Report by Pat Tyrrell, Lead Nurse, Argyll & Bute CHP on behalf of Heidi May, Board Nurse Director

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1 Highland NHS Board 4 October 2011 Item 4.6(b) TISSUE VIABILITY PRESSURE ULCER PREVENTION Report by Pat Tyrrell, Lead Nurse, Argyll & Bute CHP on behalf of Heidi May, Board Nurse Director The Board is asked to: Note the current status of pressure ulcer incidence across NHS Highland and the actions in place to improve care. 1 Background and Summary Pressure ulcers, commonly referred to as pressure sores, bed sores, pressure damage, pressure injuries and decubitus ulcers, are areas of localised damage to the skin, which can extend to underlying structures such as muscle and bone. Pressure ulcers often affect older, obese or malnourished people, or those with certain underlying conditions and reduced mobility. Ulcers occur when there is damage to tissue through unrelieved pressure, friction or the shearing of skin and often death of deeper tissues. Pressure ulcers vary in severity and are graded from Grade 1 (Non-blanchable erythema (redness) of intact skin), to Grade 4 (Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss). It is estimated that just under half a million people in the UK will develop at least one pressure ulcer in any given year. For example, around 1 in 20 people who are admitted to hospital with an acute (sudden) illness will develop a pressure ulcer. The presence of pressure ulcers has been associated with an increased risk of secondary infection and a two to four fold increase of risk of death in older people in intensive care units (Bo M, Massaia M et al, 2003). People over 70 years old are particularly vulnerable to pressure ulcers due to a combination of factors, such as: reduced blood supply ageing of the skin older people having a higher rate of mobility problems Two out of every three cases of pressure ulcers develop in people who are 70 years old or more. Recent cost data suggest that treating ulcers varies from 1,064 for a grade 1 ulcer to 24,214 for a grade 4 ulcer with total costs in the UK estimated as being billion annually, equivalent to 4% of the total NHS expenditure (Bennett et al., 2004). The majority of pressure ulcers are entirely preventable through good risk assessment and the implementation of high impact evidence based actions. In June 2008, a National Integrated Tissue Viability Programme was introduced, sponsored by the Scottish Government, with a practice development programme identified as the

2 responsibility of NHS QIS (now Healthcare Improvement Scotland, HIS) and an educational resource to be developed by NHS Education for Scotland (NES). The programme has strong links to the work undertaken by the Scottish Patient Safety Programme (SPSP), and the work on Clinical Quality Indicators, and uses terminology common to these programmes. It is also linked to significant work on Health Acquired Infection (HAI). Since pressure ulcers are connected to issues of nutrition, mobility, continence, pain, and infection control, links to parallel guidance by NHS HIS and other sources are identified. Focussing on the improvement in risk identification and assessment, as well as improvement in care delivery, will lead to an overall reduction in pressure ulcer incidence across NHS Highland. This will contribute to the Board s strategic priorities through provision of high quality evidence based and cost effective care to every patient. 2 Pressure Ulcer Prevention and Management 2.1 Incidence in NHS Highland In August 2010 NHS Highland introduced the new Pressure Ulcer reporting system through Datix. Clinical staff in all care settings are required to report all new pressure ulcers through this system. Significant work has been undertaken in each operational unit to ensure the correct information is being reported and to address areas of under and over reporting. The data for the year August 2010 to July 2011 is illustrated in Table 1: Where Pressure Ulcer developed Number % of Total Pressure ulcer developed during hospital stay Pressure ulcer developed whilst on community caseload Pressure ulcer present on admission to community caseload - community referral Pressure ulcer present on admission to community caseload - hospital discharge Pressure ulcer present on admission to hospital - patient admitted from care home Pressure ulcer present on admission to hospital - patient admitted from community Pressure ulcer present on admission to hospital - patient transferred from another hospital Wound dehiscence Not recorded Total

