Art & science tissue viability supplement

Engaging patients in pressure ulcer prevention Hudgell L et al (2015) Engaging patients in pressure ulcer prevention. Nursing Standard. 29, 36, 64-70. Date of submission: February 2 2015; date of acceptance: February 20 2015.

Abstract As patients increasingly care for themselves at home, they require accessible information to enable informed self-care. This article describes the development of an educational electronic application (app) designed for use by patients at risk of pressure ulcers, and their carers. The app can be downloaded to Windows, Android or Apple smartphones or tablets. The app is based on the current pressure ulcer prevention and management guidelines from the National Pressure Ulcer Advisory Panel and the National Institute for Health and Care Excellence, and is designed to educate patients and carers about how to prevent a pressure ulcer, how to recognise a pressure ulcer, and what to do if they suspect they are developing a pressure ulcer. We hope the app will be used to help with educational conversations among patients, carers and healthcare professionals.

Authors Lynne Hudgell Senior lecturer in tissue viability, Buckinghamshire New University, Uxbridge, England. Julie Dalphinis Lead nurse in safeguarding adults and Mental Capacity Act and lecturer practitioner, NHS Hammersmith and Fulham and Hounslow Clinical Commissioning Groups, London, and Buckinghamshire New University, High Wycombe, England. Chris Blunt Senior research fellow, Buckinghamshire New University, High Wycombe, England. Maryam Zonouzi Associate lecturer in service user involvement, Buckinghamshire New University, Uxbridge, England. Susan Procter Professor of clinical nursing innovation, Buckinghamshire New University, High Wycombe, England. Correspondence to: [email protected]

Keywords App, health technology, information, patient and carer education, pressure ulcer prevention, wound care, wound management

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PRESSURE ON THE NHS to improve efficiency while at the same time improving the quality of care for patients has led to the introduction of a series of benchmarking targets designed to enable NHS staff and commissioners to assess the quality of care provided. Many NHS staff will remember the introduction of the Quality, Innovation, Productivity and Prevention (QIPP) initiative. QIPP involved more than 160 NHS providers in developing the NHS Safety Thermometer (Department of Health (DH) 2013a). The NHS Safety Thermometer requires all NHS providers to undertake a monthly survey, on a specified day, of four nurse-sensitive patient safety indicators:  Pressure ulcers.  Falls.  Urinary tract infections in patients who have, or recently had (within the past 72 hours), an in-dwelling urethral catheter.  A documented risk assessment for thromboembolism, prophylaxis and treatment of venous thromboembolism. On April 1 2013, the QIPP initiative became part of the NHS Commissioning for Quality and Innovation (CQUIN) framework. The CQUIN framework established a financial framework for meeting targets and providing incentives for NHS providers to improve patient safety and harm-free care outcomes. Under CQUIN, providers are encouraged to develop systems for collecting baseline data and negotiating locally agreed improvement targets against which the quality of patient safety can be measured and improvement processes introduced. The improvement targets include national CQUIN targets as well as locally agreed service improvement targets. For the 2013/14 CQUIN, NHS providers could earn an extra 2.5% on top of their usual ‘out-turn’ budget (actual budget amount) if they achieved all targets agreed with commissioners (DH 2013a). In 2010, the DH produced a cost of pressure ulcers calculator (DH 2010) based on research by Bennett et al (2004) and adjusted for inflation. The cost calculator indicated that the cost of treating a pressure ulcer ranged from £1,064

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for low-grade pressure ulcers to £10,551 for high-grade pressure ulcers. The prevalence of pressure ulcers depends on location and case mix (National Institute for Health and Care Excellence (NICE) 2014). Prevalence rates of pressure ulcers in the community and in care homes are not known because of difficulties with data collection and measurement. A substantial proportion of pressure ulcers can be avoided with simple, effective nursing interventions, which include: observing patients’ skin, changing the position of patients at regular intervals, ensuring a moisture-free environment, and monitoring nutritional status (National Pressure Ulcer Advisory Panel et al 2014). In this article we describe the development of an educational electronic application (app) designed to inform those at risk and their carers about the preventive strategies they need to take to reduce the risk of developing a pressure ulcer. The app is targeted at patients, paid and unpaid carers, and NHS staff, and is designed to encourage conversations and inform patients and carers about the risk of pressure ulcers and the preventive strategies that need to be in place to keep patients free from harm.

