Feb 7, 2013 - Both of these projects ha v e required close multiagenc y w orking, the pro vision of joint risk assessmen
Briefing
Pressure Ulcer Prevention :: Zero Tolerance Within ABM University Health Board
Visit by Lesley Griffiths AM Minister for Health & Social Services
7th February 2013
Morriston Hospital, Swansea
Pressure Ulcer Prevention Within ABM University Health Board Background Before 2008, like most NHS hospitals we were seeing a high pressure ulcer prevalence in our hospitals. A culture had developed that pressure ulcers were an inevitable consequence of hospitalisation. This led to patient mortality, prolonged hospitalisation, avoidable pain and distress and cost; estimated at £2.7M per year for ABMU alone using the Department of Health productivity tool. ABM University Health Board consists of four acute and several community hospitals, with a total of 2300 beds providing: secondary, tertiary, community, Mental Heath, learning disability and hospice care.
What did we do? In early 2009, as a pilot site for NHS Wales, ABM University Health Board developed a bundle of interventions and an approach which we have subsequently been successfully able to roll out across all inpatient areas within the Health Board and through the 1,000 lives programme across the NHS in Wales to prevent hospital acquired pressure ulcers. The work was developed and piloted on one ward within Morriston Hospital (Anglesey) before spreading to over 100 wards and departments. The initial pilot work took a year before we were assured that we had the required assessments, training, systems and processes to achieve the required results of preventing the development of pressure ulcers within inpatient areas. Regular audits were undertaken with the nurses of patient’s pressure areas to derive pressure ulcer incidence and prevalence rates. We measured the reliability of pressure ulcer and nutritional risk assessment in our patients. A spot audit undertaken in the previous Swansea NHS Trust in March 2008 identified an incident rate of 13%. Further audit work undertaken in 2009 identified that the reliability of pressure ulcer risk assessments was only 70% and nutritional risk assessment was only 60%. The frequency of adverse events meant that proper root cause analysis (RCA) of pressure ulcers was not being undertaken. Interviews with clinical staff identified that pressure ulcers were seen as inevitable in our patient/client group (high frailty and acuity). Staff knew what caused pressure ulcers and how to prevent them but were not identifying consistently those at risk or intervening to stop ulcers. The pilot ward used the Deming’s “Model for Improvement” with repeated PDSA cycles and process changes to improve reliability of risk and nutritional assessments to exceed 95%. We developed a group of interventions (the “SKIN bundle”), based on Ascension Health. A multi-professional project board was established with patient and executive membership was established from the outset. After the package was deemed to be fit for purpose the Project Board spread the SKIN bundle out to all 100 inpatient areas. The initial roll out was to three wards, again undertaken through PDSA cycles to ensure the bundle was ‘fit for purpose’. Within critical care and A&E areas more intensive further development and PDSA cycles were required to ensure the bundle fully met the unit and patient needs and most importantly was effective in eliminating hospital acquired pressure ulcers. The SKIN bundle was adjusted to increase acceptance and reliability. The original pilot ward team were released to support the Tissue Viability Nurses in the provision of training, education and ‘on the job’ support for ward based staff during the roll out period.
We involved all other staff groups, patients and visitors through a bed-end communication tool. Some patients called it a “contract of care”. We posted visual prompts prominently on the ward and a safety cross in the ward entrance. Priority was given to responding to high risk or nutritional scores and accessing equipment to support prevention, including chair cushions. We met weekly with all ward staff to maintain a high profile. Safety crosses, care metrics and incident reports and repeated audits were used to capture, record and analyse pressure ulcers, which were reported monthly using run charts at ward, hospital and Health Board level. We used occurrences and also “days since ...” as measures. We have changed the thinking about pressure ulcers which are now considered nearly always avoidable. They have become very uncommon and can be investigated properly. Some of these are still avoidable. Creating belief took time but has been achieved. A number of our Ward Sisters take pride in being able to say ‘pressure ulcers do not occur here’.
