Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 49: 75–82.
Pressure injury prevention success in a regional hospital Michelle Hunter, Jennifer Kelly*, Norma Stanley, Amy Stilley and Lynn Anderson Bundaberg Hospital, Wide Bay Hospital and Health Service, Bundaberg, QLD, Australia; *School of Health, Nursing and Midwifery, University of Southern Queensland, Springfield, QLD, Australia
Abstract: Background: This paper describes quality improvement strategies implemented following the identification
of a significantly high prevalence rate and severity of pressure injuries in a regional health care facility in a large health district in Queensland, Australia. Aim: The aim of this paper is to inform health professionals of processes employed to reduce the incidence and financial burden of pressure injuries following the detection of rates that were significantly above the State average. Method: An audit of pressure injury prevalence data was conducted on a single day throughout a regional hospital. Prevalence data was compared to State averages and hospital strategies used to prevent injuries were examined. Findings: Audit reports for this acute setting revealed that despite best practice guidelines, prevalence was a major concern. Lack of accountability, poor documentation, limited education and knowledge of risk assessment and prevention were central to the need to implement quality improvement processes. Conclusion: This paper outlines the results associated with implementing quality measures to reduce the prevalence of pressure injuries. Following an audit of pressure injury prevalence data, strategies were implemented to reduce noteworthy rates. Employing specific techniques can result in significantly decreasing hospital acquired pressure injuries in health care settings throughout the world.
Keywords: pressure injury, prevention, management, documentation, sustainability, prevalence, incidence, hospital acquired pressure injury
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ressure injuries contribute to decreased q uality of life and suffering for individuals in addition to being a financial burden to the patient and health care facilities. In Australia during 2001– 2002, there were 95,695 cases of pressure injuries with 398,432 bed days lost, incurring opportunity costs of AU$285 million (Graves, Birrell, & Whitby, 2005). Of note, these cases only represented 52% of discharges from Australian public hospitals and underestimate the true financial burden (Graves et al., 2005). However, hospital acquired pressure injuries are an international issue and concern for health care workers and organisations. In the United Kingdom (UK) in 2000, the total cost of pressure injury care to the National Health Service was estimated to be between £1.4 and £2.1 billion annually (Dealey, Posnett, & Walker, 2012). Thus, the burden of caring for people who acquire a pressure injury is immense and supports strong preventative efforts by clinicians. This paper presents the result of pressure injury prevalence audit incidence data and discusses the strategies that were implemented by nurses to achieve a reduction hospital acquired pressure injuries. Strategies discussed may be applied
universally to benefit individuals and organisations. The setting for this paper is an acute care facility with ∼200 beds in a large regional health district north of Brisbane, Queensland. Pressure injuries are a nurse sensitive indicator therefore, nurses are accountable for implementing pressure injury reducing risk management strategies. Evaluation of this indicator is undertaken through analysis of prevalence and incidence rates which are benchmarked against similar healthcare facilities. Benchmarking is difficult due to broad variances in rates worldwide. Variance is due, in some part, to differing data collection approaches which makes interpreting and comparing rates difficult (Baharestani et al., 2009). Some of these variations in incidence and prevalence relate to exclusion and or inclusion of Stage 1 pressure injury, lack of differentiating between hospital acquired pressure injuries versus total pressure injury rates, variances in staging and the classification system employed (Baharestani et al., 2009). Recently published facility acquired prevalence rates in Australia were 17.3% in South Australia (South Australian Department of Health, 2007), 7.4% in Western Australia (Mulligan, Prentice,
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& Scott, 2011) and 8.8% for Queensland Health (Department of Health, 2013). However, Mulligan et al. (2011) acknowledged an increase in pressure injury prevalence from 6.3% in 2009 to 7.4% but this does not correspond with clinicians in Western Australia changing pressure injury prevention strategies. For instance, the number of patients who underwent a pressure injury risk assessment on admission increased by 30%. Also there was an 11% decrease in the use of pressure injury relieving device (Mulligan et al., 2011). Mulligan et al. concluded that although pressure injury risk assessment tools are utilised the assessments are not being translated into clinical practice and do not address people at risk. Furthermore, ‘staff education and intelligent use of pressure injury prevention resources are necessary to close this gap to improve patient safety’ (Mulligan et al., 2011, p. 3). Pressure injuries acquired during the provision of health care to patients in hospitals are considered clinical incidents. Clinical incidents are (voluntarily) reported in most Queensland Public Hospitals using a reporting system known as PRIME Clinical Incidents. The objective of gathering data using PRIME Clinical Incidents is to review pressure injury trends and causative factors so that targetted pressure injury prevention strategies can be implemented. In addition, it enables health care professionals’ knowledge and skills to prevent harm and promote patient safety. Audit reports can be extracted from PRIME Clinical Incidents for specific issues or concerns for example, falls, needle stick injuries and pressure injuries. In 2008, Queensland Health established a target for the reduction of pressure injuries in health care facilities to a prevalence rate of 10% or below (Queensland Health, 2012). Additionally, in 2012, the Queensland State Government introduced financial penalties for facilities with hospital acquired Stage 3 and 4 pressure injury. The penalty for a Stage 3 pressure injury is $30,000 and $50,000 for a Stage 4 pressure injury (Department of Health, 2013). In the United States of America in 2007, Medicare and Medicaid announced non-reimbursement of hospital acquired Stage 3 and 4 pressure injuries 76
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(Bales & Duvendack, 2011). Similarly, in Japan, the Government introduced a penalty system of reduced reimbursement per patient for each hospitalised day unless certain requirements for prevention were met (Sanada et al., 2010). Although some reduction in overall hospital acquired pressure injury prevalence rates were apparent after the introduction of financial penalties (2.77–2.31%), there was no effect on Japan’s percentage of Stage 3 and 4 pressure injuries (Sanada et al., 2010). Subsequently, the Japanese government changed to an incentive reimbursement programme for patients at high risk of pressure injury development (Sanada et al., 2010). Of note, financial penalties are controversial in relation to the delivery of health care because penalties create an extra burden on finances required to prevent and treat pressure injuries. In an effort to reduce prevalence, incidence and mortality rates and the financial burden caused by hospital acquired pressure injuries the focus on best practice guidelines was heightened. In Australia, guidelines were first produced by the Australian Wound Management Association (2001) and subsequently updated in 2012 (Australian Wound Management Association, 2012). Queensland Health (2004) produced a best practice guideline in 2004 which provided the basis for the pressure injury prevention and management programme implemented at a regional hospital in Queensland. To motivate implementation of the best practice guidelines, the Australian Council on Healthcare Standards incorporated Standard 8, Preventing and Managing Pressure Injuries, into the accreditation requirements of the National Safety and Quality Health Service Standards (Australian Commission on Safety and Quality in Health Care, 2011). Incorporating best practice guidelines into an evolving healthcare system has led to the development and implementation of facility-based pressure injury prevention programmes. Several Australian studies document a decrease in pressure injury rates and financial burden after implementing a pressure injury prevention programme. For instance, a nurse practitioner led project conducted over 2 years in a large health service
