british journal of nursing - article

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S4 BritishJournalofNursing,2013(T issueViabilitySupplement),Vol22,No12 ©2013MAHealthcareLtd Pressure ulcer prevention: making a difference across a health authority? Abstract Pressure ulcers (PUs), their cause and prevention have been discussed in the literature for many decades. Their prevention and management has been the core of a tissue viability nurse’s daily clinical and strategic workload. The important point to acknowledge is that not all PUs can be prevented but it is believed most of them can and all preventative measures must be implemented and evaluated. Initial efforts focused on establishing a baseline of incidence and prevalence. More recently, the Department of Health has proposed that PUs could be eliminated in 95% of all NHS patients and incentivised the measurement of PUs and other harms by use of the NHS Safety Thermometer through the introduction of a new initiative. A research company was commissioned to explore which communications interventions would be effective in helping health professionals to prevent and treat PUs. A campaign was subsequently set in motion to educate and inform clinical staff on the cause and prevention of PUs. Key words: Campaign Pressure ulcer Prevention Stop the Pressure Strategic Health Authority Unavoidable P ressureulcers(PUs),theircauseandpreventionhave been discussed in the literature for many decades. Theyhavecapturedtheinterestofnurses,doctors, biomedicalengineersandhealtheconomists.Their prevention and management has been the core of a tissue viabilitynurse’sdailyclinicalandstrategicworkload. In 1988, Hibbs speculated that 95% of PUs were preventable.This estimate has neither been challenged nor confirmed since.To do so would require a full clinical and scientific understanding of the aetiology of PUs as well as an investigation into the care provided to preventtheoccurrence.Thelatterrequiresevidencethrough documentation of all medical and nursing interventions. Heidi Guy, Fiona Downie, Lyn McIntyre and Jeremy Peters The important point to acknowledge is that not all PUs can be prevented, but it is believed most of them can and all preventative measures must be implemented and evaluated. In 1991, the Department of Health (DH) advised there was a 6.7% prevalence rate (see Box 1) of people with PUs.A more thorough review (DH, 1993) reported prevalence rates ranging from 2.7% to 42.7%. While it is accepted that comparing prevalence studies is difficult, this range of difference has also been supported inmorerecentreviews(Vanderweeetal,2007;vanGilder et al, 2008). Most frequently, published prevalence studies includehospitalpopulationsonly.However,in1977Barbanel et al published a prevalence of 8.8% across both acute and primary care settings. In 1991, the DH initially proposed anannualreductionof5–10%inincidence(see Box 1)and suggested that the first task towards achieving this was for health authorities to establish a baseline of incidence and prevalence.Some21yearslater,theDH(2011)hasproposed thatPUscouldbeeliminatedin95%ofallNHSpatientsand incentivisedthemeasurementofPUsandotherharmsbyuse of the NHS SafetyThermometer (The Health and Social CareInformationCentre,2012)throughtheintroductionof anewCommissioningforQualityandInnovation(CQUIN) initiativegoal(DH,2012). TheSafetyThermometerdemonstratedaprevalencerate of patients with category 2–4 PU (see Box 2) of 5.39% in October2012.Thisequatesto8833peoplein477English organisations,bothNHSandprivate,acuteandcommunity. HeidiGuyisTissueViabilityClinicalNurseSpecialistatEastand NorthHertsNHSTrustandHonoraryLecturer,Universityof Hertfordshire;FionaDownieisNurseConsultantTissueViabilityat PapworthHospitalNHSFoundationTrust,CambridgeandaSenior LecturerTissueViabilityatAngliaRuskinUniversity,Cambridge; LynMcIntyreisDeputyDirector–PatientExperienceatNHS England(MidlandsandEast);andJeremyPetersisHeadof CorporateCommunicationsatNHSPropertyServicesLtd Accepted for publication: April 2013 Box 1. Differentiation between incidence and prevalence Prevalence This is the number of people in a given population at a given time who have a pressure ulcer present (Defloor et al, 2005c) Period prevalence measures the number of people over a defined period of time Point prevalence measures the number of people on a set date, usually one particular day Incidence This is the number of people who develop a new pressure ulcer in a given population over a defined time period. (Defloor et al, 2005c) When making comparisons between pressure ulcer rates it is important to ensure that the measuring rate is the same. Incidence might be seen as a means of measuring healthcare standards because it reflects the development of new pressure ulcers, whereas prevalence will take into account those patients who had existing pressure ulcers

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Page 1: British Journal of Nursing - Article

S4� British�Journal�of�Nursing,�2013�(Tissue�Viability�Supplement),�Vol�22,�No�12

©�2

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Pressure ulcer prevention: making a difference across a health authority?

