S14 S14
Clinical focus
Meeting targets in pressure ulcer prevention in the community by collaborating with industry Abstract
Key words:
Pressure ulcer
CQUIN
Industry
Lucy Woodhouse email: [email protected] Tissue Viability Lead Clinical Specialist, Gloucestershire Care Services NHS Trust
Katriona Graham Clinical Specialist, Skin Integrity, 3M Critical and Chronic Care Solutions Division Accepted for publication 17 November 2014
I
n the community sector, staff work across a wide geographical area. This often creates challenges in terms of provision of education and training sessions, and the availability of staff to attend these sessions. Even in community hospitals, training can prove difficult due to staffing levels and a potential lack of available rooms for staff to receive crucial teaching around pressure ulcer identification and skin care. The Commissioning for Quality and Innovation (CQUIN) 2014/15 guidance (NHS England,
from 85 GP practices, covering a population of 600 000 within 4 months. Staff shortages and a lack of venues available meant that an adaptive educational approach was necessary. A dedicated programme of educational support from both the tissue viability nurse and an industry partner enabled the delivery of a wide range of educational materials to staff across the county. As a result of this partnership working, there was a reduction of category 3 and 4 pressure ulcers, and an increased awareness of the initial stages of pressure ulcer development demonstrated by an increase in grade 2 pressure ulcers.
Education
2014) states that provider organisations should work with their partners across their local health and social care system to address the causes of pressure ulcers and reduce their prevalence, regardless of source. The 2014 Commissioning for Quality and Innovation (CQUIN) target for Gloucestershire Care Service NHS Trust was a reduction in the number of acquired pressure ulcers by 17%. This article describes how the community health-care trust achieved a reduction in acquired pressure ulcers. The challenge for the three members of the tissue viability team was to train the qualified and unqualified staff within seven community hospitals and district nurse teams from 85 GP practices, covering a population of 600 000 within 4 months. Staff shortages and a lack of venues available meant that an adaptive educational approach was necessary. A dedicated programme of educational support from both the tissue viability nurse and an industry partner enabled the delivery of a wide range of educational materials to staff across the county. As a result of this partnership working, there was a reduction of category 3 and 4 pressure ulcers, and an increased awareness of the initial stages of pressure ulcer development demonstrated by an increase in grade 2 pressure ulcers.
© 2014 MA Healthcare Ltd
This article describes how a community health-care trust achieved a reduction in acquired pressure ulcers. Commissioning for Quality and Innovation 2014/15 guidance states that provider organisations should work with their partners across their local health and social care system to address the causes of pressure ulcers and reduce their prevalence, regardless of source. Gloucestershire Care Service NHS Trust was challenged to reduce the number of acquired pressure ulcers by 17% in 2013–14. The challenge for the three members of the tissue viability team was to train the qualified and unqualified staff within seven community hospitals and district nurse teams
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus: Reducing pressure ulcers with industry
Background It had been noted by members of the tissue viability team that there appeared to be confusion over the definitions of ‘acquired’ (pressure damage that occurs while the patient is receiving care in the hospital) and ‘inherited’ pressure ulcers (pressure damage present on admission when admitted into community services). Moisture-associated skin damage in the sacral area is often classified as pressure damage regardless of the cause of the lesion (Bianchi, 2012) and this was evident in this Trust, where moisture lesions were often reported as grade 2 pressure ulcers, adversely affecting CQUIN targets and funding. Training in the identification and management of pressure ulcers is currently not mandatory within the Trust and therefore staff did not regard attendance at educational sessions as a priority. Organisational methods used for staff induction within the Trust did not allow the provision of pressure ulcer education as there was no option to separate the clinical staff from general support staff. In addition to this, evidence of joint working with other care providers such as the acute sector needed to be demonstrated as part of the educational programme. As such, locality meetings delivering key training were generally attended by health professionals who enabled support of the integrated care teams, including physiotherapists, occupational therapists and re-enablement workers.
