IQC/2013/48 Improvement and Quality Committee October 2013

Transcription

1 Item 9.4 IQC/2013/48 Improvement and Quality Committee October 2013 Pressure Ulcer Prevalence Improvement Plan 1. SITUATION AND BACKGROUND This paper is to update the Improvement and Quality Committee with progress on the pressure ulcer improvement plan within NHS Tayside, and seek approval for the proposed actions in response to the national pressure ulcer change package and CEL19 (2013). Pressure ulcers severely affect the quality of life of patients in terms of pain, infection, discomfort, loss of function and dignity. They also impact on the organisation in terms of increased visits from healthcare professionals, increased cost of treating ulcers, nursing and medical time, increased complaints and the potential for litigation. With full commitment to this improvement plan, patients and the organisation will realise the increased benefits in terms of reducing harm to patients, improving patient satisfaction and reducing costs. It is important that mechanisms are in place to govern the reporting of avoidable and unavoidable pressure ulcers. In May 2009, NHS Tayside undertook a major exercise to ascertain the number of pressure ulcers in NHS Tayside hospitals (prevalence) and the number of pressure ulcers known to have developed in wards across Tayside (incidence). A paper was presented to the Executive Management Team which reported on the survey methodology, the survey results and gave the first baseline data highlighting that within hospital settings prevalence was 21% and incidence was 6.6%. A four phase improvement plan (appendix1) was developed as a result of the exercise and it was agreed to carry out a repeat survey on a six monthly basis. The first two phases of the improvement plan have been fully implemented and ongoing; phase three of the plan has been established to drive improvements for patients in their homes cared for by community nursing teams. Phase four is yet to be established; this will focus on the involvement of local authority care teams, who deliver personal care within patients own homes with or without District Nurse input. From 2012 to 2013 pressure ulcer prevention was driven, and monitored as one of the Leading Better Care outcomes and Clinical Quality Indicators (CQIs). Recently CEL 19 established pressure ulcers as one of the nine points of care interventions, therefore pressure ulcers monitoring is now integrated with the Scottish Safer Patient Programme (SPSP). Health Improvement Scotland (HIS) have published a revised pressure ulcer change package driver diagram. However the SPSP programme focuses on acute care hospitals, whereas NHS Tayside has taken a wider view in the four phased improvement plan which aims to reduce pressure ulcer occurrence throughout Tayside for acute, community and local authority care. 1

2 This report will discuss firstly the hospital results and proposed integration with SPSP change package, and secondly progress with the four phased improvement plan. The HIS change package suggests that Boards should monitor: Number of Avoidable pressure ulcers developing in acute care per 1000 bed days. This assumes that around 5% of pressure ulcers are unavoidable. Number of days between an avoidable hospital acquired pressure ulcer, grade 2 4 the aim is for each acute ward to reach a 300 day target. 95% compliance with assessment and SKIN care bundle. 2. ASSESSMENT May 2013 Hospital Point of Prevalence Study In May 2013 the hospital ward based point of prevalence study was repeated. The full results by directorate and CHP are illustrated in appendix 2. In summary:- The overall prevalence across all NHS Tayside hospitals was 21% in 2009 and is now at 3.4% and incidence was 6.6% and is now 0.85%. The 2009 target of 5% or less prevalence has been achieved. Incidence per 1000 bed days is 0.27, and for the target within SPSP for acute ward areas is There is 97% compliance with the pressure ulcer bundle across NHS Tayside hospitals. In the 6 monthly audit, no grade 3 or 4 ulcers had developed in hospital wards. This is a significant improvement, indicating that all ulcers are grade 1 and 2. NHS Tayside Improvement Plan At the start of the improvement plan there was a rapid overall reduction in all grades of ulcer demonstrating sustained improvement in the quality of care. This has generated a cost avoidance of 1.108m per year to date. However, from May 2012, there was a marked reduction in the rate of improvement once the 1% incidence was reached. This was to be expected as there are clinical areas that have patients in very high risk groups where despite preventative care outlined by policy and best practice pressure ulcers are still developing. The clinical areas whose patients fall in to this category are now able to be identified and targeted for specific improvement interventions, and consideration given to whether some these ulcers were unavoidable. In October 2012 an evaluation of new innovative products for the prevention of grade 1 ulcers commenced, the results were encouraging, and the new products are now available to all areas. In 2012 the community pressure ulcer prevention policy was launched with similar policy, practice and resource guides for community nursing staff. Barriers to Reporting the National requirements To report each ward areas outcomes in terms of days between an ulcer developing and reporting against the national target of 300 days, a system such as Qlikview would be required to extract the data from the clinical dashboard. There is no facility for this at present, each individual wards data would need to be extracted and collated manually. GDET reporting does not distinguish between grade of ulcer 2, 3 or 4 to indicate the level of harm. If this was facilitated there would be no need to continue with 6 monthly spot audits. 2