What is the package of Care? The package of care that has been developed centres on reliably undertaking the initial risk assessment of the patients susceptibility to developing pressure ulcers and then the immediate implementation of a package of care using the SKIN Bundle format that is also tailored to meet that patients individual needs as well as communicating to the patient and family of the risks and what needs to be undertaken to reduce them. All inpatients must have a pressure ulcer risk assessment (Waterlow risk assessment) undertaken on admission to hospital. This is to be repeated as determined by the score or if the patients condition / needs change. Any patients who score 15 or greater on the risk assessment are deemed to be at risk and should be put on the SKIN bundle. This requires documented nursing intervention at least every two hours in the following areas to reduce likelihood of damage: Surface – ensure patient is on the right mattress, cushion, there are no creases or wrinkles Keep moving - encourage self movement, reposition patient and inspect skin Incontinence - meet patient’s toileting or continence needs Nutrition – keep well hydrated, meet patients nutritional needs An effective nutritional risk assessment on admission, repeated if patients condition changes and appropriate so that effective immediate dietary support can be provided is another key factor in reducing a patients susceptibility to developing pressure ulcers. The following measures are recorded across all wards every month in order that the focus on this work can be maintained:
• • • • • •
Incidents of pressure ulcer development % compliance with a Waterlow risk assessment on admission % compliance with a repeat Waterlow risk assessment within agreed timeframe % compliance with nutritional risk assessment on admission % compliance with repeat nutritional risk assessment within agreed timeframe % compliance with full completion of the SKIN bundle
Current Situation The Health Board has gone from a pressure ulcer incident rate of 13% (2008) to 30 2 Below average BMI < 20 3 Healthy 0 Thin and fragile 1 Dry 1 Oedematous 1 Clammy (Temp ↑ ) 1 Previous pressure sore or scarring 2 Discoloured Grade 1 2 Broken Grade 2 - 4 3 Fully 0 Restless/fidgety 1 Apathetic 2 Restricted/Bed bound 3 Inert (due to ↓consciousness/traction) 4 Chairbound/Wheelchair 5 Continent/catheterised 0 Occasional incontinence 1 Incontinent of Urine 2 Incontinent of Faeces 2 Doubly incontinent 3 Terminal Cachexia 8 Multi Organ Failure 8 Single Organ Failure (Respiratory/Renal/Cardiac) 5 Peripheral Vascular Disease 5 Anaemia HB < 8 2 Smoking 1 Average 0 Poor 1 N.G Tube/ Fluids only 2 NBM/anorexic 3 Diabetes, CVA, MS, Motor/Sensory Paraplegia, epidural 46 Above waist Orthopaedic, below waist, spinal > 2 hours on theatre table 6 hours on theatre table Cytotoxics high dose/long term steroids Anti-inflammatory
2 5 8 4
TOTAL SCORE NURSE INITIALS Mattress (Please tick as appropriate) Enter name of other mattress if used
Pentaflex Alpha Xcell Autologic Nimbus Other mattress: Chair cushion Risk Score: 10+ AT RISK 15+ HIGH RISK 20+ VERY HIGH RISK Adapted from Waterlow Risk Score (Waterlow 2005)
Reducing Pressure Ulcer Incidents. Pressure sores (also known as a bed sore, pressure ulcer or decubitus ulcers) must be taken seriously, if left unchecked, they can lead in the worst case to death. Check yourself for red marks and sores daily, it should be a routine which is as second nature as washing yourhands.
S.O.S - SAVE OUR SKIN
Your Skin
People who smoke are also at an increased risk of developing a pressure sore, as are those who are overweight or diabetic. The damage from a pressure sore will range from slight discoloration of the skin to open sores that go all the way to the bone (severe). The affected area may feel warmer than the surrounding tissue. In light-skinned people, the discoloration may appear as dark purple or red. In darker-skinned people, the discoloration will appear darker than the surrounding tissue.
£2.4 Billion per Year.
Areas susceptible to pressure ulcers
A pressure sore is an injury to the skin and the tissue under it. A pressure sore develops when the blood supplying the tissue with oxygen and nutrients is cut off, and the tissue no longer receiving oxygen and nutrients dies. The oxygen and nutrients are essential to maintain healthy tissue. Sitting in the same position for a prolonged period of time can start the process of tissue breakdown.
