Eliminating Avoidable Pressure Ulcers. Professor Gerard Stansby

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1 Eliminating Avoidable Pressure Ulcers Professor Gerard Stansby

2 Why is this important? Important patient safety issue Pressure ulcers can be prevented (?All) Pressure ulcers are expensive for NHS Patient Safety Thermometer data will be scrutinised by commissioners and inspectors CQUINs based on pressure ulcer rates local or national? Applies to all care setting not just hospital!

3 Why are pressure ulcers important? An estimated 4 10% of patients admitted to an acute hospital develop a pressure ulcer Major cause of sickness, reduced quality of life and morbidity Associated with a 2 4-fold increase in risk of death in older people in intensive care units Substantial financial costs

4 BBC Inside Out

5 Why is this important?

6 Expensive? In 2004 the estimated annual cost of pressure ulcer care in the UK was between 1.4 billion and 2.1 billion a year Mean cost per patient of treatment for a grade IV pressure ulcer was calculated to be 10,551

7 Pressure Ulcers Risk factors include: pressure shearing friction level of mobility sensory impairment continence level of consciousness acute, chronic and terminal illness comorbidity posture cognition, psychological status previous pressure damage extremes of age nutrition and hydration status moisture to the skin Reassess on an ongoing basis 13

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9 All National Data

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11 Are there unavoidable Pressure Answer = a few Ulcers? But ask: Did you:- Evaluate the patients condition and risk Plan and implement prevention Monitor and evaluate intervention Revise interventions as required Etc.

12 Unavoidable? (no excuses please) Patients refuse interventions Terminal care Sudden unexpected event Severe peripheral arterial disease Probably needs independent root cause analysis to verify

13 Current Work: Guideline development Pressure ulcers: prevention and management of pressure ulcers update of: 'Pressure ulcers 2005 'Pressure ulcer prevention 2003 For publication May 2014

14 Scope: Groups that will be covered a) People of all ages. b) Subgroups that are identified as needing specific consideration will be considered during development but may include: people who are immobile people with neurological disease or injury (including people with multiple sclerosis) people who are malnourished people who are morbidly obese older people

15 Healthcare setting The NHS! (or where the NHS is paying)

16 NICE guidance: The process Scope: All adult patients, including primary care Consultation, scoping workshops Expert GDG group - multidisciplinary Thorough evidence search and review Economic modelling as required Cost effectiveness as well as clinical effectiveness

17 Key clinical issues that will be covered a) Risk assessment, including the use of risk assessment tools and scales. b) Skin assessment. c) Prevention, including: moisture lesions and the use of barrier creams pressure-relieving devices1, including mattresses, cushions, sheepskins, overlays, beds, limb protectors and seating skin massage/rubbing positioning and repositioning nutritional interventions (including hydration) as preventive strategies for people with and without nutritional deficiency patient and carer education, including self assessment education and training for healthcare professionals. d) Assessment and grading of pressure ulcers. e) Management:

18 Management, including: Debridement, including autolytic, mechanical and larval therapy Pressure-relieving devices1, including mattresses, cushions, sheepskins, overlays, beds, limb protectors and seating Nutritional interventions (including hydration) for people with and without nutritional deficiency Antimicrobials and antibiotics Wound dressings Management of heel pressure ulcers Other therapies, including electrotherapy, negative pressure wound therapy and hyperbaric oxygen therapy.

19 Main outcomes General a) Quality of life. b) Adverse events. Prevention c) Proportion of people who develop new pressure ulcers.

20 Economic aspects Developers will take into account both clinical and cost effectiveness when making recommendations involving a choice between alternative interventions. A review of the economic evidence will be conducted and analyses will be carried out as appropriate. The preferred unit of effectiveness is the qualityadjusted life year (QALY), and the costs considered will usually be only from an NHS and personal social services (PSS) perspective.

21 Key Definitions in Pressure Ulcer data Heath care acquired Pressure Ulcers HCA PU s preventable Pressure Ulcers PPU s Incidence Prevalence Moisture Lesions vs Pressure Ulcers?

22 Quality Standards: Joined up Thinking for the NHS NICE quality standards enable: Health and social care professionals to make decisions about care based on the latest evidence and best practice. Patients to understand what service they can expect from their health and social care providers. NHS Trusts to quickly and easily examine the clinical performance of their organisation and assess the standards of care they provide Commissioners to be confident that the services they are providing are high quality and cost effective 22

23 What the Health and Social Care Act Quality standards says about quality standards. The relevant commissioner may direct NICE to prepare statements of standards in relation to the provision of: a) NHS service b) Public health services, or c) Social care in England. NICE must keep a quality standard under review and may revise it as it considers appropriate. In discharging its duty, the Board/Secretary of State must have regard to the quality standards prepared by NICE.

24 Guidance and quality standards A comprehensive set of recommendations for a particular disease or condition Evidence Guidance Quality Standards Sentinel markers A prioritised set of concise, measureable statements designed to drive quality improvements across a pathway of care.

25 180 healthcare quality standard topics

26 Quality Standards: Definition A quality standard is a set of specific, concise statements that: act as markers of high-quality, cost-effective patient care across a pathway or clinical area; are derived from the best available evidence; and are produced collaboratively with the NHS and social care, along with their partners and service users

27 Q. What would a really good service look like? One with no PPU s Trusts/Units Clinicians Commissioners GP s Patients

28 Questions when considering potential Areas For PU Quality Standards Only c. 10 What are the bigger issues? Where is the evidence strongest? What can be measured? What can be defined? What is reasonable for the NHS? N.b. Generic Quality Standards are being developed for patient experience etc. But are there specific PU related ones? Settings Primary care etc.

29 Potential Areas For PU Quality Standards Prevention and treatment of pressure ulcers Assess and record risk Re-assess People vulnerable to pressure ulcers Patient with pressure ulcer Assess pressure ulcer Reassess Prevent pressure ulcer Treat pressure ulcer and prevent new ulcers 12

30 Obvious Potential Areas For PU Quality Standards Prevention: Equipment/Strategies Treatment: Equipment/Strategies/Interventions/dressings etc. (Acceptable numbers of PPU s?)

31 Training/Professionalism For all? Targeted to certain areas?

32 Patient/Carer Information Strategies for empowerment Awareness and prevention Self help Specific PU Information Admission Discharge Long term care Who to ask etc.

33 Thank You! Professor Gerard Stansby