3 The figures above include all ulcers both those defined as avoidable and unavoidable. There is a need to agree a governance structure for the decision making process on whether an ulcer is avoidable or unavoidable. A process chart is presented in appendix 4 for consideration and agreement. The process suggests that a SSEA occurs in the event of a grade 2 developing in a ward. An SBAR template would aid the decision making and ensure an objective decision is made, and if the ulcer was avoidable a Datix incident would be raised. Financial Implications Mechanism have been set up to establish if there are gaps between the aspirations of the policy to provide the best evidence based practice and the realities of practice within the community setting. If gaps are identified in the resources required to provide evidenced based practice and care, a financial paper will be required to alert the Executive Management Team of the requirements. Timetable for Implementation and Lead Officer By March 2014 a revised improvement plan will be implemented to include community health and social care teams. By March 2015 zero incidence of hospital acquired grade 2 or above ulcers will be achieved within in-patient settings. Eileen McKenna (Associate Nurse Director) is the accountable officer. The lead officer is Sue Mackie (Senior Nurse, Practice Development). Consultation Informing, Involving and Consulting with Public and Staff Each Directorate and CHP area will be informed of their results and be involved in developing local action plans through the Tissue Viability Network and the community sub group. 3. RECOMMENDATIONS The Improvement & Quality Committee are asked to Note the findings of the paper. Acknowledge the success to date of the hospital and community pressure ulcer prevention improvement plan. Support the update of GDET, and use of QlikView and Datix to record and collect data on both Avoidable and Unavoidable - this may require a change in the reporting template structure Grade 2 and above pressure ulcers Sue Mackie Senior Nurse Practice Development October 2013 Eileen McKenna Associate Nurse Director 3

4 Appendix 1 Four Phase Improvement Plan PHASE 1 Action Status PHASE 3 Action Profiling beds, soft form premier high specification foam mattresses and 2-6 ACTIVE systems per ward as standard in all wards across NHST Completed Developed NHST Pressure Completed / Ulcer Prevention Policy review Ulcer Prevention Policy 2012 Cascade trainer education full study day Completed Community Nursing to participate in prevalence and incidence monitoring First Study undertaken, second due in May 2013 SBAR reporting Safety Cross Policy Development and roll out December 2012 PHASE 2 Action SGHD Tissue Viability Programme Spread the pressure ulcer Prevention Clinical Quality Indicator Report Ulcers developing ward on AIM system Introduce competency checklist Ensure staff complete the NES education resource available online Implement outcome indicators Incorporate patients at risk Status in daily safety briefs Implement new documentation Patient/carer leaflet NHST working group to monitor and explore new interventions and develop guidelines for heel prevention and continence guide Improvement event for managers Implement SKIN Bundle and Safety cross Status Completed Completed Ongoing Completed In progress, Ongoing Now integrated With Clinical Dashboards Ongoing Completed Completed Completed Completed PHASE 4 Action Collaboration with Independent Sector care homes in Tayside to reduce the overall pressure ulcer prevalence Collaboration with local authorities to ensure social care officers are aware of pressure ulcer prevention and care strategies HOTSPOTS identified from each survey focused education HOTSPOT where education and practice are good identified and supplied with ACTIVE systems Theatre practice and education Ongoing In progress 4

5 Appendix 2 Results of Hospital Study May

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15 PRESSURE ULCER SAFETY CROSS Ward / area/ Health centre: Month: Grade 1 ulcers mark with a GREEN cross discuss at safety brief Grade 2 and above ulcers - mark with a Red Cross and record on GDET Complete the SBAR below, and if the ulcer was avoidable; report on DATIX If a grade 3 or 4 develops from a grade 2 update the previous entry on GDET 15