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Pressure injury prevention success in a regional hospital in New South Wales led to a reduction in hospital acquired pressure injury prevalence rates from 23.4% in 2008 to 8% in 2010 (Asimus, MacLellan, & Li, 2011). The basis of this project involved point prevalence audits, supply of appropriate, pressure reducing, equipment and mandatory staff education (Asimus et al., 2011). Similarly, in Victoria a large acute care metropolitan hospital also achieved success with a reduction in hospital acquired pressure injury prevalence over 6 years. The pressure injury prevalence rates decreased from 12.6 to 2.6% [x < 0.001] (Barker et al., 2013). The programme consisted of, compliance with risk assessment; accuracy of pressure injury risk assessment; use of prevention strategies; annual staff education and point prevalence audits (Barker et al., 2013). Furthermore, one American hospital has achieved a noteworthy result of 0% prevalence in 2008 from 9.5% in 2007 (Bales & Duvendack, 2011). This American programme incorporated training staff on assessment and prevention, conducting point prevalence audits, mattress replacement and documentation of patients who presented with a pressure injury on admission (Bales & Duvendack, 2011). Targetting the underreporting of pressure injury incidence was achieved through weekly audits of high risk patients that checked documentation of skin assessments, two hour turns, pressure injury staging and toileting (Bales & Duvendack, 2011). Methods An audit of pressure injury prevalence data was conducted in a regional hospital in Queensland, Australia. The prevalence data was collected via the Queensland Bedside Audit. The Queensland Bedside Audit is a major annual collaborate clinical event undertaken by Queensland Health whereby auditors collect data for the purpose of improving the care provided to patients in State hospitals. All auditors receive education on conducting the Queensland Bedside Audit and are tested on staging of pressure injuries prior to commencing the audit. Training includes use of an audit tool, conducting skin inspections and identification and staging of pressure injuries.
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Auditors work in pairs and full skin inspections are conducted on patients who verbally consent to involvement in the audit. Therefore, pressure injury prevalence data was collected using the Queensland Bedside Audit tool. Data was collected throughout a regional hospital on a single day by trained auditors. Data was electronically entered into a database using a scannable form. All inpatients that provided verbal consent to a full skin inspection were included in the audit with the exception of patients admitted to the mental health unit. Ethics approval was not required as monitoring of prevalence and incidence forms is part of the quality improvement programme and monitoring of standards of care. Data was collected via a routine hospital audit. Conducting this audit and reviewing pressure injury data was approved by the executive of the hospital. Pressure injury incidence data was collected from the PRIME Clinical Incidents database. Prevalence was calculated as follows: (numerator/denominator) × 100%; numerator = number of consenting inpatients with one or more hospital acquired pressure injuries; denominator = total number of consenting hospital inpatients. Incidents of all pressure injuries are voluntarily reported by clinicians into this system when identified. Incidence is reported as total number of injuries. Reported incidence of injuries were reviewed and the alarming findings led to a review of documentation, reporting processes, risk assessment procedures, provision of education and the level of involvement by hospital management. Overall, it was apparent that the organisations current pressure injury prevention programme was not effective in reducing rates. As an outcome, a working group was established to review, modify and strengthen the pressure injury prevention programme and associated strategies. The working group consisted of registered nurses who occupied positions such as, clinical nurse consultants, nurse unit managers and nursing directors within the organisation. Initially, the working group reviewed policy, documentation processes, provision of staff education, and auditing practices.
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Results The pressure injury point prevalence rates for this acute regional hospital indicated an increasing trajectory from 2008 to January 2011 (Figure 1). A peak of 15.6% was observed in 2010. Following the review and implementation of an improved pressure injury prevention programme during 2011 the prevalence rate decreased to 3% in October 2011 (Figure 1). The hospital acquired pressure injury prevalence rate has been sustained at 5% or below since October 2011 and in addition this hospital has remained below the State wide average every year since October 2011 (Figure 1). The incidence of pressure injuries from PRIME Clinical Incidents data indicated an increasing number of community acquired injuries from 5 in 2009 to 201 in 2013 (Figure 2). Hospital acquired injury incidence shows and increasing trend line but decreased from 140 in 2012 to 86 in 2013 (Figure 2). Discussion The hospital at the centre of this paper is an acute care facility with ∼200 beds and is a referral centre for a number of rural hospitals in this health district. In 2010, an increasing trend in the clinical observations of pressure injuries was observed leading to an audit of PRIME Clinical Incidents data. Further, reinforcement of the audit data was confirmed in the 2010–2011 Queensland Bedside Audit with a hospital acquired prevalence rate of
15.6% for the hospital compared with the statewide benchmark of 11.1% (Queensland Health, 2012). The noteworthy findings from the audit necessitated the formation of a group to examine the processes and strategies employed at this regional health care facility. Most significantly, documentation of admission skin assessment was lacking and therefore hospital acquired pressure injuries were not differentiated from community acquired pressure injuries. The incidence data revealed a considerable percentage of pressure injuries occurred in the community and from inter-facility transfers. Additionally, it was identified from the review of charts that documentation was inconsistent and copious, and different forms (or documents) were used throughout the hospital. Of particular note, it was observed that staff appeared to lack knowledge surrounding the goal of skin and pressure injury risk assessments and the need to implement preventative interventions. Accountability and adherence to policies and processes employed in relation to the occurrence of hospital acquired pressure injuries was minimal. Also, involvement of people in leadership or management positions at this health care facility was not obvious or apparent. Therefore, prevalence and incidence rate findings resulted in the implementation of numerous strategies and procedures that reflected a credible prevention programme. Table 1 provides an account of the strategies implemented by the group.
