Pressure Ulcer prevention - Sikker Patient

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Pressure Ulcer prevention - Sikker Patient

USING THE MODEL FORIMPROVEMENT TO ELIMINATEPRESSURE ULCERS IN WALESAdopting a Zero tolerance approach


2Introduction© ABM UHB


Who are we?3 Hamish Laing Directorof acute care &Consultant PlasticSurgeon Nigel BroadCharge Nurse Hayley PhillipsWard Sister ABM University HealthBoard, South Wales,© ABM UHBUK


Wales UK4WalesPopulation2.9MCapital CityCardiffDevolvedGovernmentfor Healthand SocialCare© ABM UHB


5ABM University Health Board,Wales Large organisation in South Wales, UKproviding primary and secondary care for600,000 people, tertiary care for 2.5million andquaternary care for 9.5 million 4 acute hospitals with 92 wards and 2500beds covering a wide range of specialities.© ABM UHB


Terminology6 Pressure sores Bed sores Decubitus ulcers PRESSURE ULCERS© ABM UHB


7What are the risk factors forpressure ulceration?© ABM UHB


Risk factors8 Elderly Immobile (paraplegia) Insensate(neurologicalconditions, diabetes) Debilitated Unrelieved pressureover a bonyprominence Hypotension Incontinence Malnutrition© ABM UHB


Pathophysiology9Pressureulcers candevelopwithin just afew hours© ABM UHB


10Why is preventing pressureulcers important?© ABM UHB


11Pressure Ulcers – what‟s theproblem Pressure ulcers are common Pressure ulcers aredevastating Pressure ulcers are lifethreatening Pressure ulcers areexpensive Pressure ulcers are (mostly)avoidable!© ABM UHB


Pressure ulcers are common12 Typical UK Hospital 10-15% incidence ofPressure Ulcers (grade2-4) Our Hospital (2005) 13% (grade 2-4) Typical Danish Hospital 15-20% (allgrades)???© ABM UHB


13Pressure ulcers are life-threateningChristopher Reeve (paraplegic actor) is said to havedied from sepsis following a pressure ulcerdeveloping© ABM UHB


Pressure Ulcers are expensive14Estimatedcost oftreatmentUKDepartmentof HealthPressureUlcerProductivityToolGrade Median Cost (£) Cost (Kr)Grade 1 1,000 9,000Grade 2 6,000 56,000Grade 3 10,000 90,000Grade 4 14,000 126,000It is estimated that the UK spends £2.4Billion (Kr 21.6 Billion ) treating pressureulcers each year!http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_116669© ABM UHB


Pressure Ulcers: Prevention15We know what causes them but we do notprevent them in a large number of patients….WHY?© ABM UHB


16Implementing changeThe Model forImprovement© ABM UHB


17Patient safety - What‟s theproblem?• More than one in tenpeople admitted tohospital in the UKare harmedunintentionally by itscare.• There is a 1 in 300chance of accidentaldeath through errors© ABM in UHBcare.


18Patient safety - What‟s theproblem?“Hospital blunderskill 90,000 patients”Rebecca Smith, Medical Editor,Daily Telegraph 29.11.07More than 90,000 patients die andalmost one million are harmedeach year because of “hospitalblunders”, research suggests.“Researchers found that up to half of themistakes made were preventable”© ABM UHB


19The First Law of HealthcareImprovement Every system is perfectly designed to getexactly the results that it gets … therefore, although not all change isimprovement, but all improvement is changeDon Berwick - Institute for Healthcare Improvement [www.ihi.org]© ABM UHB


The model for Improvement20Three key questions - What are we trying to accomplish? How will we know that a change is animprovement? What change can we make that will result inimprovement?Associates for process Improvement [API] www.apiweb.orgLangley GJ et al. The improvement Guide- A practical guide to enhancing© ABM organisational UHB performance, Jossey-Bass 1996


What are we trying to21accomplish?Aims Statements – some examples ICU: Reduce central line associated infections inthe intensive care unit [ICU] by 75% within 12months Pressure Ulcers: Reduce hospital acquiredPressure Ulcers by 50% within 18 months Communication: WHO Safer Surgery checklist iscompleted for 95% of all elective operations within3 monthsSource: © ABM Institute UHBfor Healthcare Improvement