Engaging patients Although hospital-acquired pressure ulcers remain a cause for concern, there is increasing evidence that a high proportion of these ulcers are acquired in the community by patients who are self-caring and do not receive regular health or social care services. Data on the prevalence of non-hospital acquired pressure ulcers is scarce. However, Stevenson et al (2013) did a cross-sectional observational study in two communities in the north east of England. They reported 185 adults with grade 1 pressure ulcers or above at site 1, a prevalence rate of 0.77 per 1,000. At site 2 there were 102 adults with grade 1 pressure ulcers or above, a prevalence rate of 0.40 per 1,000. Data were obtained from patients who were receiving NHS community nursing care, nursing home or residential care, GP care, rehabilitation care or specialist palliative care. Therefore, the study did not capture data from patients self-caring at home. In addition, the study was unable to identify patients who might be at risk of acquiring a pressure ulcer and therefore require preventive interventions and strategies. There is no reliable information on the prevalence of pressure ulcers acquired by patients self-caring at home who are not receiving regular health or social care services, although anecdotal data suggest this is a growing concern.

Recognition that prevention is better than cure has resulted in a shift in thinking about patient care, from reactive professional responses to the onset of symptoms or healthcare problems, to proactive prevention of the illness or problem. Proactive prevention of pressure ulcers has been established as good clinical practice for many years for at-risk patients receiving nursing care in hospital or in the community, and it is an important part of the nursing role (NICE 2014). However, enabling people who are self-caring at home to maintain their independence and not be transferred to institutional care, means that increasing numbers of frail and at-risk people are self-caring at home with variable support from health or social care (Ham et al 2012). Promoting safety in pressure ulcer prevention for patients managing their care at home requires that they and their carers develop an understanding about how to prevent the onset of a pressure ulcer and what to do to prevent further deterioration if they suspect a grade 1 pressure ulcer is developing. Educational materials are already available to patients and carers, with many NHS organisations producing leaflets and information booklets on the prevention of pressure ulcers. However, we are aware of difficulties with the distribution of these materials, since reprints are often not available and access to the information is patchy. The first aspect of practice we wanted to address was the provision of reliable, accessible education materials for use by staff, patients and carers. Developing an electronic app that can be downloaded to smartphones and mobile tablets has the advantage of always being available for download at no cost to the user or provider. The main disadvantage is that not all patients or staff have access to this technology. However, we reasoned that even if the patient does not have access to the technology, they are likely to have a friend or family member who can download the app for them, increasing knowledge of risk and preventive strategies in the family and the community. The second aspect of practice that we wanted to encourage in hospitals and in community, primary and nursing and residential care was the identification of patients at risk of pressure ulcers. We hope that by identifying patients who would benefit from downloading the app, NHS and social care staff will be encouraged to communicate with patients and carers about the risk of pressure ulcers and to discuss individual risk and preventive strategies, before the patient is discharged from the service. Health and social care professionals and carers may also find the app useful in assisting conversations about prevention.