3 Feedback to Operational Units A variety of structures are in place. Datix overview reports are provided at each Tissue Viability leadership group (TVLG) meeting; these are approximately every 6 weeks. Representation on this group is from every CHP and Raigmore and Lead Nurses all receive the papers. These reports give an overview similar to the table in the paper but at Health Board and CHP level. Managers in each CHP have access to Datix and should be reviewing these on a regular basis and sharing them with the various team leaders/charge nurses at the relevant meetings for their CHP. Each TV Datix is viewed by the TVN for the whole of Highland, as well as Tissue Viability Champions in some of the CHP's and feedback is provided to the reporter and handler, as well as being escalated if required. Final approval checks are made on each TV Datix to ensure the data is appropriate. Some structures are still being finalised with the introduction of the TVN post, building of link nurse networks and increased focus on Datix currently. The clinical governance team provide quarterly reports to each operational unit management team which are then usually discussed at local clinical governance and risk meetings. It is then up to the area to cascade that information as widely as they feel appropriate. Everyone with PU Datix permissions can draw off reports for their area or wider if permitted, so again we need to develop a culture where it is the norm for each manager to draw off the report and discuss it with the staff in a learning development format. NHS Highland is one of a small number of boards in Scotland that is using the Datix system to capture pressure ulcer information in such a comprehensive way. There is currently no single system available at national level to compare data across Health Boards. While still at an early stage it is anticipated that within the next year the Board will receive more comprehensive information to inform and support decision making around pressure ulcer prevention. From the data gathered to date it is evident that the focus on prevention of pressure ulcers must be intensified in all areas across the Board. Evidence from other areas in England and USA, which have been successful in reducing pressure ulcer incidence, has indicated that a Zero Tolerance approach works. 2.2 Actions Taken to Date NHS Highland Tissue Viability Leadership Group This group, chaired by Argyll and Bute Lead Nurse, was established in 2010, is accountable to NHS Highland NMAHP Leadership Group and has strong representation from all operational units in NHS Highland and NHS Western Isles. The achievements of the group so far are: Implementation of Clinical Quality Indicator for Pressure Ulcer prevention Audit Scotland in their report Planning Ward Nursing Legacy or Design? (Audit Scotland, 2002) emphasised that despite high numbers of nursing and midwifery staff in the NHS workforce, there was limited information available to compare nursing numbers, costs and impact on quality. The follow-up report in 2007 (Audit Scotland, 2007) recognized the progress that had been made in developing quality indicators but noted that: Boards are still measuring quality in a variety of ways and challenges [remain] in working towards a national system of quality indicators. 3

4 The national Leading Better Care Programme has developed a core set of clinical quality indicators (CQIs) in collaboration with NHS HIS, ISD and NES. These include a CQI on Pressure Ulcer prevention. The three key outcomes were that CQIs should: focus on continuous quality improvement rather than performance management include process indicators which measure aspects of nursing care such as assessment and interventions include nursing-sensitive patient outcome measures, which improve in the context of the quality of nursing care. The CQI for Pressure Ulcers has recently been refined nationally and now includes both process and outcome measures. The CQI includes the internationally recognised Safety Cross, which measures and illustrates days between pressure ulcer development. Days between measures are traditionally used for measuring rare events. However it is also recognized from work in Wales that the days between measure served as a useful motivator for staff and also as an awareness tool so that they could see the extent of the problem on their ward/care home. The count/number of pressure ulcers is used as an outcome if pressure ulcers are a frequent occurrence in the ward/care home. When pressure ulcers start to become rare events, the days between pressure ulcers can be considered as an outcome measure. The CQI also includes the SSKIN Care Bundle which focuses on the five key elements of S Surface S Skin inspection K Keep moving I Incontinence N Nutrition It is not uncommon for a care area to discover more pressure ulcers than they thought they had when the SSKIN Care Bundle is introduced. This is because the process of care is clearly evident to all involved in the care of an individual. By implementing the SSKIN Care Bundle effectively (i.e. achieving 95% compliance with the SSKIN Care Bundle), it is predicted that there will be fewer higher grades of pressure ulcers (i.e. Grades 3 and 4) as every individual s skin is being checked more regularly, and breaks in the skin will be picked up sooner by staff or the patient/resident themselves. The CQI also includes audit tool which measures the care processes that are in place and also the days between pressure ulcer occurrences for each ward area. Implementation of this newly modified CQI should be completed in all hospital wards by the end of Rationalisation of Wound Management Guidelines and Formulary The Wound Management Guidelines and Formulary ratified in July 2011 by the Area Drugs and Therapeutics Committee and the implementation plan agreed through Senior Management Team. These guidelines will provide staff with the necessary information to enable effective prevention and management of pressure ulcers, will ensure consistent approaches to prescribing, thereby improving quality of care for patients while delivering better value for money. 4