22How will we know a change is animprovement?You can‟tfatten a cowby weighingit!Source: Institute forHealthcare Improvement© ABM UHB


How will we know that a change is animprovement?23 Use a measure which is: Well defined Allows comparison between sites and over time Already in use, if possible It may not be perfect and it may be difficult tocollect. It needs to be specific enough andsensitive enough Try and find a measure which can be appliedto a whole community, population or system© ABM UHB


What change can we make that willresult in improvement?24 Study the system What is wrong now? What will deliver the biggest benefit? Avoid making change for changes sake Focus on things which regularly causeproblems Do not confuse “information on performance”(targets) with “information onimprovement”(how the system is working)© ABM UHB


What works?25 What is a “good system” ? Use simple steps that can be applied easily inlocal situations Develop bundles of interventions that havebeen shown to make a difference© ABM UHB


Care Bundles26 Groupings of best practices with respect to adisease process that individually improve care,but when applied together may result insubstantially greater improvement. The science supporting each bundle component issufficiently established to be considered thestandard of care. The bundle approach to a small group ofinterventions promotes teamwork andcollaboration.© ABM UHB


Driver Diagrams27 Primary Drivers System components which will contribute tomoving the primary outcome Secondary Drivers Elements of the associated Primary Driver. Theycan be used to create projects or a changepackage that will affect the Primary Driver.© ABM UHB


Aim Drivers InterventionsRisk Identification• Understand the risk factors for acquiring pressureulcers• Understand the local context & analyse local data toassess patients on ward/unit most at risk• Utilise patient „At risk‟ cards to quickly identify those atincreased riskReduce thePercentageof HospitalacquiredPressureUlcers(per1000 patientdays)By 50% byRisk Assessment2010 Identification, gradingof pressure ulcersexisting on admission/transfer & appropriateintervention“MEASURE”ReliableImplementation of the“SKIN bundle”[Ascension health 2004]Education• Assess pressure ulcer risk on admission for ALLpatients• Re-assess skin every 8 hours where necessary• Initiate and maintain correct and suitable preventativemeasuresAddress these areas:• Surface• Keep Moving• Incontinence• Nutrition• Initiate and maintain correct and suitable treatmentmeasures• Utilise the local Tissue Viability nursing expertise• Educate staff regarding the assessment process,identification and classification of, and treatment ofpressure ulcers• Educate Patients & family• Develop patient information pack28 © ABM UHB


How to introduce change29 Start small One patient, one setting, one service provider Take time to do a small scale trial Test and retest using Plan, Do, Study, Act[PDSA] cycles Only when the change has been reliable for90-95% of patients, consider spread to moresites© ABM UHB


30AIMMEASURESTESTSTestingmethodThe Improvement Guide, API© ABM UHB


Testing using the PDSA Cycle for Learning andImprovement• What changesare to be made?• Next cycle?ActStudy• Complete theanalysis of the data• Compare data topredictions• Summarize whatwas learnedPlan• Objective• Questions andpredictions (why)• Plan to carry outthe cycle (who,what, where, when)Do• Carry out the plan• Document problemsand unexpectedobservations• Begin analysisof the dataSource: Institute for Healthcare Improvement


Why Test Changes?32To increase the beliefthat the change willresult in improvementsin your settingTo learn how to adaptthe change to conditionsin your settingTo evaluate the costsand “side-effects” ofchangesTo minimize resistancewhen spreading thechange Source: Institute throughout for Healthcare Improvement theorganization© ABM UHB“Negative results on the fish…Let‟s try rubbing two stickstogether.”