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Art & science tissue viability supplement The third aspect of practice we wanted to address was to ensure that carers, families and patients know how to prevent further deterioration of a grade 1 pressure ulcer. The current guidelines recommend that every individual be assessed for pressure ulcer risk within eight hours of first contact with a healthcare professional (National Pressure Ulcer Advisory Panel et al 2014). However, although the guidelines recommend that patients at risk of pressure ulcers seek education to enable proactive prevention and management of pressure ulcers, there are no guidelines for patients and informal carers or family members about when to ask for professional help. We were also aware of the difficulties many carers and patients experience in receiving timely support and input from healthcare professionals when this is requested. This often leaves carers and patients unsure of what they should be doing while waiting for further advice. We are concerned that this delay could result in further unnecessary deterioration and want to enable patients and carers to take preventive actions while waiting for professional help to be given. The app is designed to help patients and carers to take correct preventive actions while waiting for this advice. Figure 1 illustrates the possible outcomes for self-caring patients at risk of developing a pressure ulcer. The pathway for patients who at present lack the knowledge and skills to recognise a developing pressure ulcer is depicted in the pathway on the left-hand side of Figure 1. The pathway depicted on the right-hand side of Figure 1 is the anticipated pathway if patients and carers are given access to the app and encouraged and supported by professional healthcare staff to implement the preventive strategies described in the app.

might contribute to patients developing a pressure ulcer, so that they know when to seek professional advice. Prevention information should be provided by a healthcare professional who can advise on the causes of pressure ulcers and the early signs of skin damage and provide information about how to prevent an ulcer occurring or deteriorating. It may be necessary to supply detailed information to patients more than once and to discuss the health implications of acquiring an ulcer. It is for these reasons that we decided to develop the app. The app was designed for easy access to the information and was written at a level that can be generally understood.

Methodology

At the start of the project, we used our local network of senior nurses associated with the Institute of Research in Nursing at Buckinghamshire New University and clinical commissioning group colleagues to contact a wide range of NHS, social care, and independent and private sector organisations to create a community education provider network supported by Health Education North West London. We worked with health and social care professionals from the 11 organisations that joined our network, along with patients and carers, to develop the app. A local educational technology company (LDnH Learning and Development) was commissioned to design the app. The educational app developers accompanied the clinical lead to several workshops, where the content of the app and the design of the text and graphics were discussed, as well as the depth and range of information to be included. Altogether, 48 health and social care professionals, patients and carers contributed to the development of the app.

Design

Developing the app The prevention and treatment of pressure ulcers is at the forefront of nursing care. It has been identified as a nurse sensitive indicator and incorporated into CQUIN targets linked to provider income. The incidence of pressure ulcers can be reduced by evidence-based preventive care, as recognised in The NHS Outcomes Framework 2014/15 (DH 2013b). Prevention and treatment strategies are required across all settings in the community, as well as in secondary care. All organisations have a responsibility to provide the best care available. Therefore, the policy and guidance to support care should be based on recommendations made by NICE (2014), which describes how professional services can prevent and treat pressure ulcers. It also emphasises the importance of providing patients and carers with information to raise awareness of the risks that

A first draft of the design model for the app was developed using NICE (2005) guidance as a basis for the information structure. Using our network to obtain contacts by referral, we invited allied healthcare professionals, paramedics, tissue viability nurses, senior nurses, nurses directly involved in caring for patients, as well as patients and carers, to a series of focus groups and workshops. An early model of the app was demonstrated at the workshops and comments were collated to inform and refine the design. As part of the evaluation process, participants were asked to complete a questionnaire before and after the focus groups and workshops. The workshops were used to inform us about current practice and to identify how we could apply our skills and resources to preventive practices. The focus groups were also used to inform us about current practice and determine how best to integrate the educational materials into practice.

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Art & science tissue viability supplement The groups widely accepted the app as a useful tool. Their input led to refinements of the app and provided valuable feedback on how the app should be designed. Suggestions included:  Use fewer words and more pictures.  Use interactive features.  Ensure vocabulary is recognisable to the general public.

The app

The app provides clear information about what a pressure ulcer is, who is at risk of developing an ulcer, how it can be prevented, and what to do if you suspect you or the person you are caring for is developing a pressure ulcer. The top ten tips included in the app are shown in Box 1. The app includes a short quiz to test the user’s knowledge, and gives the answers if they are unsure.