16 Date Patient ID Grade SBAR PRESSURE ULCER INCIDENT REPORTING TEMPLATE Ward / Health Centre Date 16

17 S SITUATION - Patient developed a pressure ulcer whilst under this ward/dn/ areas care Please circle the Grade of ulcer: Grade 2, Grade 3, Grade 4 Site of ulcer Was the ulcer caused by a device? Y / N B Do not include moisture lesions or excoriation as a pressure ulcer BACKGROUND - Please circle the patient circumstances and consider Skin condition on admission No red areas, Blanching erythema Non blanching erythema Grade 1 Grade 2 Grade 3 Grade 4 Suspected Deep Tissue Injury Situations where pressure could not be relieved or perfusion could not be improved Fall or injury prior to admission, bruising, redness damage to area on admission Patient receiving end of life care Prolonged length of time in theatre and unable to re-positioned hours Perfusion/ Haemo dynamic instability for hours A 1 Patient declining care- state which aspects, i.e. re-positioning nutrition, continence care,, Is there documentation that show that the patient / carer has been informed of the potential consequences? Other factors ASSESSMENT Was there a risk assessment and skin assessment within 6 hours of admission Did the patient have a SKIN care record Was the re-positioning interval on the SKIN care record appropriate to the level of risk? Was the SKIN bundle fully completed and care given according to the prescribed times? 2 What support surface was in place Profiling bed High specification foam mattress Dynamic Mattress Was the correct support surface put in place once the risk was identified? 3 Was the patient seated for less than 2 hours at any one time as per policy (check SKIN ) N/A 17

18 4 Heel protection - If the pressure ulcer developed on the heel; was there a method documented to provide heel protection N/A Pain - If pain was preventing re-positioning; was there a plan of care to alleviate pain N/A 5 Nutrition Patient MUST score 1 or above Was there a plan of care to improve the patients nutritional and hydration status if appropriate) N/A Is there evidence that the plan of care was actioned appropriately? N/A 6 Moisture If the patient's skin is exposed to moisture i.e. excess sweat, incontinence, were all possible interventions planned and actioned to prevent moisture damaging the microclimate of the skin? N / A 7a Were all intervention 1-6 carried out Were there circumstances where care could not be given? Explain below: - NOTE In the case of a patient declining interventions on more than one occasion, this must be documented in the records, and also written that the patient was informed of the potential for a pressure ulcer to develop, if this is not written, then the ulcer was avoidable. 18

19 7b Were there any other underlying predisposing circumstances as stated in Background to consider? Please state:- 8 In my professional judgment, the documented plan of care and interventions to prevent a pressure ulcer developing were appropriate for this patient and this pressure ulcer was UNAVOIDABLE AVOIDABLE (circle) If Avoidable, record on DATIX, consider SCEA for grade 3 or 4 ulcers and Red incidents Signature of Head of Nursing Date: Signature of SCN Date: 19

20 Definitions Department of Health, England Definitions of Avoidable & Unavoidable Pressure Ulcers Defining avoidable and unavoidable pressure ulcers Background The Department of Health (DH) has been asked to clarify what an avoidable pressure ulcer is in regards the nurse sensitive outcome indicators. DH has researched the availability of definitions, finding that there are a limited number of definitions in existence to draw from. The Wound, Ostomy and Continence Nurses Society of the US have produced a position paper, which points to a clear definition of avoidable and unavoidable pressure ulcer However, we are using a modified version of the Avoidable and Unavoidable Pressure Ulcers definitions from the Centres for Medicare and Medicaid (CMS) 2004, to keep in with UK policy terminology. The modified definitions are: Avoidable Pressure Ulcer: Avoidable means that the person receiving care developed a pressure ulcer and the provider of care did not do one of the following: evaluate the person s clinical condition and pressure ulcer risk factors; plan and implement interventions that are consistent with the persons needs and goals, and recognised standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unavoidable Pressure Ulcer: Unavoidable means that the person receiving care developed a pressure ulcer even though the provider of the care had evaluated the person s clinical condition and pressure ulcer risk factors; planned and implemented interventions that are consistent with the persons needs and goals; and recognised standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate; or the individual person refused to adhere to prevention strategies in spite of education of the consequences of non-adherence Guidance: 1 20

21 In determining whether the pressure ulcer is avoidable; commissioners, regulators or others could request to see evidence demonstrating the actions outlined in the avoidable definition are demonstrated. 1 Position Paper: Avoidable and Unavoidable Pressure Ulcers, Wound, Ostomy and Continence Nurses Society (WOCNS) March Accessed 24/08/ Skin lesions as a result of skin failure are not pressure ulcers. Reference Black et al 2011 Pressure Ulcers: Avoidable or unavoidable? Results of the National Pressure Ulcer Advisory panel Consensus Conference Ostomy Wound Management 2011;57(2):