Pressure Injury as a Quality Indicator: Literature Review and PDSA Cycle

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CLINICAL EXCELLENCE
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QUALITY INDICATORS
Pressure injury is among the hospital-acquired complications according to the (Standard, 2012).
Hospital-acquired complications form part of the quality indicators of patient healthcare among
others. This essay will explore pressure injury as a quality indicator, literature review
surrounding pressure injury and use of plan, do, study and act cycle in improvement of pressure
injury and its evaluation.
The patient is the focus in nursing care and healthcare in general. The quality of care delivered to
the patient should be at optimum and should be one that can be measured. According to
(Mainz,2014) clinical indicators not only measure quality of care provided to the patient and its
outcomes but also support quality improvement and accountability in the health care system. The
plan does study act cycle (PDSA) is a performance improvement tool used in quality
improvement. According to(Australian Commission on Safety and Quality in Health Care
(ACSQHC),(2012) the rate of hospital-acquired pressure injuries in Australian hospitals was 9.7
per 10000 hospitalizations in 2015.The pressure injuries increase discomfort to the patient and
pain, prolong hospitalization and increased financial burden in treatment of the injury.
(ACSQHC,2012) states that pressure injury as a clinical indicator is diagnosed by three features
including stage III ulcer, stage IV ulcer and unspecified decubitus ulcer.
A pressure injury refers to injury caused by excess pressure over bony prominences and can also
result due to shear and friction. This especially when the patient is pulled using the sheets against
the mattress rather than lifting. According to (World Health Organization, 2013) pressure injuries
are classified into five. Stage I includes an area of skin which has persistent redness erythema
without skin loss. Stage II includes a blister and partial loss of epidermis and dermis. Stage III

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involves skin loss involving subcutaneous tissue and fascia. Stage IV involves full thickness loss
plus muscle and tendons. Finally, the unspecified pressure area without stage specification. Risk
factors contributing to pressure injury include immobility, incontinence, obesity, malnutrition,
patients with diabetes and neurological disorders. According to(Clinical excellence
commission,2017) prevalence of pressure injury in Australian hospitals is between 9.5 to 17.6%
while in nursing homes it is 8.9%.The economic impacts of treating pressure injury in Australia
in 2012 was A$983 million per annum and the total number of bed days lost was
524661(Nguyen, Chaboyer and Whitty,2015).Pressure injury is an avoidable injury if
appropriate measure are taken and would save patients so much pain and discomfort.
Pressure injury is a quality indicator which can be reduced by quality improvement via
implementation of clinical expertise and resources (Elliott, McKinley, and Fox (2013). The
expected outcomes were a decrease in the number of patients who developed pressure injury
within the hospital. In my hospital setting an orthopedic ward, there was a report of five hospital-
acquired pressure injuries three months after hospitalization.
LITERATURE REVIEW
Pathophysiology of pressure injury involves increased pressure on the skin which leads to
decreased blood supply due to occlusion of blood vessels. This then causes tissue death which
then leads to necrosis. According to (Grey, Harding and Enoch,2014) pressure injury from shear
force results when movement of bone and subcutaneous tissue and the skin is restrained leading
to increased pressure over the site. Friction results when the patient is pulled rather than lifted
using the bed sheets resulting in blisters which may progress to ulcers with more force. Increased
moisture is a contributing factor to pressure injury which includes incontinence and wound

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drainage. Moisture leads to increased chances of tissue destruction. (Grey et.al ,2014) states the
effects of friction are five times worse in presence of moisture. This emphasizes the need of
immediate diaper change in patients who are immobile or those who are unconscious. Advanced
pressure ulcers become more difficult to treat and increase mortality rates. (Brem et.al ,2013)
states that the costs of treating a stage IV pressure ulcer was great and earlier detection of a
pressure injury would save lives and decrease expenditure used in treatment of pressure injury.
One of the most critical areas in improving pressure injury occurrence is the risk assessment tool.
There are various pressure risk assessment tools in Australia including Braden scale, Waterlow
Score,Glamorgan tool and the Norton scale. (Pancorbo‐Hidalgo, Garcia‐Fernandez, Lopez‐
Medina and Alvarez‐Nieto, 2013) state that in comparison to Waterlow and Norton Braden scale
in better in prediction of pressure injury. These tools are used by nurses to predict the patients at
high risk of developing pressure injury and act swiftly on preventing it. (Australian Wound
Management Association AWMA, 2012) states that the Waterlow tool is used for adults while
the Glamorgan tool is used for pediatrics. The patients should be assessed on admission and after
eight hours. (Pancorbo-Hidalgo et al, 2013) states that Braden and Norton are accurate compared
to nurses judgemental skills.
Resources such as pressure reducing mattress, self-adjusting mattress, pressure reducing
overlays, special beds, pressure reducing chair, cushions and positioning devices are used in
prevention of pressure injuries. This act by redistribution of pressure. Some of the mattress are
also designed to provide alternation which is thought to increase blood flow to the organs after
pressure injury. Increased blood flow leads to oxygenation of the tissue and removal of toxic
wastes which enhances healing of the pressure injury. According to (Perneger, Héliot, Rae, Borst