The past, present and future of tissue harm
What struck me again at the recent BHTA Symposium, was that the most widely-accepted science looks at either the patient’s resting surface, or how to treat force-related tissue damage (also known as pressure sores, pressure ulcers etc).
Jo Milner for example, made some useful points on textiles’ shear and its implication for tissue integrity. She also highlighted the need for careful choice of textiles for resting surface layers against the skin and being mindful when there is a low co-efficient of friction. She said, “To ensure displacement and tissue deformation does not occur at the tissue interface there must be more than one layer of the low coefficient material” – in other words, she was describing synergetic layers.
What is still missing is research into the correlation between the resting surface and what happens under the skin, as well as the ways in which support surface layers can prevent injury. Moving into this exciting area will allow us to start the prevention of tissue damage much earlier. Prevention is therefore even possible before the early visible signals of tissue harm.
It is encouraging to see that the common associated language is now moving from pressure to tissue damage. Despite the lack of progress towards prevention, there was a common theme at the BHTA symposium that tissue damage (still widely referred to – incorrectly in my view – as ‘pressure sores’) is caused by the deformation of a patient’s skin against their resting surface as a result of movement.
Movement is key to human well-being. It’s a human necessity – whether the movement is intentional, subconscious or initiated by carers either manually or using mechanical aids.
Movement is an innate action and is part of the body’s complex systems of homeostasis which protects and repairs itself by using both physiological and biomechanical mechanisms (biotensegrity) to maintain the individual’s optimum range of tissue integrity.
The human body will move to maintain homeostasis, relieve pain and discomfort; an aspect that is becoming more widely recognised and understood in the manufacturing sector, with innovations being developed to prevent for example, chronic pain and injury from standing.
Each person’s ability to maintain optimum tissue integrity is different. Analysing any tissue damage needs to exceed local observation (e.g. through present ulcer grading) by looking from the molecule level upwards to the social environment of the patient.
Latest research by the biologist, Harm Smit highlights the need to realise that “cells and tissues have a range of states related to damage” that vary from “no damage to death”. His resulting scale to classify the loss of homeostasis within cells and tissues classifies these ranges as Normal – Adapted – Stressed – Injured – Damaged – Dead.
Smit explains, “The Harm Scale has dimensions of level, size and time. A single cell moving up the Harm Scale, does not imply that the tissue containing that cell is also adapted, injured or damaged. The tissue it is in, might very well be in perfect homeostasis. However, if more cells in the tissue start to get damaged or die, in time the tissue itself may start moving on the Harm Scale. This implies that tissue damage is preceded by a process of increasing harm to tissue.”
Expanding this further in an article for Wounds UK – A five-level model for wound analysis and treatment – Smit shares more understanding of what is going on in the patient, before, during and after a force-related tissue damage incident.
So, to prevent force-related tissue damage for patients confined to bed, we need to ensure their social environment (in other words, their inbed care environment) avoids any deviation in their homeostasis to allow their their cells and tissues to remain within their ‘normal’ range. We can achieve this by taking a philesynergetic approach which matches the external environment to the patient’s innate, protective environment and is the reasoning behind Phil-e-Slide’s Safety Dance.
As stated in a recent UK Government guide, “prevention is a shared responsibility.” This is echoed by the Safety Institute of Australia who said, “Preventing harm is a primary legal and ethical responsibility for every Australian company, and the core purpose of the health and safety profession.”
As highlighted above, the solutions are available in the new research published into force-related tissue damage as well as new products and practices developed from this research.
Our common challenge is not only knowing that change is needed, but also making that change happen… which are two very different things.
Caroline Fife reasoned why in a recent LinkedIn post, “If there’s one thing I’ve learned over the past ten years, it’s that people believe what they want to believe, no matter what data you show them.”
One example of this is women experiencing cryptic pregnancy who strongly believe they are pregnant, against evidence clearly showing otherwise.
It’s like the ‘flat earth’ principle of years gone by; where new ideas are resisted because they do not match current opinion. We all have confirmation bias and common phrases given in response to change, such as, “I have not read that,” and “You did not investigate well enough,” are all indications of this within the healthcare sector.
We’ve written before about improving safe patient care and the knowledge gap. By healthcare professionals continuing to believe that the current “safe” wound care and patient handling is sufficient, shows why the Health Foundation published its report on the Spread Challenge. This report highlights “the challenges facing the NHS in improving the uptake of new ideas and practices, and the need for new approaches when developing national and local programmes to support the spread of innovation”. It promotes, “Challenging traditional ways of thinking”, and argues that “programmes to spread innovation and improvement should support those adopting an idea developed elsewhere, as well as innovators”.
Summary: The past
• In the past, little was known about why force-related tissue harm can develop into tissue damage.
• The resulting injuries (pressure sores/ pressure ulcers/ force-related tissue damage) were treated with varying degrees of success.
Summary: The present
• At present we are beginning to understand that interrelation of a patient’s resting surface, movement and what causes cells and tissues to lose homeostasis to a level where harm is caused.
• Research has identified that a patient’s innate ability to manage the loss of homeostasis within these cells and tissues can be classified on the Harm scale. These ranges are Normal – Adapted – Stressed – Injured – Damaged – Dead.
• It stands to reason that by helping patients’ cells and tissues maintain their ‘normal’ range, then damage can be prevented. This is recognising the Harm Scale. By doing so, patient safety would increase and spending on the treatment of such injuries would be eliminated.
• Products and processes exist to create the synergetic support surface layers needed to allow movement without tissue deformation that triggers the loss of homeostasis within cells and tissues.
• Initiatives are in place to challenge past thinking and introduce innovation.
Summary: The Future
• There is a focus on the prevention of force-related tissue harm. The Harm scale is used to recognise and ensure patient’s’ homeostasis remains within their normal range.
• Patients confined to bed are on resting surface layers that are synergetic.
• A philesynergetic approach is used to ensure that movement works with gravity to allow the patient’s innate biotensegrity protects against any deviation (loss) of homeostasis in their cells and tissues.
• Tissue harm is prevented.
• Terms such as pressure ulcers, pressure sores, and force-related tissue damage are relegated to the history of medicine. Budgets previously allocated to the treatment of such tissue harm is reallocated.
Therefore, a preferred trajectory is for the prevention and elimination of force-related tissue harm rather than the current focus on the treatment of force-related tissue damage.
Perhaps we need to listen back to the time-old adage, “change starts with me”. Let’s challenge our beliefs; look at the new research being published; make changes in our own practices then share with our peers and colleagues.
The future is exciting!