The solutions These challenges were overcome by prioritising workloads and working additional hours. Increasing the flexibility of the tissue viability team was crucial for delivering the education. Working in partnership with a local representative from 3M Critical & Chronic Care Solutions Division to provide training on appropriate product use and education
Box 1. Achievements as a result of education and training project 1. Reduction in grade 3 and 4 pressure ulcers 2. More appropriate use of mattresses 3. Joint working with other care providers, such as the acute sector. Reduction in the number of inherited pressure ulcers was successfully achieved through the creation of regular county-wide pressure ulcer prevention meetings 4. Increased awareness of skin checking, evident from nursing notes/wound care plans 5. Increased awareness of continence-associated problems and appropriate management. This is evident when the telephone checklist after patient safety incident data are reported 6. Clearer, more accurate patient safety incident reports. Moisture lesions are not being misreported as pressure ulcers
surrounding the correct identification of moisture lesions and pressure ulcers aided the education delivery, as did training small numbers of staff at a time. Support from nurse managers to encourage staff to attend the training sessions was a fundamental factor in achieving the necessary outcomes.
Training and education Skin care A meta-analysis by Beeckman et al (2014) indicates that there is a link between the most important aetiological factors of incontinence-associated dermatitis and pressure ulcer development. The use of barrier creams has been shown to be effective in a structured skin care regimen (Bliss et al, 2007), and a key aspect of the education centred around correct identification and classification of pressure ulcers; the differentiation of pressure ulcers and moisture lesions; and the maintenance and protection of skin integrity using the NHS Trust-recommended barrier creams and films. An incorrect diagnosis of pressure damage is liable not only to affect the Trust’s CQUIN target, but, more importantly, could mean that patients experiencing moisture-associated skin damage related to incontinence do not receive the correct treatment and management for their condition. The training focused on the importance of appropriate barrier cream usage where there is a risk of skin damage related to moisture. Furthermore, all the attending staff were provided with a simple pocket differentiation guide to take with them, along with pocket classification cards.
Dressing selection The tissue viability team developed a quick formulary reference guide to ensure appropriate dressing usage. This is a pocket-sized guide listing the wound type and the suitable dressings available from the formulary. Two formulary launch days were organised where several companies provided a 15-minute teaching slot to a variety of district nurses, practice nurses and community hospital staff. 3M delivered a session on differentiating incontinence-associated dermatitis/ moisture lesions from pressure ulcers on both formulary launch days, and this was crucial to the overall reduction in misdiagnosed pressure ulcers. Attendance was excellent, with over 120 nurses present in total. The feedback was extremely positive and staff were provided with a copy of the full formulary as well as a quick reference guide for future use.
Equipment choice A mattress selection tool was available to health professionals working in the community, but it was evident that it was not being used. The tissue viability team ascertained from feedback was that it was too complex. By working with the community equipment team, the lead tissue viability nurse created a new mattress selection tool (Figure 1) designed to aid clinicians in selecting the appropriate mattress according to the patient’s level of risk using the Braden assessment scale
© 2014 MA Healthcare Ltd
S16 S16
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
S18 S18
Clinical focus: Reducing pressure ulcers with industry
(Bergstrom et al,1987). The Braden scale is a risk assessment tool used to measure a patient’s level of risk of developing pressure damage. It was devised in the mid-1980s and has been widely researched in different clinical environments. The Trust switched from the standard Waterlow assessment tool (Waterlow, 1988) over 2 years ago for this reason. Communication with the community equipment team was essential in the development of this tool to ensure that appropriate bed frames, heights and mattress specifications were included in the selection tool, as well as consideration of the patient’s upper body strength and ability to self-move. An audit in July 2014 showed that mattress selection was generally appropriate for individual patient needs.
Results As a result of the training and education programme a number of positive outcomes have been observed. These are summarised in Box 1 and explained in more detail in the following sections.