Figure 1: Hospital acquired pressure injury prevalence
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Figure 2: Incidence from PRIME Clinical Incidents
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Table 1: Hospital pressure injury prevention strategies implemented Issue
Strategy
Standardisation of forms
Implementation of a I. Single page risk assessment tool combined with a standard care plan for patients at risk of pressure injury. The Waterlow tool for adults (Waterlow, 2005) and the Glamorgan tool for paediatrics (Wilcox, Baharestan, & Anthony, 2009) II. Skin integrity assessment record III. Patient repositioning chart IV. Elimination management chart V. Wound assessment chart for pressure injury monitoring VI. Pressure injury notification sticker (florescent pink in colour)
Standardisation of processes
Implementation of I. Risk assessment on admission and daily for all acute patients II. Skin assessment on admission, transfer and discharge (and at least daily for all at risk patients) III. Clinical photography of all identified injuries (with patient consent) IV. Care plan implemented for all at risk patients
Education and ‘marketing’ programme
I. Mandatory, yearly, self-directed learning package on pressure injury prevention management and staging for all nursing staff. An 80% pass mark was set II. Pressure injury prevention, management and staging in nursing orientation III. Development of a disc containing a power-point presentation explaining • How, when and why documentation was imperative using the revised forms • The need for accurate screening and assessment of patients IV. Introduction of resource folders in all clinical areas V. Introduction of posters outlining pressure injury staging details VI. Pressure injury education brochures given to all patients VII. Workshops on pressure injury prevention and management
Auditing
I. Commenced random auditing of 5 charts per month of documentation and intervention compliance. This was reported monthly to the pressure injury steering committee with non-compliance escalated to executive II. Commencement of annual mattress audit III. Yearly prevalence audit IV. Random patient safety rounds by nursing executive to assess documentation compliance
Improved governance and accountability
I. Policy review and implementation II. Nursing executive involvement III. F ormation of regular pressure injury prevention committee with multidiscipline representation from all clinical areas
Positive feedback to staff
Wards and departments with improved audit reports were made known and successful outcomes of particular wards or departments highlighted
Involvement of external organisations
Queensland Ambulance Services and the Royal Flying Doctors Service were provided with details surrounding the findings and possible equipment that could improve transportation conditions
Equipment
I. Purchase of additional alternating air mattresses II. Acquisition of additional leg troughs and bed cradles III. Purchase of chair cushions
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The pressure injury point prevalence audit results show a significant decrease from 15.6% in 2010 to 3.2% in October 2011. More importantly is the sustained reduction in pressure injury point prevalence below 5% since October 2011. In addition, this regional acute hospital remained below the State average since October 2011. In 2010, it was apparent that the organisation’s pressure injury prevention programme was not effective in reducing rates and the working group was needed to review, modify and strengthen the prevention programme incorporating new evidence. As such, the report by Miles, Fulbrook, Nowicki, and Franks (2013) which stated that the Prince Charles Hospital initiated a multitude of strategies involving equipment, education, governance, auditing and documentation was considered. Improved quality strategies implemented at this hospital resulted in reducing hospital acquired pressure injury prevalence rates to below 5% and this rate was sustained from 2010 to 2013. Prevention programmes are highly effective but continued success involves long term strategies to maintain sustainability. Sustainability is a key focus of pressure injury prevention programmes combined with reliable and consistent reporting and documentation. Sustainability was reinforced at the hospital in this regional area by reinforcing positive outcomes, highlighting successful outcomes and ensuring staff were aware that monitoring of reporting and documentation would be continuous. Additionally, sustainability can be enhanced through initiatives such as engaging staff in regular pressure injury prevention education to increase understanding of programmes and reinforce knowledge surrounding practice (Bales & Duvendack, 2011; Delmore, Lebovits, Baldock, Suggs, & Ayello, 2011; Kiely, 2012; Orsted, Rosenthal, & Woodbury, 2009; Revello & Fields, 2012; Sendelbach, Zink, & Peterson, 2011; Young, Ernsting, Kehoe, & Holmes, 2010). Finally, identifying unit-based champions enables continuous monitoring, assessment, evaluation and education reinforcement (Carson, Emmons, Falone, & Preston, 2012; Delmore et al., 2011; Kiely, 2012; Orsted et al., 80
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2009; Revello & Fields, 2012). Unit-based champions are being implemented throughout this hospital in 2014. Programmes that empower staff to be part of clinical decision making processes are essential to ongoing programme support (Kiely, 2012; Young et al., 2010). Pressure injury prevention programmes that are creative, fun and afford reinforcement, preserve staff engagement and motivation produce short and long term results. Meaning, programmes that have themes, reward systems, logos, posters and sometimes even mascots are more likely to succeed long term (Bales & Duvendack, 2011; Orsted et al., 2009; Sendelbach et al., 2011; Young et al., 2010). Therefore, sustainable and successful programmes are ones that embrace education, utilise unit champions, empower staff, have administrative support and are motivational through creativity. The programme introduced at this regional district hospital operationalised many of these strategies which attributed to decreasing hospital acquired pressure injuries. Limitations The pressure injury point prevalence results are encouraging but limited due to only identifying patients with injuries on a single day. Evaluation of individual strategies implemented at this health facility was not undertaken and is also a limitation in the reporting of these findings. Another limitation relates to the reliability of reporting and assessment. For instance, a rationale for the increased community acquired injury data in Figure 2 is that the data is more likely to be reflective of improved reporting of pressure injuries as opposed to increased incidence. Thus, it is unknown whether improved skin integrity assessments on admission reflect the escalating community acquired injuries and injuries received prior to admission to this regional hospital. Currently there is no routine or robust auditing or checking methods employed locally, State wide or nationally thereby, reported incidence rates may be unreliable because a significant number of pressure injuries are not documented
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Pressure injury prevention success in a regional hospital (Whittington & Briones, 2004). As such, there is a need for accurate incidence data which involves a consultation process with staff to confirm presence, staging and reporting of pressure injuries (Miles et al., 2013). Incidence data is the result of the initial report on PRIME Clinical Incidents but highlights the need to improve data collection mechanisms and data analyses to eliminate future inaccuracies. Baharestani et al. (2009, p. 99) comment that ‘incidence analyses are generally considered to provide a clearer indication of the effectiveness of a pressure ulcer prevention protocol than do prevalence analyses.’ Therefore, data needs to be checked for correct diagnosis and staging in conjunction with the patient and medical record. Conclusion The outcome from the audit at this regional hospital demonstrates that pressure injury point prevalence rates can be significantly reduced and organisational change achieved. A motivated group of registered nurses initiated and accomplished implementing a pressure injury prevention programme. The programme was embraced by staff from within and external to this health care facility to reduce pressure injury point prevalence rates from 15.6% in 2010 to 3.57% in 2013. Furthermore, prevalence rates have been sustained at below 5% for the last three years. Initiating strategies in line with best practice guidelines resulted in positive outcomes for patients and this regional hospital. Strategies such as introducing consistent documentation, education programmes, obtaining and sustaining management support, external facility involvement and positive reinforcement demonstrated that change is possible. Additionally, utilising clear and concise communication throughout the organisation combined with adopting a holistic approach to patient care has led to a substantial decline in pressure injury prevalence rates for this health care facility. Recommendations This paper illustrates that change is possible and best practice essential. Following the revelation
