increasing evidence to show that the risk of frailty actually increases with obesity which is contrary to previous thoughts of frailty as a “wasting disorder” (4). The Cardiovascular Health Study which initially defined “frailty” demonstrated higher BMI in frail patients versus those prefrail or robust (20). Vitamin D deficiency is common in older adults and has been linked with frailty and obesity, but it remains to be studied whether frail obese older adults are at higher risk of vitamin D deficiency.
Healthcare systems are set up primarily to care for existing conditions rather than prevent them in the first place. There needs to be a fundamental shift in the way we look at patient care; the bed environment and the way patients are moved, repositioned and stabilised upon it.
For many years, tissue damage has been an ‘accepted’ side of patient care. Training is still being given on moving patients – often with 4 or 5 staff – which shows practices that can create “force focal spots” (e.g. when carers are grasping the material that’s being used; this requires them to work against gravity in order to move the patient. This creates increased tension from the point of grip down, along the material to the point where it passes under the patient’s body mass). This can be seen with visible tension lines especially under the buttocks and/ or the back of the shoulders in the sitting and/or laying repositioning.
As discussed by Matthew D. Redelings et al in ‘Pressure Ulcers: More Lethal Than We Thought?’, “pressure ulcers” are associated with fatal septic infections and are reported as a cause of thousands of deaths each year in the United States. Incapacitating chronic and neurodegenerative conditions are common comorbidities, and mortality rates in blacks are higher than in other racial/ ethnic groups. They conclude by giving the advice that, ‘Special attention should be given to the plausibility of decreasing PrU-associated mortality among older adults, blacks, and persons with incapacitating conditions.’ This advice is even more relevant in the current pandemic as the BAME population is already suffering more fatal cases of COVID-19 than other sectors of society yet their care may also be contributing to the increased numbers of people who do not survive.
This is even more saddening as research is now available that demonstrates that there are 5 levels of tissue harm and the interplay within tissue when force-related tissue damage occurs leading to the occurrence of a wound, and indicates how such harm can be prevented. It also investigates the observations regarding unobvious causes of force related tissue damage and the events linking both biomechanical and biological processes at several organisational (pathological) levels together with external in bed events.
We have termed the process for protecting tissue viability and preventing harm ‘The Safety Dance’ and how this can be achieved using synergetic layers, tilt beds that enable movement with gravity so patients’ move within the limits of their internal systems. Not everyone is evenly skilled to move patients without causing unnecessary tissue harm, both for the patient and themselves. Using gravity means you no longer have to push and pull patients to change position. Watch this video for an overview of how this works.
Such a shift in focus requires an understanding of why tissue harm happens in the first place. Our latest research paper, explains how the human body’s physiological structures (tensegrity and homeostasis) permit movement without damage through mechanisms that allow the internal sliding and deformation of tissue(s) with an amount of force that is manageable by cells and tissues. Damage therefore occurs when the forces acting on a cell or a tissue become so great, they deform beyond normal ranges and to a certain point which causes harm.
We have previously considered factors that influence wound healing and why this threshold is different for individuals, even those who are of similar age with similar care needs.
I feel that the biggest change needs to be for practitioners to recognise that following a tissue damaging event, it takes up to ten days for deep tissue injuries to manifest and be seen on the skin’s surface. Many of the current practices still focus on treatment rather than prevention and there is a lack of accountability when tissue damage is caused.
Our approach to preventing “Tissue Harm” should include:-
- Advice from central bodies such as EPUAP should be based on new research detailing how tissue damage is caused. It should communicate that a wound is not the main event but a stage in tissue damage. It needs to acknowledge the need to change and facilitate it through incentives and regulation.
- Healthcare organisations need to continue using the cross-functional teams created during the pandemic to reduce the compartmentalisation of care.
- They need to continue their ‘how can we do this differently?’ approach
- Care in the community needs to be integrated into the patient care programme so it is a continuation of the preventative approach.
- The training of nurses and carers should increase awareness on the subject; and instead of a focus solely on the scoring of wounds, redirecting awareness to sources of tissue damage and the effects thereof on mortality instances.
- In Pressure Ulcers: More Lethal Than We Thought?, Matthew D. Redelings et al investigated the burden of pressure ulcer-associated mortality in the United States and found they are ‘a cause of deaths for thousands of persons each year’.
- LINET ICU Solutions recently stated that 82% of healthcare staff members who sustain an MSK injury weren‘t using supporting equipment. They highlight how bed frames with lateral tilt allow nurses to turn patients without any physical strain. Routine clinical procedures (such as positioning, personal hygiene, skin inspections and changing the bed linen) can become effortless and ergonomic. In other words, it shouldn’t need to hurt to be a Nurse. Lateral tilting beds are integral to a philesynergetic approach to inbed care as they enable movement to work with gravity and the patient’s physiological structures as discussed earlier.
- Budget setters need to look at the long-term benefits vs short term costs of taking a preventative approach:
- Less tissue damage means patients’ pain and misery reduced. Patient safety increases.
- Enormous cost savings can be made in the long term.
- In the UK, current Health Secretary, Matt Hancock confirms this in the reasoning for his vision document: “because preventative treatments cost less than retrograde treatments further down the line.”
- Pressure ulcers remain a mainly avoidable harm — costing the NHS over £8.3 million every day.
- Shorter hospital stays means more bed availability
- Less care in the community needed
- Initial cost increases for inbed care systems (such as Biotechsis®) items and tilting beds will be reduced once economies of scale reached
- Budgets for the treatment of pressure sores can be reallocated.
Doing something great starts with individuals caring beyond their own scope and being brave enough to speak out and suggest a new way of thinking. I hope you will join my voice.