1. Increased awareness of pressure ulcers Changes were made to the patient safety incident software as it was noted that it was not possible to amend a misreported category 2 pressure ulcer as moisture damage following a
review by the tissue viability nurse. There had been very few reports of moisture lesions prior to the training, with little consideration given to the effects of moisture on skin integrity and subsequent pressure damage. The training delivered explained clearly what a moisture lesion is using supporting pictures. The training ensured that staff could identify the link between incontinence and associated skin damage. When Datix patient safety information is now reviewed, a key question is asked with regard to the patient’s continence status, as well as seating, lying and positioning information. This enables the Datix handler to differentiate between moisture lesions and grade 2 pressure ulcers. The reports now received via Datix are much more accurate, since staff are now identifying moisture-damaged skin appropriately and reporting that they are using barrier creams. The grading of pressure ulcers has also improved dramatically, and seems to be a result of the training and the pressure ulcer grading cards provided at all sessions. The number of reported category 2 pressure ulcers increased between the second and third quarters of monitoring, from 13 to 37, and remained consistent (at 31) in the fourth quarter. This was probably down to an increase in reporting and an improved awareness of the earlier signs of skin damage, preventing further deterioration and resulting in a reduction of category 3 or 4 pressure ulcers, indicating that staff were putting appropriate measures in place to stop category 2
© 2014 MA Healthcare Ltd
Figure 1. New mattress selection tool designed by lead tissue viability nurse and community equipment team
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus: Reducing pressure ulcers with industry
14 12 10 8 6 4 2
Grade 1
Grade 2
Grade 3
Mar 14
Feb 14
Jan 14
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
Jul 13
0 Jun 13
Reporting levels have increased as staff are checking patients’ skin more thoroughly, resulting in more appropriate identification and documentation of pressure ulcers and skin damage associated with moisture. One element of the training programme focuses on undertaking a skin check within 6 hours of admission to a community hospital, or on a first district nurse visit to a patient’s home. This is vitally important—if this is not carried out and a patient is discharged home or to a community hospital with pressure damage, it is then reported as acquired when it was actually inherited. Nursing staff were educated that they must document pressure damage and its location in patient notes, even if they are not completely sure of the category. All categories 3 and 4 damage must be seen by the tissue viability nurse, who then grades it and documents whether the pressure damage is acquired or inherited. Following the education and training programme, an audit in July 2014 showed that 81% of patients admitted to the community hospitals had their Braden score documented and acted upon within 6 hours (Figure 4).
18 16
May 13
2. Improved documentation
Figure 2. Number of acquired pressure ulcers by grade, April 2013–March 2014
Apr 13
pressure damage deterioration (Figure 2 and 3). A comparison with the data from the previous year (2012–13) is not readily available due to the reporting system used at that time; however, there is a clear demonstration that improved education has resulted in better patient outcomes and continues to do so.
S19
Grade 4
Figure 3. Percentage reduction in pressure ulcers across the observation period 60 50 40
© 2014 MA Healthcare Ltd
3. Improved multidisciplinary approach In total 180 staff from the multidisciplinary team were trained. The improved knowledge has been evident in the quality of information within their reporting. The tissue viability team has noticed that the detail given when reporting is more relevant and staff are considering factors such as incontinence when feeding back. Training was not only aimed at nurses but also physiotherapists, occupational therapists, social workers and the re-ablement team as it is often these members of the multidisciplinary team reviewing and visiting patients where nursing involvement is not always required. Following the educational sessions, members of the multidisciplinary team have reported feeling more confident at identifying pressure and moisture damage, and in the ordering of appropriate equipment. Some members of the multidisciplinary team have also reported that the training helped them overcome their ‘squeamish’ reaction to pressure ulcers. Education regarding product use and harm-free care with regard to pressure ulcers was also well received, providing staff with the confidence to assess, discuss with district nurses and advise on pressure care. One example of this good practice is an occupational therapist who attended the training. She completed a full assessment of a patient including examining the pressure areas and discovered a grade 1 pressure ulcer on the sacrum. She knew how to assess and explained to the patient that she needed to stand where possible and reposition herself regularly. She also advised on the use of a barrier cream to protect her skin. She discussed the matter with the district nurses, made them aware of the patient and asked them to
30 20 10 0 Quarter 1
Quarter 2
Quarter 3
Quarter 4
(Baseline)
(5% reduction)
(10% reduction)
(17% reduction)
Target
Actual
provide a cushion, demonstrating that the training resulted in more joint working from multidisciplinary teams and the recognition and reporting of pressure ulcer damage.
Keeping the project on track No changes were made to the initial project plans. It was a challenge to ensure that sufficient numbers of staff attended training, resulting in more work than originally envisioned by the team. Throughout the process it was observed that lunchtimes allowed better access to staff and greater numbers of attendees to attend the educational sessions. One area of note was the differing insights and requirements of the community teams with regard to the overall management of patients. Communication between teams was essential to achieve a joined-up approach in order to reach an achievable pressure ulcer reduction target.
