Identifying and Preventing Pressure Ulcers at Armidale Hospital

Hunter New England Area Health Service

Abstract

Armidale Hospital provides timely and effective prevention and treatment methods for patients at risk of a Pressure Ulcer or at the lowest level of acuity of a Pressure Ulcer.

The main method of the new care was to introduce a bright pink Pressure Ulcer identification sticker to be placed in each patient’s medical record. The sticker is effective in bringing the Pressure Ulcer to the attention of all staff as soon as it is first noted. The introduction of the sticker system has resulted in more accurate and timely reporting of Pressure Ulcers. Subsequently, intervention has become timely and effective in preventing worsening of Pressure Ulcers.

Aim

To improve early identification of patients at risk of Pressure Ulcers admitted to Armidale Hospital to ensure prevention and harm reduction.

Nature of the Problem

Pressure Ulcers in patients admitted to Armidale Hospital were not being identified in a timely manner and, therefore, not receiving timely treatment. Although rates recorded in IIMS were comparable to other hospitals, a medical record audit showed only 50 per cent of Pressure Ulcers were being recorded. In addition, the stage of the Pressure Ulcer was not consistently noted. About 40 per cent of patients with a fractured neck or femur developed Pressure Ulcers, with 80 per cent of these patients being transferred from another facility. We were unable to identify whether our inpatients had been admitted with a Pressure Ulcer or acquired it in the care of Armidale Hospital. In addition, the Waterlow Risk assessment was rarely completed.

Extent of the Problem

Whole of hospital Pressure Ulcer Audit Oct 2005 - May 2006

• Most Pressure Ulcers detected in medical and surgical wards
• 50 per cent of Pressure Ulcers noted in IIMS
• Nursing history Pressure Ulcer risk assessment 13/18 patients (but not Waterlow as required by Hunter New England Health policy)
• Wound charts not always used
• Stage not consistently noted in patient record

Pressure Ulcers in Fractured Neck of Femur (#NOF) audited in March 2007

• 38 per cent of patients with #NOF developed a Pressure Ulcer
• 50 per cent noted in IIMS
• 83 per cent transferred to Armidale Hospital from another facility
• 83 per cent were Grade 1 or 2
• 33 per cent noted on day of arrival (DOA) and 50 per cent on second day
• Pressure Ulcer Risk Assessment not consistently completed
• No referrals to dietitian

A whole of hospital approach was undertaken with the Pressure Ulcer incidence in all patients admitted overnight to Armidale Hospital measured and reviewed each month by a working group. During the period between January and June 2007, Armidale Hospital had 10,597 overnight occupied bed days (all inpatient types) or 2,129 patients who were admitted overnight. During the period July to December 2007, Armidale Hospital had 10,363 overnight occupied bed days or 2,334 patients who were admitted overnight.

Strategic Importance

Hunter New England Health Strategic Directions 2006-2010 Area Healthcare Services Plan states that the service will “introduce programs for all clinical staff involved in the care of aged care and rehabilitation patients, to develop competencies in the  assessment, management and documentation of pressure ulcers”. It also states that the health service will also “establish mechanisms to monitor compliance with Hunter New England Health Pressure Ulcer Prevention Policy, including mattress replacement”.

In addition, the Policy measures include per cent KPIs achieved for pressure wounds (Hunter New England Health Area Health Strategic Plan July 2007).

Armidale Hospital recognised the need to implement additional measures to ensure improvement in Pressure Ulcer care.

Planning and Implementing Solutions

The changes that were required:

• Consistent use of Waterlow Risk on admission
• Updated Pressure Ulcer Manual in all wards
• Introduce pink Pressure Ulcer sticker system to alert staff of at-risk patients
• Alternating airflow mattress
• Provision of pressure-relieving equipment to patients at risk
• Referral to dietitian
• Education for staff about wound management

An audit revealed very low compliance with risk assessment within 24 hours of patient admission. In addition, the Pressure Ulcers Risk Score was being used and not the Waterlow. The working group gave this information to another group undertaking a review of the Nursing History form and appropriate changes were made.

