Prepared by Rosemary Beenie

Nurse Manager, Clinical Informatics

Liverpool Hospital

March 2014

Pressure Injury Prevention and Management Strategies in

SWSLHD

Background

The Waterlow Pressure Ulcer Risk Assessment scoring

system was introduced at Liverpool in the early 2000’s

A point prevalence audit conducted in 2008 found that only

37% of patients had a Waterlow assessment completed,

and only 54% of patients deemed ‘at risk’ were on

appropriate mattresses

Each ward had their own mattress rental preferences as

there were no hospital wide guidelines

Actions

A hospital wide system for the rental of mattresses was

developed

‘Waterlow Wednesday’ was introduced

On Wednesday of every week a staff member would audit

Waterlow score and mattress for every patient

Results were collated by the Wound CNC and distributed

monthly to NUMs

Mattress Rental Guide

Mattress model Supplier

Phone number

Mattress model Supplier

Phone number

Mattress model Supplier

Phone number

Compliance improved but……

Waterlow Wednesdays were taking 2-3 hours to complete

for ward staff, plus hours for results to be collated for

monthly reports

Large amount of paperwork generated, but audit forms lost

Staff did not remember when Waterlow assessments were

due for each patient

Confusion about the ‘Wednesday’ - Patients admitted on

Thursday could wait almost a week before assessment

The improvements were not

sustainable……

The audits were conducted weekly, but collated monthly –

feedback loop lag

Advice about the preventive measures to be taken was on

the back of the form – staff didn’t always turn it over

Other priorities took precedence

eMR - 2010

The Waterlow assessment tool had already been built in

eMR for community nursing

We worked with the eMR team to make it suitable for the

inpatient setting – adding a preventive measures segment,

and rules to remind staff when to re-assess

eMR was used to reinforce policy – assessment to be done

on admission, on transfer to a new ward, and every 7 days

The computer doesn’t know when the patient’s condition

has changed, this requires nursing judgement to reassess

eMR Waterlow Assessment tool

Preventive equipment – mandatory for

score of 15 or more

Assessment due – the Patient Access List

Apples indicate an assessment is due, click on the apple to

open and complete the form

eMR Waterlow Benefits

Quicker than paper – calculations done by the computer

Reminders when assessment or reassessment is due

Recognises when a patient is transferred to a new ward.

Resets the timer if an ad hoc form is completed due to

change in condition

Prompt to record pressure relieving options (planned or

implemented) when the patient is ‘high risk’ i.e. score of 15

or higher

Automated referral to dietician if MST is 3 or more

More eMR Benefits

The PowerChart flowsheet allows comparison of

assessments over time

NUM or delegate can review scores for each patient and

ensure appropriate pressure relieving devices are available

(or removed when no longer required)

Aids but does not override clinical judgement

Waterlow Wednesday audit process automated and

centralised – now takes less than 15 minutes to collate and

distribute weekly compliance reports

Compliance Reports

Detailed Compliance Reports

Automated reports run weekly for the whole hospital,

but can be run any time at a ward level

What have we achieved?

Compliance with Waterlow assessments improved from

37% in 2008 to 79% in 2009 using paper processes

By 2011, after the eMR implementation, compliance

improved to 91%. Since 2012 it has been sustained

between 80%-95%

Utilisation of appropriate pressure relieving mattresses

increased from 54% in 2008 to over 89% in 2011

An estimated saving of 151 hours per month in manual

auditing

How have our patients benefited?

Point prevalence audits show the incidence of Hospital

Acquired Pressure Injuries has dropped from 13% in 2009

to 8% in 2011 and 5.6% in 2013

Deep ulceration (Grade 3 & 4) dropped from 27% in 2009,

to 3% in 2011 and 1.6% in 2013

An estimated 43 additional patients prevented from

developing a pressure injury over 24 months

Less pain and discomfort, less occasions of extended

length of stay

Where to from here?

New reports to identify whether the Waterlow assessments

are performed within 8 hours of admission or transfer to a

ward

Electronic documentation of pressure injuries when they do

occur

Acknowledgements

Matthew Wilson, former CNC Wound Care Liverpool

Hospital

Cara Bowen, CNC Wound Care, Liverpool Hospital

The eMR team and report writers from the Information and

Technology Division, Sydney & South Western Sydney

LHDs.