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
Clinical Clinical focus: focus: Reducing Reducing pressure pressure ulcers ulcers with with industry industry
KEY POINTS Partnership working with industry in an open, transparent manner ensuring that parties’ visions were shared ensured results achieved improved patient care and better clinical outcomes for the Trust Education of the multi-disciplinary team in correct skin damage identification leads to timely intervention and correct management pathways. An adaptive approach to pressure injury identification and management may be required in order to meet current targets and guidelines
Recommendations Although the project was a success, the authors would recommend involving the continence team in training to ensure appropriate continence product use and education around incontinence-associated dermatitis prevention and management. Furthermore, separating the clinical nursing staff from clerical staff at induction training to provide education around correct pressure ulcer identification is recommended.
Conclusion The NHS is currently undergoing many changes, but improving the care of patients and their experience remains
Figure 4. Results of audit to assess whether patients were receiving an early assessment upon admission (n=161)
19%
Yes
No
81%
central to the Government’s quality agenda. In line with this, industry must support this agenda and ensure that there is a patient and clinician focus for every aspect of the company’s activities (Department of Health, 2012). As people continue to live longer, resulting in an ageing population, the associated risk factors for the development of pressure ulcers will also increase for those nursed both in hospitals and in the community setting. Working with industry can aid in the delivery of quality care and good patient outcomes by providing continuing education and support for NHS clinical staff, helping them to deliver the Harm-Free Care initiative (Fletcher and Ousey, 2010). When working in partnership with industry, goals should be jointly agreed by the NHS organisation and the company. They should be transparent and ensure that the best interests of the patient are met. It is this that makes joint working with industry different from sponsorship (Timmons and Shorney, 2010).Working with industry in this manner should not be viewed as showing bias by the clinician or Trust (Fletcher and Ousey, 2010), but as an opportunity to provide the right care at the right time to the right patient. Improving patient outcomes does not require a complex approach and incorporating a structured programme alongside industry can assist the clinician and trusts to provide the education necessary to make small changes in practice that can have a greater impact on patient care (Timmons and Shorney, 2010). The tissue viability team believes that working jointly with industry in this instance ensured support for the team in the organisation of the training dates, attendance logs, training in appropriate product usage and the delivery of timely and flexible education. Working in partnership with industry can viewed with a degree of suspicion, but the authors believe by working in an open, transparent manner with a shared vision can ensure results that achieve improved patient care and better clinical outcomes for the Trust. CWC Conflict of interest: First-named author is an employee of 3M Critical and Chronic Care Solutions Division, 3M Healthcare. Beeckman D, Van Lancker A, Van Hecke A, Verhaeghe S (2014) A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Res Nurs Health 37(3): 204–18 Bliss DZ, Zehrer C, Savik K, Smith G, Hedblom E (2007) An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: economics of skin damage prevention. J Wound Ostomy Continence Nurs 34(2):143–52 Bergstrom N, Braden BJ, Laguzza A, Holman V (1987) The Braden scale for predicting pressure sore risk. Nurs Res 36(4): 205–10 Bianchi J (2012) The use of faecal management systems to combat skin damage. Wounds UK 8(2): S11–S16 Department of Health (2012) The Mandate—a mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015. http://tinyurl.com/ ox6pmlo (accessed 17 November 2014) NHS England (2014) Commissioning for Quality and Innovation (CQUIN) 2014/15 guidance. http://tinyurl.com/owtx3ao (accessed 17 November 2014) Fletcher J, Ousey K (2010) Could collaboration with industry and higher education be the way forward? Wounds UK 6(4): 8–9 –9 Timmons J, Shorney R (2010) Achieving quality in wound care: what can industry do to help? Wounds UK 6(3): 56–60 Waterlow J (1988) The Waterlow card for the prevention and management of pressure sores: Towards a pocket policy. CARE: Science and Practice 6(1): 8–12
© 2014 MA Healthcare Ltd
S20 S20 S20
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus
Meeting targets in pressure ulcer prevention in the community by collaborating with industry Abstract
Key words:
Pressure ulcer
CQUIN
Industry
Lucy Woodhouse email: [email protected] Tissue Viability Lead Clinical Specialist, Gloucestershire Care Services NHS Trust
Katriona Graham Clinical Specialist, Skin Integrity, 3M Critical and Chronic Care Solutions Division Accepted for publication 17 November 2014
I
n the community sector, staff work across a wide geographical area. This often creates challenges in terms of provision of education and training sessions, and the availability of staff to attend these sessions. Even in community hospitals, training can prove difficult due to staffing levels and a potential lack of available rooms for staff to receive crucial teaching around pressure ulcer identification and skin care. The Commissioning for Quality and Innovation (CQUIN) 2014/15 guidance (NHS England,
from 85 GP practices, covering a population of 600 000 within 4 months. Staff shortages and a lack of venues available meant that an adaptive educational approach was necessary. A dedicated programme of educational support from both the tissue viability nurse and an industry partner enabled the delivery of a wide range of educational materials to staff across the county. As a result of this partnership working, there was a reduction of category 3 and 4 pressure ulcers, and an increased awareness of the initial stages of pressure ulcer development demonstrated by an increase in grade 2 pressure ulcers.