AbstractPressure ulcers (PUs), their cause and prevention have been discussed in the literature for many decades. Their prevention and management has been the core of a tissue viability nurse’s daily clinical and strategic workload. The important point to acknowledge is that not all PUs can be prevented but it is believed most of them can and all preventative measures must be implemented and evaluated. Initial efforts focused on establishing a baseline of incidence and prevalence. More recently, the Department of Health has proposed that PUs could be eliminated in 95% of all NHS patients and incentivised the measurement of PUs and other harms by use of the NHS Safety Thermometer through the introduction of a new initiative. A research company was commissioned to explore which communications interventions would be effective in helping health professionals to prevent and treat PUs. A campaign was subsequently set in motion to educate and inform clinical staff on the cause and prevention of PUs.

Key words: Campaign ■ Pressure ulcer ■ Prevention ■ Stop the Pressure ■ Strategic Health Authority ■ Unavoidable

P ressure�ulcers�(PUs),�their�cause�and�prevention�have�been�discussed� in� the� literature� for�many�decades.�They�have�captured�the�interest�of�nurses,�doctors,�biomedical�engineers�and�health�economists.�Their�

prevention� and� management� has� been� the� core� of� a� tissue�viability�nurse’s�daily�clinical�and�strategic�workload.�

In� 1988,� Hibbs� speculated� that� 95%� of� PUs� were�preventable.�This� estimate� has� neither� been� challenged� nor�confirmed� since.� To� do� so� would� require� a� full� clinical�and� scientific� understanding� of� the� aetiology� of� PUs�as� well� as� an� investigation� into� the� care� provided� to�prevent�the�occurrence.�The�latter�requires�evidence�through�documentation� of� all� medical� and� nursing� interventions.�

Heidi Guy, Fiona Downie, Lyn McIntyre and Jeremy Peters

The� important� point� to� acknowledge� is� that� not� all�PUs� can� be� prevented,� but� it� is� believed� most� of� them�can� and� all� preventative� measures� must� be� implemented��and� evaluated.� In� 1991,� the� Department� of� Health� (DH)�advised� there� was� a� 6.7%� prevalence� rate� (see� Box 1)� of�people� with� PUs.� A� more� thorough� review� (DH,� 1993)�reported� prevalence� rates� ranging� from� 2.7%� to� 42.7%.�While� it� is� accepted� that� comparing� prevalence� studies� is�difficult,� this� range� of� difference� has� also� been� supported�in�more� recent� reviews� (Vanderwee�et� al,�2007;�van�Gilder�et� al,� 2008).� Most� frequently,� published� prevalence� studies�include�hospital�populations�only.�However,�in�1977�Barbanel�et� al�published�a�prevalence�of�8.8%�across�both�acute� and�primary� care� settings.� In� 1991,� the� DH� initially� proposed�an�annual�reduction�of�5–10%�in�incidence�(see�Box 1)�and�suggested� that� the� first� task� towards� achieving� this� was� for�health� authorities� to� establish� a� baseline� of� incidence� and�prevalence.�Some�21�years�later,�the�DH�(2011)�has�proposed�that�PUs�could�be�eliminated�in�95%�of�all�NHS�patients�and�incentivised�the�measurement�of�PUs�and�other�harms�by�use�of� the� NHS� Safety�Thermometer� (The� Health� and� Social�Care�Information�Centre,�2012)�through�the�introduction�of�a�new�Commissioning�for�Quality�and�Innovation�(CQUIN)�initiative�goal�(DH,�2012).