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that change was vital to decrease pressure injury rates, a whole of organisation approach was implemented to introduce best practice. Changing hospital acquired pressure injury point prevalence rates was initially considered difficult but adopting a cohesive and consistent approach throughout the facility involving key internal and external stakeholders resulted in positive outcomes. However, a key issue for continuing these best practice standards is sustaining motivation and success rates. The importance of pressure injury prevention education for commencing and continuing staff regarding hospital policy and procedures is central and necessary. Additionally, positive reinforcement is pivotal to success and ensuring that pressure injury prevention is at the forefront of practitioners care is paramount. Thus, the sustainability of successful outcomes from the strategies employed is considered imperative but continued results require resources. It is recommended that the issue of pressure injury prevention is given serious consideration by health care organisations and supported through the provision of resources such as staff and equipment. Staff are required to ensure consistent and reliable documentation is maintained. Further, PRIME Clinical Incidents data is collated and verified to ensure accurate incidence reporting including preparation and monitoring of audit reports. Of key significance is the need for the provision of positive reinforcement of staff. Without ongoing resources prevention of harm and patient safety will remain an ongoing or re-emerging issue for health care facilities. References
Asimus, M., MacLellan, L., & Li, P. (2011). Pressure ulcer prevention in Australia: The role of the nurse practitioner in changing practice and saving lives. International Wound Journal, 8(5), 508–513. Australian Commission on Safety and Quality in Health Care (ACSQHC). (2011). National safety and quality health service standards. Retrieved from http://www.safetyandquality.gov.au/wp-content/ uploads/2011/09/NSQHS-Standards-Sept-2012.pdf Australian Wound Management Association (AWMA). (2001). Clinical practice guidelines for the
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prediction and prevention of pressure ulcers. Perth, WA: Cambridge Media. Australian Wound Management Association (AWMA). (2012). Pan pacific clinical practice guideline for the prevention and management of pressure injury. Osborne Park, WA: Cambridge Media. Baharestani, M. M., Black, J. M., Carville, K., Clark, M., Cuddigan, J. E., & Dealey, C. (2009). Dilemmas in measuring and using pressure ulcer prevalence and incidence: An international consensus. International Wound Journal, 6(2), 97–104. Bales, I., & Duvendack, T. (2011). Reaching for the moon: Achieving zero pressure ulcer prevalence, an update. Journal of Wound Care, 20(8), 374–377. Barker, A. L., Kamar, J., Tyndall, T. J., White, L., Hutchinson, A., Klopfer, N., & Weller, C. (2013). Implementation of pressure ulcer prevention best practice recommendations in acute care: An observational study. International Wound Journal, 10(3), 313–320. Carson, D., Emmons, K., Falone, W., & Preston, A. M. (2012). Development of a pressure ulcer program across a university health system. Journal of Nursing Care Quality, 27(1), 20–27. Dealey, C., Posnett, J., & Walker, A. (2012). The cost of pressure ulcers in the United Kingdom. Journal of Wound Care, 21(6), 261–266. Delmore, B., Lebovits, S., Baldock, P., Suggs, B., & Ayello, E. A. (2011). Pressure ulcer prevention program: A journey. Journal of Wound, Ostomy and Continence Nursing, 38(5), 505–513. Department of Health. (2013). Health funding principles and guidelines 2013–2014. Queensland Government. Retrieved from http://www.health.qld. gov.au/hhsserviceagreement/docs/documents/sd3fund-prin-guide.pdf Graves, N., Birrell, F. A., & Whitby, M. (2005). Modelling the economic losses from pressure ulcers among hospitalised patients in Australia. Wound Repair and Regeneration, 3, 462–467. Kiely, C. (2012). Cultural transformation in pressure ulcer prevention and care. Journal of Wound, Ostomy and Continence Nursing, 39(4), 443–446. Miles, S. J., Fulbrook, P., Nowicki, T., & Franks, C. (2013). Decreasing pressure injury prevalence in an Australian general hospital: A 10-year review. Wound Practice and Research, 21(4), 148–156. Mulligan, S., Prentice, J., & Scott, L. (2011). Wounds west wound prevalence survey 2011 state wide overview report. Retrieved from http://www.health.wa.gov.au/ woundswest/docs/WWWPS_11_state_report.pdf
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Orsted, H. L., Rosenthal, S., & Woodbury, M. G. (2009). Pressure ulcer awareness and prevention program: A quality improvement program through the Canadian association of wound care. Journal of Wound, Ostomy and Continence Nursing, 36(2), 178–183. Queensland Health. (2004). Pressure ulcer prevention and management resource guidelines. Brisbane, QLD: Queensland Government. Queensland Health. (2012). Pressure injury prevention information for clinicians. Retrieved from http:// www.health.qld.gov.au/psq/pip/docs/info-clinicians.pdf Revello, K., & Fields, W. (2012). A performance improvement project to increase nursing compliance with skin assessment in a rehabilitation unit. Rehabilitation Nursing, 37(1), 37–42. Sanada, H., Nakagami, G., Mizokami, Y., Minami, Y., Yamamoto, A., & Oe, M. (2010). Evaluating the effect of the new incentive system for high-risk pressure ulcer patients on wound healing and costeffectiveness: A cohort study. International Journal of Nursing Studies, 47, 79–286. Sendelbach, S., Zink, M., & Peterson, J. (2011). Decreasing pressure ulcers across a healthcare system: Moving beneath the tip of the iceberg. Journal of Nursing Administration, 41(2), 84–89. South Australian Department of Health. (2007). South Australian pressure ulcer point prevalence survey report 2007. Retrieved from http://www.sahealth.sa.gov.au/ wps/wcm/connect/9c35d880438d7e25acaeffbc736a4 e18/2010maypuppsreport2007.pdf?MOD=AJPERES &CACHEID=9c35d880438d7e25acaeffbc736a4e18 Waterlow, J. (2005). Pressure ulcer prevention manual. Retrieved from http://www.judy-waterlow.co.uk/thewaterlow-manual.htm Whittington, K. T., & Briones, R. (2004). National prevalence and incidence study: 6 year sequential acute care data. Advances in Skin and Wound Care, 17, 490–494. Wilcox, J., Baharestan, M. M., & Anthony, D. (2009). The development of the Glamorgan paediatric pressure ulcer risk assessment scale. Journal of Wound, 41(1), 17–21. Young, J., Ernsting, M., Kehoe, A., & Holmes, K. (2010). Results of a clinician-led evidence-based task force initiative relating to pressure ulcer risk assessment and prevention. Journal of Wound, Ostomy and Continence Nursing, 37(5), 495–503. Received 04 August 2014
Accepted 04 November 2014
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Pressure injury prevention success in a regional hospital Michelle Hunter, Jennifer Kelly*, Norma Stanley, Amy Stilley and Lynn Anderson Bundaberg Hospital, Wide Bay Hospital and Health Service, Bundaberg, QLD, Australia; *School of Health, Nursing and Midwifery, University of Southern Queensland, Springfield, QLD, Australia
Abstract: Background: This paper describes quality improvement strategies implemented following the identification
of a significantly high prevalence rate and severity of pressure injuries in a regional health care facility in a large health district in Queensland, Australia. Aim: The aim of this paper is to inform health professionals of processes employed to reduce the incidence and financial burden of pressure injuries following the detection of rates that were significantly above the State average. Method: An audit of pressure injury prevalence data was conducted on a single day throughout a regional hospital. Prevalence data was compared to State averages and hospital strategies used to prevent injuries were examined. Findings: Audit reports for this acute setting revealed that despite best practice guidelines, prevalence was a major concern. Lack of accountability, poor documentation, limited education and knowledge of risk assessment and prevention were central to the need to implement quality improvement processes. Conclusion: This paper outlines the results associated with implementing quality measures to reduce the prevalence of pressure injuries. Following an audit of pressure injury prevalence data, strategies were implemented to reduce noteworthy rates. Employing specific techniques can result in significantly decreasing hospital acquired pressure injuries in health care settings throughout the world.