Education
2014) states that provider organisations should work with their partners across their local health and social care system to address the causes of pressure ulcers and reduce their prevalence, regardless of source. The 2014 Commissioning for Quality and Innovation (CQUIN) target for Gloucestershire Care Service NHS Trust was a reduction in the number of acquired pressure ulcers by 17%. This article describes how the community health-care trust achieved a reduction in acquired pressure ulcers. The challenge for the three members of the tissue viability team was to train the qualified and unqualified staff within seven community hospitals and district nurse teams from 85 GP practices, covering a population of 600 000 within 4 months. Staff shortages and a lack of venues available meant that an adaptive educational approach was necessary. A dedicated programme of educational support from both the tissue viability nurse and an industry partner enabled the delivery of a wide range of educational materials to staff across the county. As a result of this partnership working, there was a reduction of category 3 and 4 pressure ulcers, and an increased awareness of the initial stages of pressure ulcer development demonstrated by an increase in grade 2 pressure ulcers.
© 2014 MA Healthcare Ltd
This article describes how a community health-care trust achieved a reduction in acquired pressure ulcers. Commissioning for Quality and Innovation 2014/15 guidance states that provider organisations should work with their partners across their local health and social care system to address the causes of pressure ulcers and reduce their prevalence, regardless of source. Gloucestershire Care Service NHS Trust was challenged to reduce the number of acquired pressure ulcers by 17% in 2013–14. The challenge for the three members of the tissue viability team was to train the qualified and unqualified staff within seven community hospitals and district nurse teams
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus: Reducing pressure ulcers with industry
Background It had been noted by members of the tissue viability team that there appeared to be confusion over the definitions of ‘acquired’ (pressure damage that occurs while the patient is receiving care in the hospital) and ‘inherited’ pressure ulcers (pressure damage present on admission when admitted into community services). Moisture-associated skin damage in the sacral area is often classified as pressure damage regardless of the cause of the lesion (Bianchi, 2012) and this was evident in this Trust, where moisture lesions were often reported as grade 2 pressure ulcers, adversely affecting CQUIN targets and funding. Training in the identification and management of pressure ulcers is currently not mandatory within the Trust and therefore staff did not regard attendance at educational sessions as a priority. Organisational methods used for staff induction within the Trust did not allow the provision of pressure ulcer education as there was no option to separate the clinical staff from general support staff. In addition to this, evidence of joint working with other care providers such as the acute sector needed to be demonstrated as part of the educational programme. As such, locality meetings delivering key training were generally attended by health professionals who enabled support of the integrated care teams, including physiotherapists, occupational therapists and re-enablement workers.