The�Safety�Thermometer�demonstrated�a�prevalence�rate�of�patients�with�category�2–4�PU�(see�Box 2)�of�5.39%� in�October�2012.�This�equates� to�8833�people� in�477�English�organisations,�both�NHS�and�private,�acute�and�community.�

Heidi�Guy�is�Tissue�Viability�Clinical�Nurse�Specialist�at�East�and�North�Herts�NHS�Trust�and�Honorary�Lecturer,�University�of�Hertfordshire;�Fiona�Downie�is�Nurse�Consultant�Tissue�Viability�at�Papworth�Hospital�NHS�Foundation�Trust,�Cambridge�and�a�Senior�Lecturer�Tissue�Viability�at�Anglia�Ruskin�University,�Cambridge;��Lyn�McIntyre�is�Deputy�Director�–�Patient�Experience�at�NHS�England�(Midlands�and�East);�and�Jeremy�Peters�is�Head�of��Corporate�Communications�at�NHS�Property�Services�Ltd

Accepted for publication: April 2013

Box 1. Differentiation between incidence and prevalence

Prevalence

■ This is the number of people in a given population at a given time who have a pressure ulcer present (Defloor et al, 2005c)

■ Period prevalence measures the number of people over a defined period of time

■ Point prevalence measures the number of people on a set date, usually one particular day

Incidence

■ This is the number of people who develop a new pressure ulcer in a given population over a defined time period. (Defloor et al, 2005c)

■ When making comparisons between pressure ulcer rates it is important to ensure that the measuring rate is the same. Incidence might be seen as a means of measuring healthcare standards because it reflects the development of new pressure ulcers, whereas prevalence will take into account those patients who had existing pressure ulcers

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Of�these�people,�2007�(22%)�were�reported�as�having�a�new�incidence�of�a�PU.�So,�is�5.39%�a�true�decline�since�the�6.7%�reported�in�1991�and�is�it�good�enough?�After�several�decades�of� increasing� awareness� and� two� decades� of� international,�national� and� governmental� guidance� (DH,� 2001;� NICE,�2003;�NICE,�2005;�European�Pressure�Ulcer�Advisory�Panel/�National�Pressure�Ulcer�Advisory�Panel�(EPUAP/NPUAP),�2009;�DH�2010)�the�question�must�be�asked—why�were�they�not�all�prevented?

The� Strategic� Health�Authority� (SHA)� cluster� of� NHS�Midlands� and�East� (2012a),�which� provides� health� care� for�

15�million�people,�established�a�formal�ambition�to�eliminate�avoidable� category� 2–4� PUs� (McIntyre� et� al,� 2012).� It� is� a�reasonable�assumption�that� if�a�PU�is�avoidable�and�can�be�prevented,�then�it�should�be�prevented.

To� support� the� strategy� to� eliminate� avoidable� PUs,� a�definition�of�‘unavoidable’�(NHS�Midlands�and�East,�2012b)�has� been� adopted� (see� Box 3).�This� definition� recognises�that� there� are� certain� circumstances� and� clinical� conditions�that� may� result� in� the� unavoidable� development� of� PU.� It�also� recognises� that� there� are� certain� accepted� preventative�strategies�that�need�to�be�in�place�to�prevent�a�PU�occurring�and�only�if�these�are�all�used�and�re-evaluated�for�effectiveness�can� it� be� clearly� shown� that� any� PU� that� subsequently�developed,� despite� these� interventions,� is� unavoidable.�This�requires� documented� evidence� of� care� interventions� to�include:

�■ Risk�assessment�■ Skin�inspection�■ Pressure�reducing/relieving�equipment�■ Repositioning�■ Management�of�incontinence�and�moist�skin�■ Nutritional�support.These�care�interventions�are�not�new.�All�of�the�above�have�

been�extensively�researched�or�discussed�in�the�literature�over�the�past�few�decades.�

Risk assessmentNorton� et� al� (1962)� is� the� first� published� risk� assessment�tool� to� guide� nurses� to� identify� those� patients� who� may�be�at�particular� risk�of�PU�development.�Since� then,�many�other�risk�assessment� tools�have�been�devised� for�generalist�and�specialist�areas� (Guy,�2012),�most�notably�the�Waterlow�(2005)� and� Braden� (Bergstrom� et� al,� 1987)� scores.� Risk�assessment�is�not�a�new�concept�and�while�a�numerical�tool�is� not� always� entirely� reliable� (Papanikolaou� et� al,� 2007)�and� whether� it� is� better� than� clinical� judgement� has� been�challenged�(Webster�et�al,�2011),�it�formalises�assessment�and�is�an�auditable�action.�It�has�long�been�an�accepted�precursor�to�PU�prevention.

