Ralph Boutflower, Tissue Viability Specialist Practitioner, and Debbie Cheetham, Lead Nurse Patient Safety, discuss the improvement work that City Hospitals Sunderland NHS Foundation Trust has done around pressure ulcers.
What’s the background to the trust starting improvement work around pressure ulcers?
Prior to 2012, tissue viability was managed at an individual ward level by the respective clinical teams supported by our vascular nurses and podiatrists. When we started collecting data for the NHS Safety Thermometer, this revealed that our Trust was a national outlier for pressure ulcer prevalence. This focused our attention on the significant organisational challenges ahead. Our Executive Committee subsequently invested in a Tissue Viability Team for the Trust, comprising a Tissue Viability Specialist Practitioner, Dietitian, Podiatrist and Medical Photographer.
What were the issues that were identified when you first started your improvement work?
Investigating our position as a national outlier necessitated a complete review of our practice. We identified the need to perform accurate assessments, including a Braden risk assessment, patient skin assessment and a MUST nutritional assessment both on admission and at regular intervals throughout the patients’ hospital stay. This review also highlighted the need to standardise practice based on the application of the Trust’s Pressure Ulcer Prevention & Care policy.
We also detected a culture of acceptance that pressure ulcers were inevitable as opposed to avoidable and a perception that pressure ulcers were just a nursing issue to tackle. From this, we concluded that a fundamental change in mind-set was required to challenge such beliefs and attitudes.
We also reviewed our stock of pressure relieving surfaces and dynamic mattresses and identified a need to invest in more to meet an increasing patient demand.
What changes did you make to the procedures that led to improvement?
We created a real multidisciplinary team approach to pressure ulcer prevention and management, with each team member communicating with and supporting the other to ensure that the best care pathway was initiated and adhered to for each individual patient.
We emphasised the need for staff to assess every patient’s skin integrity, pressure ulcer risk and nutritional status on admission and throughout their hospital stay.
We now expect our staff to report all categories of pressure ulcer (including category 1 pressure damage) as patient harm via our incident reporting system.
We also devised a more detailed incident reporting form to enable us to distinguish between community and hospital acquired pressure ulcers and created a more comprehensive investigation template to ensure that any lessons learned or actions to improve practice are implemented by the appropriate team.
Our medical photographer now records images of all pressure ulcers (category 2 and above) to ensure robust documentation for medical records, but also to help track improvement or deterioration of these injuries.
The Tissue Viability team provides in-house tissue viability study days in conjunction with a clinical nursing advisor and our bed contractors. These study days focus on wound assessment and pressure ulcer prevention & care, in accordance with our Trust policy and we include discussion and explanation of our NHS Safety Thermometer Results and what is expected of our staff to improve and sustain high standards of patient care. The role of each Tissue Viability team member is described and the process for referrals to each service clearly outlined. A key strategy was bringing our dietitians & doctors on board and ensuring a true multi-disciplinary approach to tissue viability. Now, every patient with a pressure ulcer, irrespective of category, is referred to a dietitian, who devises an individual nutritional plan to accelerate and support the healing process.
What education did you do around pressure ulcers?
We reviewed our education & training programmes utilising the Kirkpatrick Four Levels Evaluation Model, as part of the Investing in Behaviours collaborative programme with NHS England North. This programme focuses on fundamental behavioural change in order to affect change and drive improvement.
We identified our target audience, which was Registered Nurses, Health Care Assistants, Allied Health Professionals and medical staff who deliver frontline care. We then outlined our learning objectives, which were, identifying patients at risk of pressure ulcers, accurately assessing and categorising the pressure ulcer, implementing the Pressure Ulcer Prevention & Care Policy and the “SSKIN bundle” and improving incident reporting. Within the education, we challenged the 4 hourly changes that were embedded in practice and emphasised the need for 2 hourly positional changes instead.
We also held various events within the Trust, including Lessons Learned Seminars based on real cases, Skin Symposiums and celebration of National Pressure Ulcer Day.
The Tissue Viability Specialist Practitioner also introduced informal, drop-in education sessions on the wards, where the team focus on current cases and review the care and management of their patients with pressure ulcers.
What was key to making these changes?
Preventing and treating pressure ulcers is now a true multi-disciplinary approach in our trust, and we have transformed the traditional perception that pressure ulcers are a nursing issue to the principle that pressure ulcers are everybody’s business. We have also cultivated a fundamental cultural shift and moved from an attitude of accepting that that pressure ulcers are inevitable to the ethos that pressure ulcers are avoidable.
The Kirkpatrick Four Levels Evaluation Model provided a cohesive framework to both drive and monitor improvement. We used this model as the basis for our successful business case to support the continuation and expansion of the Tissue Viability Service. The resulting additional investment from our Executive Committee has enabled us to expand the service to allow seven day working.
The Kirkpatrick model also helped us to devise drivers in the form of aide memoires and posters to re-enforce the identified critical behaviours required to achieve our goal of reducing hospital acquired pressure ulcers.
Our work to encourage and improve incident reporting within the Trust aligns completely to the Open & Honest / Transparency agenda and our strategies to improve the organisational safety culture which is part of the Investing in Behaviours Programme.
The Trust’s Tissue Viability Steering Group is also working closely with the Trust’s Nutrition Steering Group in order to devise strategies to improve MUST assessment and nutritional intake for patients either with pressure ulcers or at high risk of developing pressure ulcers.
Did using the Safety Thermometer help with noticing improvement?
The data from the Safety Thermometer has definitely helped, both in monitoring improvement and assisting us in identifying our outlying wards so that we can focus our efforts to work with those teams in order to drive down the prevalence of hospital acquired pressure ulcers. The data support that we have received from the National Safety Thermometer Team has also been really helpful, as it has enabled us to understand the data and feed it back to our staff in a way that they can understand.
Our Safety Thermometer data is incorporated into our corporate dashboard which is reported to our Board of Governors, to assist with monitoring our organisational performance.
We have also established a monthly Executive Team Safety Walkabout to coincide with the Safety Thermometer survey days. This demonstrates support and commitment at the highest level and allows clinical teams to engage with members of the Executive Team to discuss their Safety Thermometer results, celebrating their successes and explaining their improvement plans. Our Chief Executive participates in these walkabouts and wears his “Stop Pressure Ulcer” badge with pride, re-enforcing the ethos that pressure ulcers are everyone’s business.
We also collect additional data, in the form of the number of incidents reported regarding pressure ulcers as leading indicators for our Kirkpatrick Plan. This allows us to monitor the incidence in addition to the prevalence of pressure ulcers.
How have you shared and celebrated this success?
We use a reward and recognition scheme where we challenge wards to get 30, 60 and 100 consecutive pressure ulcer free days and to reward the team for this achievement we give cakes, presented by our Head of Nursing & Patient Safety. Anyone who gets 365 consecutive days free will be nominated for our annual Trust reward and recognition awards. This gives incentive to the staff and demonstrates that our senior team recognise and acknowledge their efforts.
We have been asked to present our progress to date at the forthcoming NHS England North Investing in Behaviours Programme Learning and Sharing Event in September and also to participate in a web-ex for a 6C’s Week of Action in October.
What would be your main advice to other trusts that want to improve?
We consider that the four things that have helped us the most are:
- use of the NHS Safety Thermometer data to drive service improvement for patient safety and identifying the wards where additional support is required .
- use of the Kirkpatrick Four Levels Evaluation Model to provide us with a framework to structure our approach.
- taking a truly multi-disciplinary approach to ensure that our patients receive the best pathway of care for their needs
- taking every opportunity to learn lessons from every incident of patient harm reported.
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