FIGURE 1 Pathways demonstrating how use of the app affects outcome in patients at risk of developing pressure ulcers Who is at risk? Anyone can be at risk Older people, those who are poorly nourished or incontinent, people with reduced mobility, progressive neurological conditions, spinal injury, or deteriorating conditions.

SITUATION Patients and carers may not have the knowledge and skills to: Identify when someone is at risk of developing a pressure ulcer. Recognise a developing pressure ulcer.

SITUATION Patients and carers can access the app to read and understand the risks and check for skin changes.

ACTION Nursing services contacted early for an urgent assessment of need.

RESULT A pressure ulcer occurs. Patients and carers try to manage the pressure ulcer with over-the-counter products.

RESULT The patient can continue to maintain their quality of life. Continue to maximise independence. Reduction in human and service costs.

ACTION As the pressure ulcer deteriorates, community services are finally contacted for advice. Reactive care rather than effective preventive care.

RESULT Long-term bed rest to relieve the pressure. Possible hospital admission. Intervention of nursing services to heal the ulcer. Increased financial costs.

OUTCOME Patients and carers have the knowledge and confidence to implement prevention strategies. Management strategies may be activated immediately to prevent further deterioration, rather than waiting for professional help to provide advice.

OUTCOME Poor quality of life. Pain and discomfort. Life-threatening risk of infection. Physical deterioration of underlying conditions.

The educational app is now available and can be freely downloaded from the NHS app store: apps.nhs.uk/app/puinfo Alternatively search for PUInfo in the app store on your Apple, Windows or Android mobile device and look for the logo.

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It also contains some pictures of what can happen if a pressure ulcer remains undetected or untreated. These pictures, which were included following consultation with patients and carers, come with a warning so those who prefer not to see such images can avoid them. We are piloting the app and will review patient and staff access as part of the process. The app is free to download. Search for PUInfo in the app store on your Apple, Windows or Android mobile device and look for the logo.

Discussion The app has been uploaded onto the NHS app store and is one of several educational apps available to patients and healthcare professionals to download. Electronic educational tools are likely to become more prevalent as this technology develops and the public become more comfortable about accessing information in this way. In developing this app, we have identified a number of benefits to patients and staff:  Free access to educational materials that are based on recommendations set out in national guidance and designed by users of these materials, including patients, carers and clinicians.  Use of these materials by in-service educational teams as part of the induction and training programme for healthcare assistants.  Potential to standardise knowledge and preventive strategies across service providers in a given region. However, implementing the app has not been without challenges. One of the biggest challenges, and one which we have not yet been able to address, is who to refer the self-caring patient to if they need further professional advice. For patients under the care of a hospital or community service, or for those living in a nursing or residential care home, the referral pathway will be dictated by the policies and procedures of that organisation. Access to appropriately trained staff should be readily available. For patients self-caring at home, however, the referral pathway is not clear. Following extensive local consultation, we have indicated in the app that the GP should be the first point of contact if a pressure ulcer is suspected of developing, while being aware that many practices are not organised to respond in a timely fashion to patients self-referring with this problem. To be able to respond appropriately, GPs need to work closely with community nursing services. However, integrated working between GPs and community nursing services

in the UK remains an unresolved problem (Procter et al 2013), which affects the extent to which patients self-caring at home can receive interventions that conform to the national standards set out in the guidance (NICE 2014). Commissioners should ensure timely referral pathways are in place for all patients who suspect they might be developing a pressure ulcer. This includes patients self-caring at home who are not in direct receipt of NHS care. Only by moving to a whole-system, preventive model will it be possible to reduce the number of pressure ulcers treated by hospital and community services.