Preventative interventionsSkin� inspection� of� all� bony� areas� will� highlight� to� nursing�staff�the�early�signs�of�pressure�damage.�Webster�et�al�(2011)�suggest�it�is�more�useful�than�a�risk�assessment�tool.�Looking�for� reddened� areas� is� key.� If� noted,� then� care� interventions�need� to� be� re-evaluated.� Skin� inspections� need� to� be�undertaken� as� often� as� possible� in� relation� to� the� risk� of�the� patient� and� the� outcomes� documented.� Patients� with�a� darker� skin� colour� may� well� be� at� increased� risk� of� PU�development� (Scanlon� and� Stubbs,� 2004;� van� Gilder� et� al,�2008)� because� their� skin�will� not� present�with� a� reddened�area.�Other�changes� in� skin� tone�or� temperature�may�need�to�be�considered�(EPUAP/NPUAP,�2009).

The�support�surface�has�long�been�recognised�as�playing�a�part�in�the�prevention�of�PUs�(Norton�et�al,�1962).�Studies�over� the� years� that� have� compared� pressure-reducing� foam�mattresses� with� standard� foam� mattresses� have� consistently�demonstrated�that�fewer�patients�develop�PUs�on�the�former�(NICE,� 2004).�Despite� some� evidence� that� patients� nursed�

Box 2. International NPUAP/EPUAP pressure ulcer classification system 2009

Category 1: non-blanchable erythema

Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category 1 may be difficult to detect in individuals with dark skin tones. May indicate ‘at-risk’ persons

Category 2: partial thickness

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanguinous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates deep tissue injury). This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration or excoriation

Category 3: full thickness skin loss

Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.The depth of a category/stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and category/stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable

Category 4: full thickness tissue loss

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a category/stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable

Unstageable/unclassified: full thickness skin or tissue loss—depth unknown

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a category/stage 3 or 4. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed

Suspected deep tissue injury—depth unknown

Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment

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on� alternating� pressure-relieving� mattresses� are� less� likely�to� develop� a� PU� than� those� nursed� on� standard� foam,�there�is�also�evidence�that�patients�may�still�develop�PU�on�alternating�mattresses�(Nixon�et�al,�2006).�Thus,�the�mattress�(or�chair�cushion)�only� forms�part�of� the�prevention�plan�and�must�sit�alongside�regular�repositioning.

Immobility�is�thought�to�be�one�of�the�major�risk�factors�for� PU� development.� Barbanel� et� al� (1977)� found� that�PUs�were�most� likely� to�be� found� in� the�more� immobile�patients.� This� has� been� supported� by� many� researchers�since� (Sharp� and� McClaws,� 2006).� If� a� person� can� move�independently� at� frequent� enough� intervals,� they� are�unlikely� to� develop� a� PU.� Repositioning� is� probably� the�oldest�form�of�PU�prevention�and�remains�to�this�day�the�most�important�(Norton�et�al,�1962;�DeFloor�et�al,�2005a;�Krapfl�and�Gray,�2008).

More� recently,� the� confusion� between� moisture� and�pressure�damage�has�been�recognised�(DeFloor�et�al,�2005b;�Downie� and�Guy,� 2012).� Perhaps� it� could� be� conjectured�that� the� prevalence� figures� of� today� cannot� be� compared�to� those� of� decades� ago� because� many� category� 2� ulcers�may�have�been�moisture�lesions.�Today,�these�two�distinctly�separate� aetiological� lesions� are� diagnosed� differently� and�moisture� lesions� are� possibly� less� frequently� identified� as�PUs.�However,�this�risk�factor�was�included�in�the�Norton�(1962)� risk� assessment� and� others� since,� as� moisture-damaged�skin�is�at�increased�risk�of�pressure�damage.�Hence,�interventions�must�be�put�in�place�to�protect�the�skin�from�body�fluids.