The working group discussion about the Pressure Ulcer Manual included: what to include (TOC), format and the desirable order of information. Information was sourced from NSW and QLD Health manuals available on the internet and adapted to the needs of Armidale Hospital. The updated manual was distributed in June 2007 and discussed at ward meetings. Staff have indicated they are able to readily access the updated manual

Methods to clearly identify a patient with a Pressure Ulcer were investigated. Our partner hospital, Tamworth Rural Referral Hospital, had introduced a bright pink Pressure Ulcer sticker system, which is placed in the patient’s medical record. This sticker was trialled in the surgical ward in July 2007.The rate of reporting of Pressure Ulcers on IIMS and efficiency in noting management of the Pressure Ulcer improved significantly. It allowed for quick and easy identification that a patient had a Pressure Ulcer and ensured appropriate management. IIMS reporting was no longer the province of some staff members. The sticker is now used in all wards.

The hospital had two alternating pressure mattresses in 2005. One was an overlay which was frequently out of action as parts went missing. With up to four #NOF patients in a month, as well as many other patients at high risk of Pressure Ulcers, the hospital required another alternating pressure mattress. Information on mattresses was obtained from other facilities. A trial of the Nimbus 3 from Huntleigh Healthcare was undertaken over Christmas 2007 with different types of patients in all wards. This mattress is available for rental when required.

Armidale Hospital recognised that its customers in this project were patients admitted to Armidale Hospital and/or transferred from other Hunter New England Health facilities, their carers, their families, residential aged care facility staff and equipment suppliers. Patients and staff were asked for feedback on innovations. Press Pressure Ulcer management is also included in the transfer/discharge notes where relevant.

Outcomes and Evaluation

In the first half of 2007 (1H2007) Armidale Hospital had 60 patients who developed one Pressure Ulcer  in 10,597 overnight bed days = rate of 0.57 per cent.
Also we only had five patients who were admitted with one or more Pressure Ulcers in 10,597 overnight bed days = rate of 0.05 per cent.

During the second half of 2007 (2H2007) Armidale Hospital had 22 patients who developed a Pressure Ulcer in 10,363 overnight occupied bed days = rate of 0.21 per cent.
Armidale Hospital had 21 patients who were admitted with a Pressure Ulcer in 10,363 overnight occupied bed days = rate of 0.20 per cent.

These figures are best shown in the graph below showing the month-by-month trend toward a decrease in pressure ulcers acquired at Armidale Hospital and a concomitant increase in patients with existing pressure ulcers being identified on admission.

The significant decrease in Pressure Ulcers after June 2007can be attributed to:

• Better identification of patients admitted to Armidale Hospital with a Pressure Ulcer
• Better awareness of Pressure Ulcers through the provision of updated Pressure Ulcer Manuals in all departments
• Use of the pink sticker Pressure Ulcer identification sticker
• Provision of an alternating pressure mattress in the surgical ward for high-risk patients
• More diligent reporting of Pressure Ulcer in IIMS (70 per cent recorded compared to less than 50 per cent in 1h2007).

The significant increase in recording of patients admitted with a Pressure Ulcer can be attributed to:

• The question “Was the pressure ulcer present on admission?”  included in IIMS
• Increased rate of assessment of Pressure Ulcer risk on admission (particularly surgical and medical wards)
• Doctors in the Emergency Department note Pressure Ulcer on admission.

Sustaining Change

The Pressure Ulcer stickers were unexpectedly deleted from the stores stock list in early 2008, but the Tamworth and Armidale hospitals group used the opportunity to redesign the stickers and have them reprinted.

The Quality Coordinator checks IIMS for Pressure Ulcer notifications each month and cross references them with coding entries supplied by the Medical Records Manager. Thus all Pressure Ulcers and their management are noted in IIMS of the Pressure Ulcer.

NUMs note equipment / mattress used when managing the incident. This will ensure that any improvement or deterioration can be better attributed to care and equipment available for the patient.

An audit of equipment for prevention of Pressure Ulcer at the hospital is being undertaken and several items have been included in wish-lists for the new financial year.

Increasing referrals to the Dietitian is the next target for the Pressure Ulcer Working Group.

Future Scope

The Hunter New England Health Pressure Ulcer Working Group have released a draft procedure that includes the use of the stickers. Therefore, a Pressure Ulcer identification sticker could be used across Hunter new England Health in the future, based on the stickers which originated in Tamworth and now adapted for use in both Armidale and Tamworth hospitals.

Project Team

Ms Tania Slack-Smith, Occupational Therapist
Ms Bernadette Foster, RN
Dr Gerald De Gabriele, Geriatrician
Ms Nicci Mortimer, NUM
Ms Debbie Spokes, NUM
Ms Wendy Lam, DDON
Ms Lee Lawrence, Occupational Therapist

Contact

This project was entered in the 2008 NSW Health Awards, Making Prevention Everybody's Business category.

More about the 2008 NSW Health Awards