The solutions These challenges were overcome by prioritising workloads and working additional hours. Increasing the flexibility of the tissue viability team was crucial for delivering the education. Working in partnership with a local representative from 3M Critical & Chronic Care Solutions Division to provide training on appropriate product use and education
Box 1. Achievements as a result of education and training project 1. Reduction in grade 3 and 4 pressure ulcers 2. More appropriate use of mattresses 3. Joint working with other care providers, such as the acute sector. Reduction in the number of inherited pressure ulcers was successfully achieved through the creation of regular county-wide pressure ulcer prevention meetings 4. Increased awareness of skin checking, evident from nursing notes/wound care plans 5. Increased awareness of continence-associated problems and appropriate management. This is evident when the telephone checklist after patient safety incident data are reported 6. Clearer, more accurate patient safety incident reports. Moisture lesions are not being misreported as pressure ulcers
surrounding the correct identification of moisture lesions and pressure ulcers aided the education delivery, as did training small numbers of staff at a time. Support from nurse managers to encourage staff to attend the training sessions was a fundamental factor in achieving the necessary outcomes.
Training and education Skin care A meta-analysis by Beeckman et al (2014) indicates that there is a link between the most important aetiological factors of incontinence-associated dermatitis and pressure ulcer development. The use of barrier creams has been shown to be effective in a structured skin care regimen (Bliss et al, 2007), and a key aspect of the education centred around correct identification and classification of pressure ulcers; the differentiation of pressure ulcers and moisture lesions; and the maintenance and protection of skin integrity using the NHS Trust-recommended barrier creams and films. An incorrect diagnosis of pressure damage is liable not only to affect the Trust’s CQUIN target, but, more importantly, could mean that patients experiencing moisture-associated skin damage related to incontinence do not receive the correct treatment and management for their condition. The training focused on the importance of appropriate barrier cream usage where there is a risk of skin damage related to moisture. Furthermore, all the attending staff were provided with a simple pocket differentiation guide to take with them, along with pocket classification cards.
Dressing selection The tissue viability team developed a quick formulary reference guide to ensure appropriate dressing usage. This is a pocket-sized guide listing the wound type and the suitable dressings available from the formulary. Two formulary launch days were organised where several companies provided a 15-minute teaching slot to a variety of district nurses, practice nurses and community hospital staff. 3M delivered a session on differentiating incontinence-associated dermatitis/ moisture lesions from pressure ulcers on both formulary launch days, and this was crucial to the overall reduction in misdiagnosed pressure ulcers. Attendance was excellent, with over 120 nurses present in total. The feedback was extremely positive and staff were provided with a copy of the full formulary as well as a quick reference guide for future use.
Equipment choice A mattress selection tool was available to health professionals working in the community, but it was evident that it was not being used. The tissue viability team ascertained from feedback was that it was too complex. By working with the community equipment team, the lead tissue viability nurse created a new mattress selection tool (Figure 1) designed to aid clinicians in selecting the appropriate mattress according to the patient’s level of risk using the Braden assessment scale
© 2014 MA Healthcare Ltd
S16 S16
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
S18 S18
Clinical focus: Reducing pressure ulcers with industry
(Bergstrom et al,1987). The Braden scale is a risk assessment tool used to measure a patient’s level of risk of developing pressure damage. It was devised in the mid-1980s and has been widely researched in different clinical environments. The Trust switched from the standard Waterlow assessment tool (Waterlow, 1988) over 2 years ago for this reason. Communication with the community equipment team was essential in the development of this tool to ensure that appropriate bed frames, heights and mattress specifications were included in the selection tool, as well as consideration of the patient’s upper body strength and ability to self-move. An audit in July 2014 showed that mattress selection was generally appropriate for individual patient needs.
Results As a result of the training and education programme a number of positive outcomes have been observed. These are summarised in Box 1 and explained in more detail in the following sections.