Conclusion Preventing pressure ulcers in patients self-caring at home or living in residential or nursing homes is important to all healthcare providers. It improves patient safety and outcomes, reduces pain and suffering, and improves the standards of care received, as well as saving money. In contrast to treatment in hospitals, community care requires empowered and knowledgeable patients and carers who can independently take preventive and early intervention actions against damage and subsequent deterioration. The role of the healthcare professional needs to expand to include proactive education of patients at risk of pressure ulcer damage and their carers, so that they have the knowledge and confidence to implement evidence-based, preventive self-care. The app is designed to assist healthcare professionals in educating patients at risk of a pressure ulcer and their carers about the preventive and early interventions they can take to reduce the risk of getting a pressure ulcer and to prevent further deterioration of a stage 1 pressure ulcer. It is available for patients and carers to download free of charge and provides an accessible reference

BOX 1 Top ten tips for pressure ulcer prevention

 Keep moving. Patients should seek advice from healthcare professionals about how to achieve this within the constraints of their condition.

 Change your position regularly (every two hours if possible). If you are unable to move yourself, ask a carer.

 Inspect your skin every day, or ask your carer to check for you.  Check for reddened or broken skin or blisters over bony areas such as elbows.

 Keep skin clean and dry.  Wash with mild soap and warm water, and pat dry.  Change continence pads when wet or soiled.  Do not rub or massage sore skin or red areas.  If skin is broken, do not apply shop-bought dressings, ointments or creams.  Get advice from the GP or nurse before the skin deteriorates further.

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Art & science tissue viability supplement point to remind patients and carers of the key evidence-based preventive strategies NS Acknowledgement We would like to thank Health Education North West London for funding this project and supporting our work. We would also like to thank all the patients, carers, and health and social care practitioners who provided such valuable information and support. In particular we would like to thank: Janice Sigsworth, director of nursing at Imperial College Healthcare NHS Trust; Sue Burgis, head of

practice development and innovation at Imperial College Healthcare NHS Trust; Theresa Murphy, director of patient experience and nursing at Hillingdon Hospitals NHS Foundation Trust; Louise Ashley, chief nurse and director of quality governance at Central London Community Healthcare NHS Trust; Jean Lewis, tissue viability nurse specialist at Central London Community Healthcare NHS Trust; and Vimal Sriram, learning and improvement fellow at NIHR CLAHRC Northwest London (National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care).

References Bennett G , Dealey C, Posnett J (2004) The cost of pressure ulcers in the UK . Age and Ageing. 33, 3, 230 -235.

Department of Health (2013b) The NHS Outcomes Framework 2014/15. tinyurl.com/oszjunx (Last accessed: April 21 2015.)

Department of Health (2010) Pressure Ulcers: Productivity Calculator. tinyurl.com/ k9rcr69 (Last accessed: April 21 2015.)

Ham C, Dixon A , Brooke B (2012) Transforming the Delivery of Health and Social Care: The Case for Fundamental Change. The King’s Fund, London.

Department of Health (2013a) Delivering the NHS Safety Thermometer CQUIN 2013/14. tinyurl.com/b7kptql (Last accessed: April 21 2015.)

National Institute for Health and Care Excellence (2005) Pressure Ulcers: The Management of Pressure Ulcers in Primary and Secondary

Care. Clinical guideline No. 29. NICE, London. National Institute for Health and Care Excellence (2014) Pressure Ulcers: Prevention and Management of Pressure Ulcers. Clinical guideline No. 179. NICE, London.

Procter S, Wilson PM, Brooks F, Kendall S (2013) Success and failure in integrated models of nursing for long term conditions: multiple case studies of whole systems. International Journal of Nursing Studies. 50, 5, 632- 643.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. tinyurl.com/os6qyar (Last accessed: April 21 2015.)

Stevenson R , Collinson M, Henderson V et al (2013) The prevalence of pressure ulcers in community settings: an observational study. International Journal of Nursing Studies. 50, 11 , 1550 -1557.

Call for papers Nursing Standard is welcoming submissions from experienced or new authors on a variety of subjects, including:

• • • • • •

Management of infected wounds Bariatric pressure injury Necrotic wounds Pressure injury due to tracheostomy tubes Paediatric wound care Management of fungating wounds

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Engaging patients in pressure ulcer prevention.

As patients increasingly care for themselves at home, they require accessible information to enable informed self-care. This article describes the dev...
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