Poor� nutritional� status� has� long� been� associated� with� a�higher� risk� of� PU� development� (Berlowitz� and�Wilking,�1989;�Langer�et�al,�2003)�and�Waterlow�(2005)�was�first�to�include� this� risk� in� her� assessment� tool.�The� relationship�between� low� serum� albumin� and� PU� risk� has� been�debated�for�many�years.�Anthony�et�al�(2000)�demonstrated�that� serum� albumin� may� be� a� useful� predictor� for� PU�development�but�suggested�further�studies�were�needed.�In�2000,� Russell� reviewed� several� papers� dating� back� to� the�1980s� that� demonstrated� correlation� between� low� serum�albumin,� malnutrition� and� low� body� mass� index� (BMI)�with�PU�development.�More�recently,�Kottner�et�al�(2011)�found�that�PUs�occurred�significantly�more�often�in�people�with�a�low�BMI.�

Over�the�decades,�all�of�the�above�have�been�explored�and�promoted�as�key�preventative�interventions.�These�elements�have�been�the�standard�of�PU�prevention�the�world�over.�In�recent�years�they�have�become�the�core�of�PU�prevention�care� bundles� (Healthcare� Improvement� Scotland,� 2011).�Yet�PUs�are� still�occurring.�Perhaps� these�are� the�5%�that�were� not� preventable,� or� perhaps� elements� of� the� care�pathway�are�not�being�delivered.�What�is�it�that�makes�the�difference�in�PU�prevention?�In�2009,�Bales�and�Padwojski�successfully�eradicated�hospital-acquired�PUs� for�1�month�in� a� 300-bed� community� hospital� after� a� management�priority� programme� was� introduced.� A� follow-up� report�demonstrated� sustainability� for� both� the� programme� and�near�consistent�eradication�of�PUs� (Bales�and�Duvendack,�2011).� All� of� the� aforementioned� care� interventions� are�included�in�the�programme�as�well�as�other�educational�and�motivational� drivers� and� senior� management� involvement�and�engagement.�So�is�it�these�additional�factors�that�matter?�The�education�about�what� is�needed�to�be�undertaken�to�prevent�PUs�has�been�delivered�widely�and�increasingly�now�for� over� five� decades.� It� is�well� recognised� that� education�can�be�a�poor�driver� for�change�(van�Gaal,�2010).�Clearly,�more�is�needed�to�ensure�the�delivery�and�effectiveness�of�preventative�interventions.�Bales�and�Padwojski�(2009)�and�Bales�and�Duvendack�(2011)�have�demonstrated�that�it�can�be�achieved�in�one�hospital�organisation�but� there� is� little�evidence�in�the�literature�of�a�wider�attempt�to�introduce�a�preventative�programme.

This�is�what�is�happening�in�NHS�Midlands�and�East.�The�care� delivery� elements� of� the� programme� are� not� new,� they�constitute� all� that� has� been� mentioned� so� far� and� certainly�many� if� not� all� organisations� were� already� using� these�interventions�for�preventative�patient�care.�What�is�making�the�difference�now�is�involvement�and�engagement�from�the�very�highest� staff� levels� within� the� health� authority� organisation�and�multifactorial�modes�of�guideline�and�educational�delivery.

NHS Midlands and East’s ambition to eliminate all avoidable pressure ulcersCommunicationsThe�work�to�deliver�this�ambition�has�been�supported�by�an�integrated�communications�campaign�aimed�at�frontline�staff,�based�on�the�findings�of�unique�market�research.�

Enventure�Research,�a�market�research�company�working�with�the�public�sector,�were�commissioned�in�January�2012�to� explore� which� communications� interventions� would� be�effective�in�helping�health�professionals�to�prevent�and�treat�PUs.� Using� quantitative� (paper� and� online� questionnaires)�and� qualitative� techniques� (focus� groups),� they� investigated�current� knowledge,� attitudes� and� perceptions� of� frontline�staff� (Thurman� and� Robinson,� 2012).� The� response� to�the� quantitative� element� of� this� research� was� good,� with�nearly� 1600/287 000� (+/-� 2.5%� of� the� 95%� confidence�interval)� staff� sharing� their� detailed� views� (Thurman� and�Robinson,� 2012).�There� was� a� real� passion� among� staff� to�prevent�PUs,�but�there�was�a�need�to�bridge�the�knowledge�and� experience� gap.� Of� the� respondents,� 92%� believed� a��well-researched� and� planned� campaign� could� be� successful�if�hard�hitting,�direct,� simple�and�using�atypical�approaches.�

Box 4: The SSKIN care bundle

Surface

Skin inspection

Keep your patients moving

Incontinence/moisture

Nutrition

Box 3: Definition of unavoidable pressure ulcer

The definition of an unavoidable pressure ulcer has been defined in full elsewhere (NHS Midlands and East, 2012b), but to summarise:

If all risk assessments, preventative interventions and continuous re-evaluations of implemented care have been instigated and a pressure ulcer develops, then it may be deemed unavoidable. There may be some other conditions and circumstances that lead to the development of an unavoidable pressure ulcer

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These�findings�continue�to�form�the�basis�of�all�phases�of�the�Stop�the�Pressure�campaign.

A� multidisciplinary� communications� project� group� was�formed�and,�after�looking�closely�at�the�findings,�decided�the�following�would�be�instrumental�in�driving�the�campaign:

�■ Key�messaging��■ A�‘conversion�moment’�approach�■ A� period� of� sustained� reinforcement� using� a� widely�integrated�campaign�around�the�key�messaging

�■ Empowering� staff� to� communicate� more� clearly� with�patients�and�carers.The� campaign,�‘Stop� the� Pressure’� (www.stopthepressure.

com),� launched� in�April� 2012�with� a� string�of�phases,� each�featuring� innovative� communications� channels,� all� tying� in�directly�with�the�research�conclusions.�

One� of� the� first� products� was� a� short� video� animation�intended� to� shock� people� (the� conversion� moment)� about�the� impact� of� developing� a� PU� and� outline� a� refined�and� graphically� enhanced,� simple� prevention� care� bundle�approach� (see� Box 4)� (Healthcare� Improvement� Scotland,�2011).�It�has�been�a�big�hit�on�several�internet�platforms�and�on� DVD.�A� powerful� film—The� Swans’� Story—shows� the�impact�that�an�avoidable�PU�can�have�on�a�family.�

Another�key�output�is�a�unique�online�tool�that�simplifies�all�the�procedures.�Staff�can�scroll�and�click�their�way�along�the�‘Pressure�Ulcer�Path’,�understanding�what�to�do�and�opening�documentation.� This� has� led� to� all� organisations� across�the� Midlands� and� East� regions� implementing� standardised�

protocols.�Alternative�poster�and�pocket�versions�of�the�Path�have�also�been�distributed.�

The�SSKIN�care�bundle�is�central�to�the�whole�programme.�An�interactive�web�page,�visual�guides,�educational�slides�and�200 000� lanyard� cards� have� made� it� easy� for� staff� to� access�and�share.

Building� on� this,� a� new� microsite,�‘Learning� to� stop� the�pressure’,�has�been�created�to�make�training�and�educational�resources—which�vary�according�to�the�users�role—available�together�for�easy�access.�

One� of� the� research� findings� was� the� importance� of�educating�patients� and�carers� about�PU�prevention,� as� their�lack�of�knowledge�was� seen�as� a�key�barrier.�Working�with�Enventure� and� a� patient� and� carer� couple,� new� research�has� now� been� conducted� into� the� most� effective� ways� to�communicate�with�the�general�public�so�that�they�too�know�what�to�look�for�and�how�to�prevent�PUs.

Organisations� are� participating� in� ongoing� change�implementation� programmes� to� assist� the� clinical� teams� in�delivering� all� aspects� of� the� ambition� pathway.� Members�of� these� include� tissue� viability� nurse� specialists� (TVNs),�directors� and� deputy� directors� of� nursing,� clinical� nursing�team�staff� (registered�and�unregistered),�dieticians�and�other�professionals�allied�to�healthcare.