1. Increased awareness of pressure ulcers Changes were made to the patient safety incident software as it was noted that it was not possible to amend a misreported category 2 pressure ulcer as moisture damage following a
review by the tissue viability nurse. There had been very few reports of moisture lesions prior to the training, with little consideration given to the effects of moisture on skin integrity and subsequent pressure damage. The training delivered explained clearly what a moisture lesion is using supporting pictures. The training ensured that staff could identify the link between incontinence and associated skin damage. When Datix patient safety information is now reviewed, a key question is asked with regard to the patient’s continence status, as well as seating, lying and positioning information. This enables the Datix handler to differentiate between moisture lesions and grade 2 pressure ulcers. The reports now received via Datix are much more accurate, since staff are now identifying moisture-damaged skin appropriately and reporting that they are using barrier creams. The grading of pressure ulcers has also improved dramatically, and seems to be a result of the training and the pressure ulcer grading cards provided at all sessions. The number of reported category 2 pressure ulcers increased between the second and third quarters of monitoring, from 13 to 37, and remained consistent (at 31) in the fourth quarter. This was probably down to an increase in reporting and an improved awareness of the earlier signs of skin damage, preventing further deterioration and resulting in a reduction of category 3 or 4 pressure ulcers, indicating that staff were putting appropriate measures in place to stop category 2
© 2014 MA Healthcare Ltd
Figure 1. New mattress selection tool designed by lead tissue viability nurse and community equipment team
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
Clinical focus: Reducing pressure ulcers with industry
14 12 10 8 6 4 2
Grade 1
Grade 2
Grade 3
Mar 14
Feb 14
Jan 14
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
Jul 13
0 Jun 13
Reporting levels have increased as staff are checking patients’ skin more thoroughly, resulting in more appropriate identification and documentation of pressure ulcers and skin damage associated with moisture. One element of the training programme focuses on undertaking a skin check within 6 hours of admission to a community hospital, or on a first district nurse visit to a patient’s home. This is vitally important—if this is not carried out and a patient is discharged home or to a community hospital with pressure damage, it is then reported as acquired when it was actually inherited. Nursing staff were educated that they must document pressure damage and its location in patient notes, even if they are not completely sure of the category. All categories 3 and 4 damage must be seen by the tissue viability nurse, who then grades it and documents whether the pressure damage is acquired or inherited. Following the education and training programme, an audit in July 2014 showed that 81% of patients admitted to the community hospitals had their Braden score documented and acted upon within 6 hours (Figure 4).
18 16
May 13
2. Improved documentation
Figure 2. Number of acquired pressure ulcers by grade, April 2013–March 2014
Apr 13
pressure damage deterioration (Figure 2 and 3). A comparison with the data from the previous year (2012–13) is not readily available due to the reporting system used at that time; however, there is a clear demonstration that improved education has resulted in better patient outcomes and continues to do so.
S19
Grade 4
Figure 3. Percentage reduction in pressure ulcers across the observation period 60 50 40
© 2014 MA Healthcare Ltd
3. Improved multidisciplinary approach In total 180 staff from the multidisciplinary team were trained. The improved knowledge has been evident in the quality of information within their reporting. The tissue viability team has noticed that the detail given when reporting is more relevant and staff are considering factors such as incontinence when feeding back. Training was not only aimed at nurses but also physiotherapists, occupational therapists, social workers and the re-ablement team as it is often these members of the multidisciplinary team reviewing and visiting patients where nursing involvement is not always required. Following the educational sessions, members of the multidisciplinary team have reported feeling more confident at identifying pressure and moisture damage, and in the ordering of appropriate equipment. Some members of the multidisciplinary team have also reported that the training helped them overcome their ‘squeamish’ reaction to pressure ulcers. Education regarding product use and harm-free care with regard to pressure ulcers was also well received, providing staff with the confidence to assess, discuss with district nurses and advise on pressure care. One example of this good practice is an occupational therapist who attended the training. She completed a full assessment of a patient including examining the pressure areas and discovered a grade 1 pressure ulcer on the sacrum. She knew how to assess and explained to the patient that she needed to stand where possible and reposition herself regularly. She also advised on the use of a barrier cream to protect her skin. She discussed the matter with the district nurses, made them aware of the patient and asked them to
30 20 10 0 Quarter 1
Quarter 2
Quarter 3
Quarter 4
(Baseline)
(5% reduction)
(10% reduction)
(17% reduction)
Target
Actual
provide a cushion, demonstrating that the training resulted in more joint working from multidisciplinary teams and the recognition and reporting of pressure ulcer damage.
Keeping the project on track No changes were made to the initial project plans. It was a challenge to ensure that sufficient numbers of staff attended training, resulting in more work than originally envisioned by the team. Throughout the process it was observed that lunchtimes allowed better access to staff and greater numbers of attendees to attend the educational sessions. One area of note was the differing insights and requirements of the community teams with regard to the overall management of patients. Communication between teams was essential to achieve a joined-up approach in order to reach an achievable pressure ulcer reduction target.
