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They can develop in less than eight hours but take months to heal. Pressure injuries – localized damage to a patient's skin or soft tissue – are painful and can unnecessarily lengthen a patient's stay in hospital.
So it seems obvious that pressure injuries are something that patients and their care team want to avoid. But that's easier said than done – especially for patients in critical care units who are often immobile, confined to their beds and on blood pressure medications.
That's why Toronto Western Hospital's (TW) Medical Surgical/Neuroscience Intensive Care Unit (MSNICU) decided to do away with diapers for all patients including those in Level 3 beds – the ones in the most critical condition in the hospital.
"When I transitioned to the manager position in July 2017, we had just had two significant pressure injuries on the unit," says Rebecca Sinyi, Manager, MSNICU, TW. "We had often talked about getting rid of diapers for patients, but that was the extra impetus we needed to finally do away with them."
Diapers increase risk for pressure injuries because they trap heat against the skin and are predisposed to moisture since they don't absorb very well. Just like with babies, moisture in contact with the skin can cause the skin to thin and become friable – essentially crumbling under any type of friction.
Though there are several stages of pressure injury, at their worst, the skin can disintegrate to the bone. Patients with pressure injuries can't transfer to rehabilitation or other facilities for further treatment as the pain from the injury makes it impossible for them to participate.
Change has helped unit focus on proper skin health
In the TW ICU, Level 3 patients were not only wearing diapers, they were also lying on quilted lifter pads that boost the patient. The combination of the two was a recipe for increased heat to a patient's skin – the perfect storm for a pressure injury and bacterial infections.
"When our team looked into how we could eliminate diapers, we realized the beds used for Level 3 patients already had built-in temperature and moisture control necessary to reduce the risk of pressure injuries," Rebecca explains. "The diapers and other layers were actually impeding the bed's technology so we knew it was time to get rid of them."
Within a week, the unit decreased their quota of diapers and lifter pads. They ordered a thin incontinence pad and let the bed take care of climate control. As per regular practice, staff continued to rotate patients every two hours – from lying on their right side, to left side, to on their back – another way to decrease the risk of pressure injury.
The change has helped the unit stay focused on proper skin health. Without the diaper, patient skin is exposed, which is helpful for staff to notice any changes in skin condition. They are also looking at how to reduce pressure injuries caused from other sources like medical devices such as breathing tubes.
"It has been great for our patients," says Rebecca. "We've had a patient with us for the last six months and her skin is like anyone else's."
The unit is confident that thanks to this change in practice, they will reduce overall pressure injuries and costs from no longer ordering diapers. The team also feels well positioned to incorporate recommendations from Caring Safely's Hospital Acquired Condition (HAC) Prevention Bundle for pressure injuries, which will roll out across UHN this year.