Use the PDSA Cycle to:33 Answer the first two questions of the Model forImprovement Develop a change Test a change“What tests canwe complete bynext Tuesday?” Implement a change© ABM UHB


34This is different!The Cycles Build on Each Other…A PSDChangesThat ResultinImprovementImplementationof changeHunchesTheoriesIdeas© ABM UHBA PSDVery smallscale testSource: Institute for Healthcare ImprovementFollow-uptestsWide-scale tests ofchange


35Measurement and Data Collectionduring PDSA Cycles Collect useful data, not perfect data - thepurpose of the data is learning, not evaluation Use a pencil and paper until the informationsystem is ready Use sampling as part of the plan to collect thedata Use qualitative data (feedback) rather thanwait for quantitative Record what went wrong during the datacollection© ABM UHB


Measurement36Tracking a few key measures over time is the single most powerfultool a team can use.© ABM UHB


Keys and Barriers to Success37KeysBarriersPDSA cycles• Small, rapid cycle• Seek usefulness not perfection-stickers• Improve as fast as you testMultidisciplinary approach• Early adopters• „having made a difference‟LeadershipEvidenced basedMeasurement over timeOutcome & process measuresRun charts - feedbackMonthly review© ABM UHBResistance to change„ not invented here‟„already doing this‟„this week‟s gimmick‟Culture & behaviourEducate, educateClinician engagementScepticismResourcesData collectionPerson dependenceSustainable processSource: McKinsey


In Conclusion38 Safety and quality are big issues in healthcare While they are system/organisation issues,everyone can make a difference Shifts in mindsets & capabilities are moreimportant than specific tools But the model for improvement is a proventool: start with the aim, choose measures, runrapid cycles Making change stick in a system requiresaddressing several dimensions simultaneously© ABM UHB


39Introducing the SKIN BundleNigel BroadCharge NurseHayley PhillipsWard SisterABM University Health Board, Wales UK


40 © ABM UHB


Aim Drivers InterventionsRisk Identification• Understand the risk factors for acquiring pressureulcers• Understand the local context & analyse local data toassess patients on ward/unit most at risk• Utilise patient „At risk‟ cards to quickly identify those atincreased riskReduce thePercentageof HospitalacquiredPressureUlcers(per1000 patientdays)By 50% byRisk AssessmentReliableImplementation of the“SKIN bundle”[Ascension health 2004]2010 Identification, gradingof pressure ulcersexisting on admission/transfer & appropriateinterventionEducation• Assess pressure ulcer risk on admission for ALLpatients• Re-assess skin every 8 hours where necessary• Initiate and maintain correct and suitable preventativemeasuresAddress these areas:• Surface• Keep Moving• Incontinence• Nutrition• Initiate and maintain correct and suitable treatmentmeasures• Utilise the local Tissue Viability nursing expertise• Educate staff regarding the assessment process,identification and classification of, and treatment ofpressure ulcers• Educate Patients & family• Develop patient information pack41 © ABM UHB


The SKIN Bundle42A bundle of evidence-based interventions thatare known to prevent pressure ulcersdeveloping in at risk patientsSthe Surface the patient sits and lies uponK Keeping the patient moving (or turning)Imanaging Incontinence and keeping skin dryN ensuring that Nutritional state is assessedand managed© ABM UHB


43SKIN Bundle of careimplementationSurface Mattress andCushion Include safetychecks Sheet – check forwrinkles etc. Reassess pressure*: We ulcer use Waterlow risk score* scoringatleast daily© ABM UHBKeep Moving Reposition patient Inspect skin Encourage mobility Written advice forpatient and carers


SKIN Bundle of care44ImplementationIncontinence Toileting assistance Continence products Specialists Non oil-based creamswith continenceproducts Keep clean and dryNutrition Nutritional risk tool Follow instructions Ensure optimalintake Use of charts ifrequired Keep well hydrated© ABM UHB


Baseline assessment audit45 Hospital: Pressure ulcer Incidence-13% Pilot Ward Baseline incidence rate for pressure ulcers - 4.5% Nutritional assessment completion - 50% Pressure risk assessment completion - 80%Source: spot audit March ’08© ABM UHB


Preparation phase46Staff Briefing and brainstormDevelop „SKIN Bundle‟ communication toolAgree metrics and start to measure baselineEducate staff with Tissue Viability Nurse [TVN]supportEnsure Pressure Ulcer prevention is given highpriority e.g. team briefing, posters, visual cuesDevelop patient information leafletsPatient involvement is essential© ABM UHB