Keywords: pressure injury, prevention, management, documentation, sustainability, prevalence, incidence, hospital acquired pressure injury
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ressure injuries contribute to decreased q uality of life and suffering for individuals in addition to being a financial burden to the patient and health care facilities. In Australia during 2001– 2002, there were 95,695 cases of pressure injuries with 398,432 bed days lost, incurring opportunity costs of AU$285 million (Graves, Birrell, & Whitby, 2005). Of note, these cases only represented 52% of discharges from Australian public hospitals and underestimate the true financial burden (Graves et al., 2005). However, hospital acquired pressure injuries are an international issue and concern for health care workers and organisations. In the United Kingdom (UK) in 2000, the total cost of pressure injury care to the National Health Service was estimated to be between £1.4 and £2.1 billion annually (Dealey, Posnett, & Walker, 2012). Thus, the burden of caring for people who acquire a pressure injury is immense and supports strong preventative efforts by clinicians. This paper presents the result of pressure injury prevalence audit incidence data and discusses the strategies that were implemented by nurses to achieve a reduction hospital acquired pressure injuries. Strategies discussed may be applied
universally to benefit individuals and organisations. The setting for this paper is an acute care facility with ∼200 beds in a large regional health district north of Brisbane, Queensland. Pressure injuries are a nurse sensitive indicator therefore, nurses are accountable for implementing pressure injury reducing risk management strategies. Evaluation of this indicator is undertaken through analysis of prevalence and incidence rates which are benchmarked against similar healthcare facilities. Benchmarking is difficult due to broad variances in rates worldwide. Variance is due, in some part, to differing data collection approaches which makes interpreting and comparing rates difficult (Baharestani et al., 2009). Some of these variations in incidence and prevalence relate to exclusion and or inclusion of Stage 1 pressure injury, lack of differentiating between hospital acquired pressure injuries versus total pressure injury rates, variances in staging and the classification system employed (Baharestani et al., 2009). Recently published facility acquired prevalence rates in Australia were 17.3% in South Australia (South Australian Department of Health, 2007), 7.4% in Western Australia (Mulligan, Prentice,
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& Scott, 2011) and 8.8% for Queensland Health (Department of Health, 2013). However, Mulligan et al. (2011) acknowledged an increase in pressure injury prevalence from 6.3% in 2009 to 7.4% but this does not correspond with clinicians in Western Australia changing pressure injury prevention strategies. For instance, the number of patients who underwent a pressure injury risk assessment on admission increased by 30%. Also there was an 11% decrease in the use of pressure injury relieving device (Mulligan et al., 2011). Mulligan et al. concluded that although pressure injury risk assessment tools are utilised the assessments are not being translated into clinical practice and do not address people at risk. Furthermore, ‘staff education and intelligent use of pressure injury prevention resources are necessary to close this gap to improve patient safety’ (Mulligan et al., 2011, p. 3). Pressure injuries acquired during the provision of health care to patients in hospitals are considered clinical incidents. Clinical incidents are (voluntarily) reported in most Queensland Public Hospitals using a reporting system known as PRIME Clinical Incidents. The objective of gathering data using PRIME Clinical Incidents is to review pressure injury trends and causative factors so that targetted pressure injury prevention strategies can be implemented. In addition, it enables health care professionals’ knowledge and skills to prevent harm and promote patient safety. Audit reports can be extracted from PRIME Clinical Incidents for specific issues or concerns for example, falls, needle stick injuries and pressure injuries. In 2008, Queensland Health established a target for the reduction of pressure injuries in health care facilities to a prevalence rate of 10% or below (Queensland Health, 2012). Additionally, in 2012, the Queensland State Government introduced financial penalties for facilities with hospital acquired Stage 3 and 4 pressure injury. The penalty for a Stage 3 pressure injury is $30,000 and $50,000 for a Stage 4 pressure injury (Department of Health, 2013). In the United States of America in 2007, Medicare and Medicaid announced non-reimbursement of hospital acquired Stage 3 and 4 pressure injuries 76
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(Bales & Duvendack, 2011). Similarly, in Japan, the Government introduced a penalty system of reduced reimbursement per patient for each hospitalised day unless certain requirements for prevention were met (Sanada et al., 2010). Although some reduction in overall hospital acquired pressure injury prevalence rates were apparent after the introduction of financial penalties (2.77–2.31%), there was no effect on Japan’s percentage of Stage 3 and 4 pressure injuries (Sanada et al., 2010). Subsequently, the Japanese government changed to an incentive reimbursement programme for patients at high risk of pressure injury development (Sanada et al., 2010). Of note, financial penalties are controversial in relation to the delivery of health care because penalties create an extra burden on finances required to prevent and treat pressure injuries. In an effort to reduce prevalence, incidence and mortality rates and the financial burden caused by hospital acquired pressure injuries the focus on best practice guidelines was heightened. In Australia, guidelines were first produced by the Australian Wound Management Association (2001) and subsequently updated in 2012 (Australian Wound Management Association, 2012). Queensland Health (2004) produced a best practice guideline in 2004 which provided the basis for the pressure injury prevention and management programme implemented at a regional hospital in Queensland. To motivate implementation of the best practice guidelines, the Australian Council on Healthcare Standards incorporated Standard 8, Preventing and Managing Pressure Injuries, into the accreditation requirements of the National Safety and Quality Health Service Standards (Australian Commission on Safety and Quality in Health Care, 2011). Incorporating best practice guidelines into an evolving healthcare system has led to the development and implementation of facility-based pressure injury prevention programmes. Several Australian studies document a decrease in pressure injury rates and financial burden after implementing a pressure injury prevention programme. For instance, a nurse practitioner led project conducted over 2 years in a large health service