Ten� issues� of� an� email� marketing� bulletin� ‘Under� the�skin’� have� kept� senior� staff� engaged,� and� more� recently� an�educational� ‘Stop� the� Pressure’� board� game� has� provided�learning�in�a�fun�way.�

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Clinical expert working groupThe� expert� working� group� (EWG)� came� into� existence�in� September� 2011.� This� group� was� made� up� of� TVNs,�clinical� commissioners� and� lead�nurses�based� in� the�East�of�England�(EoE)�region�of�the�NHS�Midlands�and�East�cluster.�The�primary�goal�of� the�group�was� to� review� the� available�evidence� behind� PU� prevention� and,� where� necessary,� the�management�of�PUs.�The�secondary�outcome�was�to�ensure�this�evidence�was�relevant,�up�to�date�and�available�as�a�simple�resource�toolkit�to�all�multidisciplinary�clinical�staff�wherever�they�were�based�to�assist�in�the�prevention�of�PUs.�The�EWG�were�all�in�agreement�that�this�was�an�essential�route�to�take�to�progress�towards�achieving�the�ambition.�With�the�ultimate�aim�being�all�NHS�organisations�in�NHS�Midlands�and�East�using� the� same� processes� and� accompanying� tools,� ranging�from�a�PU�grading�tool�to�PU�prevention/management�care�bundles.

In�the�reviewing�of�the�available�evidence�it�became�clear�that� some� areas� that� first� appeared� simple� were� not� always�straightforward.� For� example,� in� the� area� of� risk� assessment�timing,� what� happened� to� patients� who� were� complex�and� attending� outpatients� for� several� hours� or� women� in�maternity�units?�Using�the�latter�example,�the�following�is�an�illustration�of�the�process�the�EWG�undertook:�

�■ Review�of�available�literature�■ Area�discussed�within�EWG�■ Experts�in�the�area�consulted,�i.e.�midwives��■ Solution�identified�(screening�tool�in�this�case)��■ Local�EoE� tissue�viability�network�consulted�and� lobbied�for�their�opinion�on�the�potential�solution�

�■ Screening�tool�adapted�or�agreed�and�signed�off�by�EWG.�This�process�was�employed�for�all�aspects�of�PU�prevention/

management,� including� the� investigating� and� reporting� of�PUs.�The�processes�and�guidelines�produced�by�the�EWG�in�this� way� were� made� available� through� the� ‘stopthepressure’�webpath,�which�makes�them�easily�accessible�to�all�clinical�staff.

Effectiveness of the strategyIn� the� Midlands� and� East,� data� on� PU� prevalence� is�collected�on�the�same�day�each�month�via� the�NHS�Safety�Thermometer,� for� some� 56 000� to� 60 000� patients.� The�monthly� Safety�Thermometer� census� is� carried� out� in� all�NHS� care� provided� in� hospitals,� community� healthcare,�mental-health� and� learning-disability� providers.�This� ‘point�prevalence� data’� has� been� collected� across� all� organisations�and�therefore�the�improvement�of�care�can�be�seen�over�time.

The� NHS� Safety� Thermometer� is� a� measurement� tool�used� to� ‘measure’� the� ‘harm-free� care’� being� delivered��to� organisations� on� a� monthly� basis� and� gives� a� snapshot�of� the� four� harms� for� all� patients.� The� four� harms� are��PUs,�falls,�CAUTIs�and�venous�thromboembolism.�

Across�the�Midlands�and�East�there�has�been�support�and�commitment� to� achieve� the� SHA� ambition� to� ‘eliminate�avoidable� category� 2,� 3� and� 4� pressure� ulcers’� from� board�level�through�to�clinicians�working�in�practice.�The�collection�of� Safety� Thermometer� data� to� measure� the� level� of�improvement�was�agreed�and�piloted�across�the�SHA�cluster�from� November� 2011,� with� one� primary� care� trust� (PCT)�cluster� initially� collecting� 100%� data� from� their� area.�This�was� repeated� in�December�2011�with�an� increased�number�of�PCT�clusters�taking�part�until�all�17�collected�the�baseline�measurement� in� March� 2011.�This� rollout� allowed� for� the�development� of� processes� and� sharing� of� good� practice� to�ensure� that� the� data� collection� was� completely� accurate,�timely�and�that�organisations� learnt� from�each�other.�It�also�ensured� executive� support� and� early� indications� of� where�improvements�needed� to�be�made� and�helped� to� shape� the�work� streams� (NHS�Midlands� and�East,� 2011)� that� support�the�delivery�of�the�ambition.

Data� collected�during� the�October�2012�monthly� census�has�reported�that�the�prevalence�of�patients�with�a�category�2,�3�or�4�PU�has�reduced�from�1.7%�to�1.09%,�a�reduction�of�36%�over�7�months�compared�to�the�April�2012�level.�The�data�also�demonstrates�that�the�prevalence�of�the�most�severe�PUs�at�category�4�has�halved�in�the�same�period.

ConclusionThere�is�still�some�way�to�go�towards�eliminating�all�avoidable�PUs�in�the�NHS�Midlands�and�East�cluster,�but�as�the�latest�Safety�Thermometer�data�shows,�this�multifaceted�programme�of�change�delivery�is�taking�effect.�The�most�senior�members�of�the�involved�organisations�are�engaged�with�the�ambition�and�teams�delivering�care�at�the�patient�front�have�clear�and�simple�processes�to�follow.� BJN

Conflict of interest: none

Anthony�D,�Reynolds�T,�Russell�L�(2000)�An�investigation�into�the�use�of�serum�albumin,�in�pressure�sore�prediction.�J Adv Nurs 32(2):�359-65

Bales� I,� Padwojski� A� (2009)� Reaching� for� the� moon:� achieving� zero�pressure�ulcer�prevalence.�J Wound Care 18(4):�137-44

Bales� I,� Duvendack�T� (2011)� Reaching� for� the� moon:� achieving� zero�pressure�ulcer�prevalence,�an�update.�J Wound Care�20(8):�374-7

Barbanel� JC,� Jordan� MM,� Nicol� SM,� Clark� MO� (1977)� Incidence� of�pressure� sores� in� the�Greater�Glasgow�Health�Board�area.�Lancet�10(2):�548-50

Bergstrom�N,�Braden�BJ,�Laguzza�A,�Holman�V�(1987)�The�Braden�scale�for�predicting�pressure�sore�risk.�Nurs Res�36(4):�205-10

Berlowitz� DR,� Wilking� SV� (1989)� Risk� factors� for� pressure� sores.� A�comparison� of� cross-sectional� and� cohort-derived� data.� J Am Ger Soc�37(11):�1043-50

Defloor�T,�Bacquerb�D,�Grypdoncka�MHF� (2005a)�The�effect�of�various�combinations�of�turning�and�pressure�reducing�devices�on�the�incidence�of�pressure�ulcers.�Int J Nurs Stud 42:�37-46

Defloor�T,� Schoonhoven� L,� Fletcher� J� et� al� (2005b)� Statement� of� the�European� Pressure� Ulcer�Advisory� Panel—pressure� ulcer� classification�differentiation� between� pressure� ulcers� and� moisture� lesions.� J Wound Ostomy Continence Nurs�32(5):�302-6

Defloor�T,�Clark�M,�Witherow�A�et�al�(2005c)�EPUAP�statement�on�prevalence�and�incidence:�Monitoring�of�pressure�ulcer�occurrence.�EPUAP Review 6(3):�74-80

Department�of�Health�(1991)�The Health of the Nation.�HMSO,�LondonDepartment� of� Health� (1993)� Pressure sores: A key quality indicator.

HMSO,�London

KEY POINTS

n Not all pressure ulcers (PUs) can be prevented (unavoidable), but many can�

n PU care and knowledge has increased as a result of involvement and engagement from the very highest staff levels within the health authority organisation and multifactorial modes of guideline and educational delivery

n Repositioning is probably the oldest form of PU prevention and remains to this day the most important

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