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
Clinical Clinical focus: focus: Reducing Reducing pressure pressure ulcers ulcers with with industry industry
KEY POINTS Partnership working with industry in an open, transparent manner ensuring that parties’ visions were shared ensured results achieved improved patient care and better clinical outcomes for the Trust Education of the multi-disciplinary team in correct skin damage identification leads to timely intervention and correct management pathways. An adaptive approach to pressure injury identification and management may be required in order to meet current targets and guidelines
Recommendations Although the project was a success, the authors would recommend involving the continence team in training to ensure appropriate continence product use and education around incontinence-associated dermatitis prevention and management. Furthermore, separating the clinical nursing staff from clerical staff at induction training to provide education around correct pressure ulcer identification is recommended.
Conclusion The NHS is currently undergoing many changes, but improving the care of patients and their experience remains
Figure 4. Results of audit to assess whether patients were receiving an early assessment upon admission (n=161)
19%
Yes
No
81%
central to the Government’s quality agenda. In line with this, industry must support this agenda and ensure that there is a patient and clinician focus for every aspect of the company’s activities (Department of Health, 2012). As people continue to live longer, resulting in an ageing population, the associated risk factors for the development of pressure ulcers will also increase for those nursed both in hospitals and in the community setting. Working with industry can aid in the delivery of quality care and good patient outcomes by providing continuing education and support for NHS clinical staff, helping them to deliver the Harm-Free Care initiative (Fletcher and Ousey, 2010). When working in partnership with industry, goals should be jointly agreed by the NHS organisation and the company. They should be transparent and ensure that the best interests of the patient are met. It is this that makes joint working with industry different from sponsorship (Timmons and Shorney, 2010).Working with industry in this manner should not be viewed as showing bias by the clinician or Trust (Fletcher and Ousey, 2010), but as an opportunity to provide the right care at the right time to the right patient. Improving patient outcomes does not require a complex approach and incorporating a structured programme alongside industry can assist the clinician and trusts to provide the education necessary to make small changes in practice that can have a greater impact on patient care (Timmons and Shorney, 2010). The tissue viability team believes that working jointly with industry in this instance ensured support for the team in the organisation of the training dates, attendance logs, training in appropriate product usage and the delivery of timely and flexible education. Working in partnership with industry can viewed with a degree of suspicion, but the authors believe by working in an open, transparent manner with a shared vision can ensure results that achieve improved patient care and better clinical outcomes for the Trust. CWC Conflict of interest: First-named author is an employee of 3M Critical and Chronic Care Solutions Division, 3M Healthcare. Beeckman D, Van Lancker A, Van Hecke A, Verhaeghe S (2014) A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Res Nurs Health 37(3): 204–18 Bliss DZ, Zehrer C, Savik K, Smith G, Hedblom E (2007) An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: economics of skin damage prevention. J Wound Ostomy Continence Nurs 34(2):143–52 Bergstrom N, Braden BJ, Laguzza A, Holman V (1987) The Braden scale for predicting pressure sore risk. Nurs Res 36(4): 205–10 Bianchi J (2012) The use of faecal management systems to combat skin damage. Wounds UK 8(2): S11–S16 Department of Health (2012) The Mandate—a mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015. http://tinyurl.com/ ox6pmlo (accessed 17 November 2014) NHS England (2014) Commissioning for Quality and Innovation (CQUIN) 2014/15 guidance. http://tinyurl.com/owtx3ao (accessed 17 November 2014) Fletcher J, Ousey K (2010) Could collaboration with industry and higher education be the way forward? Wounds UK 6(4): 8–9 –9 Timmons J, Shorney R (2010) Achieving quality in wound care: what can industry do to help? Wounds UK 6(3): 56–60 Waterlow J (1988) The Waterlow card for the prevention and management of pressure sores: Towards a pocket policy. CARE: Science and Practice 6(1): 8–12
© 2014 MA Healthcare Ltd
S20 S20 S20
Community Wound Care December 2014 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 6, 2015. For personal use only. No other uses without permission. . All rights res