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Pressure injury prevention success in a regional hospital in New South Wales led to a reduction in hospital acquired pressure injury prevalence rates from 23.4% in 2008 to 8% in 2010 (Asimus, MacLellan, & Li, 2011). The basis of this project involved point prevalence audits, supply of appropriate, pressure reducing, equipment and mandatory staff education (Asimus et al., 2011). Similarly, in Victoria a large acute care metropolitan hospital also achieved success with a reduction in hospital acquired pressure injury prevalence over 6 years. The pressure injury prevalence rates decreased from 12.6 to 2.6% [x < 0.001] (Barker et al., 2013). The programme consisted of, compliance with risk assessment; accuracy of pressure injury risk assessment; use of prevention strategies; annual staff education and point prevalence audits (Barker et al., 2013). Furthermore, one American hospital has achieved a noteworthy result of 0% prevalence in 2008 from 9.5% in 2007 (Bales & Duvendack, 2011). This American programme incorporated training staff on assessment and prevention, conducting point prevalence audits, mattress replacement and documentation of patients who presented with a pressure injury on admission (Bales & Duvendack, 2011). Targetting the underreporting of pressure injury incidence was achieved through weekly audits of high risk patients that checked documentation of skin assessments, two hour turns, pressure injury staging and toileting (Bales & Duvendack, 2011). Methods An audit of pressure injury prevalence data was conducted in a regional hospital in Queensland, Australia. The prevalence data was collected via the Queensland Bedside Audit. The Queensland Bedside Audit is a major annual collaborate clinical event undertaken by Queensland Health whereby auditors collect data for the purpose of improving the care provided to patients in State hospitals. All auditors receive education on conducting the Queensland Bedside Audit and are tested on staging of pressure injuries prior to commencing the audit. Training includes use of an audit tool, conducting skin inspections and identification and staging of pressure injuries.
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Auditors work in pairs and full skin inspections are conducted on patients who verbally consent to involvement in the audit. Therefore, pressure injury prevalence data was collected using the Queensland Bedside Audit tool. Data was collected throughout a regional hospital on a single day by trained auditors. Data was electronically entered into a database using a scannable form. All inpatients that provided verbal consent to a full skin inspection were included in the audit with the exception of patients admitted to the mental health unit. Ethics approval was not required as monitoring of prevalence and incidence forms is part of the quality improvement programme and monitoring of standards of care. Data was collected via a routine hospital audit. Conducting this audit and reviewing pressure injury data was approved by the executive of the hospital. Pressure injury incidence data was collected from the PRIME Clinical Incidents database. Prevalence was calculated as follows: (numerator/denominator) × 100%; numerator = number of consenting inpatients with one or more hospital acquired pressure injuries; denominator = total number of consenting hospital inpatients. Incidents of all pressure injuries are voluntarily reported by clinicians into this system when identified. Incidence is reported as total number of injuries. Reported incidence of injuries were reviewed and the alarming findings led to a review of documentation, reporting processes, risk assessment procedures, provision of education and the level of involvement by hospital management. Overall, it was apparent that the organisations current pressure injury prevention programme was not effective in reducing rates. As an outcome, a working group was established to review, modify and strengthen the pressure injury prevention programme and associated strategies. The working group consisted of registered nurses who occupied positions such as, clinical nurse consultants, nurse unit managers and nursing directors within the organisation. Initially, the working group reviewed policy, documentation processes, provision of staff education, and auditing practices.
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Results The pressure injury point prevalence rates for this acute regional hospital indicated an increasing trajectory from 2008 to January 2011 (Figure 1). A peak of 15.6% was observed in 2010. Following the review and implementation of an improved pressure injury prevention programme during 2011 the prevalence rate decreased to 3% in October 2011 (Figure 1). The hospital acquired pressure injury prevalence rate has been sustained at 5% or below since October 2011 and in addition this hospital has remained below the State wide average every year since October 2011 (Figure 1). The incidence of pressure injuries from PRIME Clinical Incidents data indicated an increasing number of community acquired injuries from 5 in 2009 to 201 in 2013 (Figure 2). Hospital acquired injury incidence shows and increasing trend line but decreased from 140 in 2012 to 86 in 2013 (Figure 2). Discussion The hospital at the centre of this paper is an acute care facility with ∼200 beds and is a referral centre for a number of rural hospitals in this health district. In 2010, an increasing trend in the clinical observations of pressure injuries was observed leading to an audit of PRIME Clinical Incidents data. Further, reinforcement of the audit data was confirmed in the 2010–2011 Queensland Bedside Audit with a hospital acquired prevalence rate of
15.6% for the hospital compared with the statewide benchmark of 11.1% (Queensland Health, 2012). The noteworthy findings from the audit necessitated the formation of a group to examine the processes and strategies employed at this regional health care facility. Most significantly, documentation of admission skin assessment was lacking and therefore hospital acquired pressure injuries were not differentiated from community acquired pressure injuries. The incidence data revealed a considerable percentage of pressure injuries occurred in the community and from inter-facility transfers. Additionally, it was identified from the review of charts that documentation was inconsistent and copious, and different forms (or documents) were used throughout the hospital. Of particular note, it was observed that staff appeared to lack knowledge surrounding the goal of skin and pressure injury risk assessments and the need to implement preventative interventions. Accountability and adherence to policies and processes employed in relation to the occurrence of hospital acquired pressure injuries was minimal. Also, involvement of people in leadership or management positions at this health care facility was not obvious or apparent. Therefore, prevalence and incidence rate findings resulted in the implementation of numerous strategies and procedures that reflected a credible prevention programme. Table 1 provides an account of the strategies implemented by the group.