SKIN Bundle communication47tool© ABM UHB


Pilot „SKIN Bundle‟48 Deming's PDSA methodology commencedwith small client group: “Model forImprovement” Addressed risk scoring documentation set 100% compliance, daily review Audit of SKIN bundle communication tool –daily© ABM UHB


Outcome measures [Metrics]49 Document pressure sores of all grades (1 – 4)on Safety Cross if they occur Count “days since last pressure ulcerdeveloped on this ward” and display on SafetyCross Incident form for any sore grade 2 and above Calculate rate per 1000 bed-days© ABM UHB


Safety Cross501 23 45 67 8 9 10 11 1213 14 15 16 17 1819 20 21 22 23 24Days sincelast PU© ABM UHB25 2627 28596 days 29 30 31No new PUWard acquiredPUPatientadmitted withPU


Initial outcomes51 Full compliance with risk score: 100% Managing the risk score consistently SKIN Bundle communication tool used withpatient involvement Use of written patient information andeducation leaflets© ABM UHB


Project started April 28 th 200852No new pressure ulcers of anygrade developed on the wardfor 638days= 12,760 patient bed-days© ABM UHB


Pressure Ulcer occurred on January 25th2010!53Incident Grade 2 PressureUlcer on heel Incident formcompleted Outcome – PressureUlcer had healedwithin 4 daysRoot cause analysis Was patientassessed properly? Had assessmentplan beenmaintained? Could somethinghave been donedifferently?© ABM UHB


What has happened since?54 We have not had another pressure ulcerdevelop on the ward since that incident Today we have gone a further 596 “dayswithout a pressure ulcer” = 11,920 Bed days Since April 28 th 2008 we have just had onepressure ulcer develop on this ward: before4.5% of all our patients developed one whichwould equate to 188 patients in the same timeperiod© ABM UHB


Spreading the intervention55 Successful rollout to all 92 inpatient wards(2500 beds) in four acute hospitals and 6community hospitals across by April 2010 We have now seen the approach embedded inall clinical areas since the end of May 2010 We continue to monitor the measures andcollect them monthly through routine nursing“metrics”© ABM UHB


56Some more results from ourhospitalsLongestspell onsome typicalwardswithout apressureulcerdevelopingWard typeLongest spell(days)Plastic surgery 638General (internal) medicine 431Orthopaedic surgery 542Intensive care 263Respiratory medicine 442General surgery 389Elderly care 474© ABM UHB


57New Pressure Ulcers (all grades I-IV) developing in all ourhospitals(2500 beds) each month between April 2010 – August 2011Before we started the number of pressure ulcers developingeach month was at least 400-450 (13% of all inpatients)© ABM UHB


Key challenges58 Ward management focus and staff “buy-in” Equipment issues Maintaining momentum Managed roll out Publicity / communications© ABM UHB


Keys factors – to success59 Communication tool – patient partnership Staff education and engagement – all staffgroups “Model for Improvement” Create a “Culture of Change” Risk scoring and managing those scores Tissue Viability Nursing support Clear executive engagement© ABM UHB


Conclusions60 It is possible to translate evidencebasedknowledge into clinical practicein a sustained and effective wayusing this methodology Zero tolerance is a realistic objectivefor hospital acquired pressure ulcers© ABM UHB


ANY QUESTIONS?61© ABM UHB


62How the SKIN bundle worksOvercoming problems: A Hands on guidefor cliniciansBreakout session A: Nigel Broad


Session summary63 Introduction Review of key points Preparation for skin bundle implementation Examples of PDSA “it’s a simple process” Achieving Staff Participation Changing Culture Keeping momentum and recognisingachievements Conclusions© ABM UHB


64Implementing the SKIN bundlein your organisationManaging, Measuring, Spread andSustaining change: A Hands on guide formanagersBreakout session B: Hamish Laing


Session summary65 Introduction Review of key points Establishing the measure(s) Measurement Managing the change Spread Sustaining the change Conclusions© ABM UHB


66Team sessionWhat will you do in yourhospital or organisation bynext Tuesday?


67Feedback from Teams


68Concluding remarksABM University Health Board, Wales UK

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