Pressure Ulcers Cost the NHS
Needs You
Contact Ward staff for details of the 1000 Lives+ SOS campaign
S.O.S SAVE OUR SKIN 1000 LIVES CAMPAIGN
Pressure Ulcers Zero Tolerance What is the problem – • Pressure Ulcers cost 4% of the National Health Service budget. • Nice Guidelines have shown a range of 10% - 14% incidence of hospital acquired Grade 1 to 4 Pressure Ulcers. • Incidence rates within the Welsh Centre for Plastic Surgery has shown to be at 4.2%.
Aim – • To reduce Pressure Ulcer Incidence by 50% per 1000 patient bed days.
SKIN Bundle Communication Tool for Pressure Ulcer Prevention Patient Name Date 28th April 2008 12am 4am 8am 12pm 4pm 8pm Time Surface 1 Therapulse
2 Roho Cushion
Keep Moving
1 Skin Assessed 2 Right Side
“Pressure ulcer prevention being uppermost part of the nursing agenda, the culture has changed. Pressure ulcers are just not acceptable anymore. ” Staff Nurse Band 5 Anglesey ward
Method –
3 Left Side 4 Back
Incontinence 1 Catheter
2 Clean and Dry
Nutrition
• Firstly a process mapping session was undertaken to identify the risk tools already used and their effectiveness. From this session a clear picture was established and a way forward was planned which involved utilising the development of a new skin bundle communication tool.
1 Protein drinks 2 Fluid balance
• Staff education and updating was identified as paramount for the project to succeed. Patient, relatives and carers input in the development of a skin bundle communication tool and also what was required for the patient was invaluable.
Waterlow
• When the skin bundle and development of the new processes were refined a pilot was undertaken. • The wards implementing the change have been the catalyst for change on the next wards identified for change. This has seen staff teaching and educating the new wards prior to the model of care being implementing.
The above is an example of elements that can be used under each section of the bundle and can be tailored to each individual patient.
The PDSA cycle Model of Improvement to test a change idea
• New ways of risk assessing were recognized and the managing of these results was seen as crucial. A number of PDSA cycles were implemented to ensure the new processes were effective.
seriously. Pressure sores are debilitating and not only cost lots of money to heal, but also impact on my quality of life tremendously
Measurements for Improvement –
”
• Implementation of the Skin bundle and risk assessments was measured daily by use of a traffic light system. Patient risk scores including pressure ulcer risk scores (Waterlow), Nutritional risk scores were set at 100% compliance. The compliance was measured daily and audited weekly.
MA Pressure Ulcer Patient
• Pressure ulcer incidence of grade 2 and above would be recorded as a clinical incident as set out in the NICE guidelines. • Pressure Ulcers were then measured by % of Pressure Ulcers per 1000 bed days and also number of days since last Pressure Ulcer incident on that particular ward.
Effects of the Change – • The effects of the change made due to the project have shown significant quality improvements for the care of the patients within the Welsh Centre for Plastic Surgery. • It has also had tremendous value with regard, to decreasing the amount of money spent on managing pressure ulcers both within the primary and secondary care settings. • The model of care developed has proved so successful that it has seen it rolled out to 12 other areas, with a vision of it being rolled out to every ward within the trust within the next 12 months. • The plastic Surgery Centre is 100% compliant with their risk scores and also the management of the risk scores. • All staff within the department have been educated in the prevention of pressure ulcers and the importance on managing the risk assessment scores. • All patients identified as at risk are educated on methods effective in preventing pressure ulcers. Also available is written information on simple methods to prevent pressure ulcers, which has been developed since the project.
Implementation Team
“it is only right that this is taken
Results – February 2013 There has been a dramatic reduction in hospital acquired pressure ulcers across ABMU Health Board. From around 450 a month to less than 10. Many wards have gone hundreds of days without a ulcer developing: 9 wards have had no incidents for over 3 years! Pressure ulcer Incidence has decreased from 10% incidence to 0.1% since the introduction of the new methods.
Message for Others – By maintaining a process that gives 100% compliance with risk assessments and managing them in an appropriate manner will ensure a dramatic decrease in the incidence of pressure Ulcers and in some areas will eradicate them. This can only be achieved through a collaborative approach using enthusiastic, knowledgeable staff, patients and their carers.
Challenges – • Keeping people motivated - use whatever it takes! • Start small, when successful aim big and roll out. • Project team needs to keep focussed and pushing forward. • Ensure your management team are behind the innovation. • Remember success breeds success.