Figure 1: Hospital acquired pressure injury prevalence
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Figure 2: Incidence from PRIME Clinical Incidents
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Table 1: Hospital pressure injury prevention strategies implemented Issue
Strategy
Standardisation of forms
Implementation of a I. Single page risk assessment tool combined with a standard care plan for patients at risk of pressure injury. The Waterlow tool for adults (Waterlow, 2005) and the Glamorgan tool for paediatrics (Wilcox, Baharestan, & Anthony, 2009) II. Skin integrity assessment record III. Patient repositioning chart IV. Elimination management chart V. Wound assessment chart for pressure injury monitoring VI. Pressure injury notification sticker (florescent pink in colour)
Standardisation of processes
Implementation of I. Risk assessment on admission and daily for all acute patients II. Skin assessment on admission, transfer and discharge (and at least daily for all at risk patients) III. Clinical photography of all identified injuries (with patient consent) IV. Care plan implemented for all at risk patients
Education and ‘marketing’ programme
I. Mandatory, yearly, self-directed learning package on pressure injury prevention management and staging for all nursing staff. An 80% pass mark was set II. Pressure injury prevention, management and staging in nursing orientation III. Development of a disc containing a power-point presentation explaining • How, when and why documentation was imperative using the revised forms • The need for accurate screening and assessment of patients IV. Introduction of resource folders in all clinical areas V. Introduction of posters outlining pressure injury staging details VI. Pressure injury education brochures given to all patients VII. Workshops on pressure injury prevention and management
Auditing
I. Commenced random auditing of 5 charts per month of documentation and intervention compliance. This was reported monthly to the pressure injury steering committee with non-compliance escalated to executive II. Commencement of annual mattress audit III. Yearly prevalence audit IV. Random patient safety rounds by nursing executive to assess documentation compliance
Improved governance and accountability
I. Policy review and implementation II. Nursing executive involvement III. F ormation of regular pressure injury prevention committee with multidiscipline representation from all clinical areas
Positive feedback to staff
Wards and departments with improved audit reports were made known and successful outcomes of particular wards or departments highlighted
Involvement of external organisations
Queensland Ambulance Services and the Royal Flying Doctors Service were provided with details surrounding the findings and possible equipment that could improve transportation conditions
Equipment
I. Purchase of additional alternating air mattresses II. Acquisition of additional leg troughs and bed cradles III. Purchase of chair cushions
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The pressure injury point prevalence audit results show a significant decrease from 15.6% in 2010 to 3.2% in October 2011. More importantly is the sustained reduction in pressure injury point prevalence below 5% since October 2011. In addition, this regional acute hospital remained below the State average since October 2011. In 2010, it was apparent that the organisation’s pressure injury prevention programme was not effective in reducing rates and the working group was needed to review, modify and strengthen the prevention programme incorporating new evidence. As such, the report by Miles, Fulbrook, Nowicki, and Franks (2013) which stated that the Prince Charles Hospital initiated a multitude of strategies involving equipment, education, governance, auditing and documentation was considered. Improved quality strategies implemented at this hospital resulted in reducing hospital acquired pressure injury prevalence rates to below 5% and this rate was sustained from 2010 to 2013. Prevention programmes are highly effective but continued success involves long term strategies to maintain sustainability. Sustainability is a key focus of pressure injury prevention programmes combined with reliable and consistent reporting and documentation. Sustainability was reinforced at the hospital in this regional area by reinforcing positive outcomes, highlighting successful outcomes and ensuring staff were aware that monitoring of reporting and documentation would be continuous. Additionally, sustainability can be enhanced through initiatives such as engaging staff in regular pressure injury prevention education to increase understanding of programmes and reinforce knowledge surrounding practice (Bales & Duvendack, 2011; Delmore, Lebovits, Baldock, Suggs, & Ayello, 2011; Kiely, 2012; Orsted, Rosenthal, & Woodbury, 2009; Revello & Fields, 2012; Sendelbach, Zink, & Peterson, 2011; Young, Ernsting, Kehoe, & Holmes, 2010). Finally, identifying unit-based champions enables continuous monitoring, assessment, evaluation and education reinforcement (Carson, Emmons, Falone, & Preston, 2012; Delmore et al., 2011; Kiely, 2012; Orsted et al., 80
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2009; Revello & Fields, 2012). Unit-based champions are being implemented throughout this hospital in 2014. Programmes that empower staff to be part of clinical decision making processes are essential to ongoing programme support (Kiely, 2012; Young et al., 2010). Pressure injury prevention programmes that are creative, fun and afford reinforcement, preserve staff engagement and motivation produce short and long term results. Meaning, programmes that have themes, reward systems, logos, posters and sometimes even mascots are more likely to succeed long term (Bales & Duvendack, 2011; Orsted et al., 2009; Sendelbach et al., 2011; Young et al., 2010). Therefore, sustainable and successful programmes are ones that embrace education, utilise unit champions, empower staff, have administrative support and are motivational through creativity. The programme introduced at this regional district hospital operationalised many of these strategies which attributed to decreasing hospital acquired pressure injuries. Limitations The pressure injury point prevalence results are encouraging but limited due to only identifying patients with injuries on a single day. Evaluation of individual strategies implemented at this health facility was not undertaken and is also a limitation in the reporting of these findings. Another limitation relates to the reliability of reporting and assessment. For instance, a rationale for the increased community acquired injury data in Figure 2 is that the data is more likely to be reflective of improved reporting of pressure injuries as opposed to increased incidence. Thus, it is unknown whether improved skin integrity assessments on admission reflect the escalating community acquired injuries and injuries received prior to admission to this regional hospital. Currently there is no routine or robust auditing or checking methods employed locally, State wide or nationally thereby, reported incidence rates may be unreliable because a significant number of pressure injuries are not documented