5 Development of Education Plan NHS Education for Scotland (NES), in partnership with NHS Healthcare Improvement Scotland (HIS), at the request of the Scottish Government have developed both an educational workbook and an education and development tool for the prevention and management of pressure ulcers. Following the success of the Cleanliness Champions programme all Senior Charge Nurse and Team leaders across NHS Highland are being asked to complete the NES Educational package by the end of They will then roll this out to all staff within their areas. Pressure Relieving Equipment The group are about to undertake a review of the availability of pressure relieving equipment across NHS Highland. Equipment plays a major role in the success of prevention and it is important that all areas have access to the appropriate types of equipment to enable effective prevention. As staff awareness grows the demand for more equipment may also increase. Appointment of Tissue Viability Nurse Specialist Lynn Garrett, experienced Tissue Viability Nurse Specialist was appointed to post in June Although this post is based within Argyll and Bute it does have Boardwide strategic responsibility for one day per week. She will support the delivery of the key improvement actions in each operational unit. She is currently working with Lead Nurses to develop effective infrastructures within each operational unit to ensure that all aspects of the plan are taken forward. 2.3 Next Steps Zero Tolerance In order to focus effort and maximize impact, work is progressing towards adopting a zero tolerance approach supported by a STEP UP campaign. (Systems To Eradicate Pressure Ulcers Programme). This campaign will include awareness raising and education for staff and public, target setting for % reduction in incidence of pressure ulcers over defined time period for each area, root cause analysis of each grade 3 and 4 pressure ulcer and shared learning events across NHS Highland. Data will be published on a monthly basis to demonstrate progress against targets for pressure ulcer prevention. Learning gained through the improvement work to reduce healthcare associated infection and other SPSP priorities will be utilised and the Board will work closely with Dr Susan Baxter, the national lead for Tissue Viability in Scotland. The first two shared learning events for staff using multi site video conference will take place in early November. Contribution to Board Objectives BC.2 Patients experience no harm from healthcare services BC.4 Healthcare and treatments are provided to consistent standards 5

6 Governance Implications 4.1 Staff Governance: Effective implementation of this strategy will require good leadership and supervision within each operational unit and at a senior level, this will be supported by appropriate education and training for staff. Sharing and learning events and analysis will ensure lessons are learnt and these will inform best practice for clinicians 4.2 Patient and Public Involvement Awareness raising will be undertaken through public engagement networks and through press releases. 4.3 Clinical Governance A zero tolerance approach to pressure ulcers across NHS Highland will lead to improved outcomes for patients through the: - improvement in risk identification and assessment - implementation of best practice in planning and delivery of care - implementation of effective monitoring systems 4.3 Financial Governance The cost to NHS Highland of pressure ulcers is considerable. Reducing the incidence and severity of pressure ulcers will see a potential considerable improvement of the patient experience and a cost saving in not only clinicians time but medications, dressings and extended bed days. Although the focus on prevention may see an initial impact on the cost of provision of essential pressure relieving equipment. Pat Tyrrell Lead Nurse Argyll & Bute CHP 23 September

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