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Pressure injury prevention success in a regional hospital (Whittington & Briones, 2004). As such, there is a need for accurate incidence data which involves a consultation process with staff to confirm presence, staging and reporting of pressure injuries (Miles et al., 2013). Incidence data is the result of the initial report on PRIME Clinical Incidents but highlights the need to improve data collection mechanisms and data analyses to eliminate future inaccuracies. Baharestani et al. (2009, p. 99) comment that ‘incidence analyses are generally considered to provide a clearer indication of the effectiveness of a pressure ulcer prevention protocol than do prevalence analyses.’ Therefore, data needs to be checked for correct diagnosis and staging in conjunction with the patient and medical record. Conclusion The outcome from the audit at this regional hospital demonstrates that pressure injury point prevalence rates can be significantly reduced and organisational change achieved. A motivated group of registered nurses initiated and accomplished implementing a pressure injury prevention programme. The programme was embraced by staff from within and external to this health care facility to reduce pressure injury point prevalence rates from 15.6% in 2010 to 3.57% in 2013. Furthermore, prevalence rates have been sustained at below 5% for the last three years. Initiating strategies in line with best practice guidelines resulted in positive outcomes for patients and this regional hospital. Strategies such as introducing consistent documentation, education programmes, obtaining and sustaining management support, external facility involvement and positive reinforcement demonstrated that change is possible. Additionally, utilising clear and concise communication throughout the organisation combined with adopting a holistic approach to patient care has led to a substantial decline in pressure injury prevalence rates for this health care facility. Recommendations This paper illustrates that change is possible and best practice essential. Following the revelation
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that change was vital to decrease pressure injury rates, a whole of organisation approach was implemented to introduce best practice. Changing hospital acquired pressure injury point prevalence rates was initially considered difficult but adopting a cohesive and consistent approach throughout the facility involving key internal and external stakeholders resulted in positive outcomes. However, a key issue for continuing these best practice standards is sustaining motivation and success rates. The importance of pressure injury prevention education for commencing and continuing staff regarding hospital policy and procedures is central and necessary. Additionally, positive reinforcement is pivotal to success and ensuring that pressure injury prevention is at the forefront of practitioners care is paramount. Thus, the sustainability of successful outcomes from the strategies employed is considered imperative but continued results require resources. It is recommended that the issue of pressure injury prevention is given serious consideration by health care organisations and supported through the provision of resources such as staff and equipment. Staff are required to ensure consistent and reliable documentation is maintained. Further, PRIME Clinical Incidents data is collated and verified to ensure accurate incidence reporting including preparation and monitoring of audit reports. Of key significance is the need for the provision of positive reinforcement of staff. Without ongoing resources prevention of harm and patient safety will remain an ongoing or re-emerging issue for health care facilities. References
Asimus, M., MacLellan, L., & Li, P. (2011). Pressure ulcer prevention in Australia: The role of the nurse practitioner in changing practice and saving lives. International Wound Journal, 8(5), 508–513. Australian Commission on Safety and Quality in Health Care (ACSQHC). (2011). National safety and quality health service standards. Retrieved from http://www.safetyandquality.gov.au/wp-content/ uploads/2011/09/NSQHS-Standards-Sept-2012.pdf Australian Wound Management Association (AWMA). (2001). Clinical practice guidelines for the
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prediction and prevention of pressure ulcers. Perth, WA: Cambridge Media. Australian Wound Management Association (AWMA). (2012). Pan pacific clinical practice guideline for the prevention and management of pressure injury. Osborne Park, WA: Cambridge Media. Baharestani, M. M., Black, J. M., Carville, K., Clark, M., Cuddigan, J. E., & Dealey, C. (2009). Dilemmas in measuring and using pressure ulcer prevalence and incidence: An international consensus. International Wound Journal, 6(2), 97–104. Bales, I., & Duvendack, T. (2011). Reaching for the moon: Achieving zero pressure ulcer prevalence, an update. Journal of Wound Care, 20(8), 374–377. Barker, A. L., Kamar, J., Tyndall, T. J., White, L., Hutchinson, A., Klopfer, N., & Weller, C. (2013). Implementation of pressure ulcer prevention best practice recommendations in acute care: An observational study. International Wound Journal, 10(3), 313–320. Carson, D., Emmons, K., Falone, W., & Preston, A. M. (2012). Development of a pressure ulcer program across a university health system. Journal of Nursing Care Quality, 27(1), 20–27. Dealey, C., Posnett, J., & Walker, A. (2012). The cost of pressure ulcers in the United Kingdom. Journal of Wound Care, 21(6), 261–266. Delmore, B., Lebovits, S., Baldock, P., Suggs, B., & Ayello, E. A. (2011). Pressure ulcer prevention program: A journey. Journal of Wound, Ostomy and Continence Nursing, 38(5), 505–513. Department of Health. (2013). Health funding principles and guidelines 2013–2014. Queensland Government. Retrieved from http://www.health.qld. gov.au/hhsserviceagreement/docs/documents/sd3fund-prin-guide.pdf Graves, N., Birrell, F. A., & Whitby, M. (2005). Modelling the economic losses from pressure ulcers among hospitalised patients in Australia. Wound Repair and Regeneration, 3, 462–467. Kiely, C. (2012). Cultural transformation in pressure ulcer prevention and care. Journal of Wound, Ostomy and Continence Nursing, 39(4), 443–446. Miles, S. J., Fulbrook, P., Nowicki, T., & Franks, C. (2013). Decreasing pressure injury prevalence in an Australian general hospital: A 10-year review. Wound Practice and Research, 21(4), 148–156. Mulligan, S., Prentice, J., & Scott, L. (2011). Wounds west wound prevalence survey 2011 state wide overview report. Retrieved from http://www.health.wa.gov.au/ woundswest/docs/WWWPS_11_state_report.pdf
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Orsted, H. L., Rosenthal, S., & Woodbury, M. G. (2009). Pressure ulcer awareness and prevention program: A quality improvement program through the Canadian association of wound care. Journal of Wound, Ostomy and Continence Nursing, 36(2), 178–183. Queensland Health. (2004). Pressure ulcer prevention and management resource guidelines. Brisbane, QLD: Queensland Government. Queensland Health. (2012). Pressure injury prevention information for clinicians. Retrieved from http:// www.health.qld.gov.au/psq/pip/docs/info-clinicians.pdf Revello, K., & Fields, W. (2012). A performance improvement project to increase nursing compliance with skin assessment in a rehabilitation unit. Rehabilitation Nursing, 37(1), 37–42. Sanada, H., Nakagami, G., Mizokami, Y., Minami, Y., Yamamoto, A., & Oe, M. (2010). Evaluating the effect of the new incentive system for high-risk pressure ulcer patients on wound healing and costeffectiveness: A cohort study. International Journal of Nursing Studies, 47, 79–286. Sendelbach, S., Zink, M., & Peterson, J. (2011). Decreasing pressure ulcers across a healthcare system: Moving beneath the tip of the iceberg. Journal of Nursing Administration, 41(2), 84–89. South Australian Department of Health. (2007). South Australian pressure ulcer point prevalence survey report 2007. Retrieved from http://www.sahealth.sa.gov.au/ wps/wcm/connect/9c35d880438d7e25acaeffbc736a4 e18/2010maypuppsreport2007.pdf?MOD=AJPERES &CACHEID=9c35d880438d7e25acaeffbc736a4e18 Waterlow, J. (2005). Pressure ulcer prevention manual. Retrieved from http://www.judy-waterlow.co.uk/thewaterlow-manual.htm Whittington, K. T., & Briones, R. (2004). National prevalence and incidence study: 6 year sequential acute care data. Advances in Skin and Wound Care, 17, 490–494. Wilcox, J., Baharestan, M. M., & Anthony, D. (2009). The development of the Glamorgan paediatric pressure ulcer risk assessment scale. Journal of Wound, 41(1), 17–21. Young, J., Ernsting, M., Kehoe, A., & Holmes, K. (2010). Results of a clinician-led evidence-based task force initiative relating to pressure ulcer risk assessment and prevention. Journal of Wound, Ostomy and Continence Nursing, 37(5), 495–503. Received 04 August 2014
Accepted 04 November 2014
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