NHS Lothian s Pressure Ulcer Improvement Journey Ruth Ropper, Lead Nurse Tissue Viability Jacqui Pringle, Quality Improvement Facilitator Shona Baird, Tissue Viability Nurse Watch this presentation on Twitter https://tinyurl.com/yakgr8sq
WRITE, IMPRINT OR ATTACH LABEL Surname... Forenames DoB.. CHI No... Sex.. Location USA - 2000 s Institute for Healthcare Improvement 2008-2010 2008-2010 2002 2008 Adapted Waterlow Pressure Area Risk Assessment Chart More than one score/category can be used: 10+= At Risk : 15+ = High Risk : 20+ = Very High Risk Undertake and document risk assessment within 6 hours of admission or on first home visit. Reassess if there is a change in individual s condition and repeat regularly according to local protocol. Scoring Sex Male 1 Female 2 Age 14 49 1 50 64 2 65 74 3 75 80 4 81+ 5 Build/Weight for Height (BMI=weight in Kg/height in m 2 ) Average BMI 20-24.9 0 Above average BMI 25-29.9 1 Obese BMI > 30 2 Below average BMI < 20 3 Continence Complete/catheterised 0 Incontinent urine 1 Incontinent faeces 2 Doubly incontinent (urine & faeces) 3 Skin Type Visual Risks Area Healthy 0 Tissue paper (thin/fragile) 1 Dry (appears flaky) 1 Oedematous (puffy) 1 Clammy (moist to touch)/pyrexia 1 Discoloured (bruising/mottled) 2 Broken (established ulcer) 3 Mobility Fully mobile 0 Restless/fidgety 1 Apathetic (sedated/depressed/reluctant to move) 2 Restricted (restricted by severe pain or disease) 3 Bedbound (unconscious/unable to change position/traction) 4 Chair bound (unable to leave chair without assistance) 5 2006 2005 2004 - IHI 100,000 lives campaign
Collaborative working
Facts and figures about Lothian Lothian Population approx. 860,000 Area = 1,725 km² or 700 square miles TV Team Size Adult services 5.35 WTE (6) Children's services 1.0 WTE (1) NHS Lothian UK s second largest Health Authority Approx 29,000 staff 21 hospitals, including 4 major teaching hospitals 130 GP practices 2 Prisons Approx 160 Care Homes
2011-2012 The Early Days Count of pressure ulcers developed in NHS Lothian hospitals reported on Datix 40 National Tools in use Adapted Waterlow risk Assessment Grading tool with Grade 1-4 Count of pressure ulcers 35 30 25 20 15 10 5 Baseline Median Extended Median Target Median 0 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Pressure Ulcer Reporting on Datix incident System 2011 - PU Grade 2 4 in Medical Directorate only testing small 2012 - All areas started to report not accurate
2012-2013 Different ideas, different teams! Tissue Viability Service (TVS) One to None Project Linked to SPSP targets Acute inpatients/care Homes SSKIN bundle Education/Link Nurse focus Awareness raising Quality Improvement Support Team (QIST) Changes linked to SPSP targets Documentation Multiple Bundles tested (Falls, SSKIN etc.) Care rounding developed and tested - hospitals Datix reporting not accurate, challenges of two different work streams
2014: Joint working TVS and QIST Cross team working Skills set TVS PU assessment, Grading, SSKIN bundle elements QIST Quality processes, tools and support, data analysis, PSDA cycles National Reporting 300 days between PU, 95% Harm free care, acute only, Safety crosses Whole organisation working together Datix reporting - more consistent, reliable, learning
Care Rounding Tool with SSKIN bundle elements Registered Nurse to prescribe frequency of Care Rounding [CR] based upon risk assessment and clinical condition Site: Ward: date: 1hrly 2hrly (please circle) 3hrly 4hrly Signature & Print Time of Care Rounding 08.00 am.. 24 hour period----- 07.00 am Pressure Area Care Elimination Food Fluid & Nutrition Falls Pain General Name DoB Addressograph, or Unit no. / CHI Codes ( Y) Yes, (N) No, (N/A) not applicable, (AS) Asleep (I) Independent, (NW) not on ward, (TH) at theatre. 08.00 am 24 hour period 07.00 am Waterlow score less than 10 low risk requires only a daily skin review,: Outcome of skin review use codes: Due to low risk status move to have you mobilised since last CR) Waterlow 10+ - Visual skin check Outcome of skin review: (R) Red, (B) Broken, NAD, If any changes in outcome of skin check, please review frequency of CR &/or re-assessment of Waterlow Score Vulnerable areas? Heel (L) (R ), Hips (L) (R), Sacrum, Spine, Other.. ( Circle areas if red or broken skin) review Tissue Viability intranet site for guidance Positioning (R) right side, (L) left side,(b) Back (C) Chair Mattress Type please circle Pentaflex if other type Seat / Cushion Reflextion if other type please state: Have you mobilised since last CR Do you need the toilet? Is the patient Continent of urine (at time of Care Rounding) Continence Product changed Catheter Care performed Catheter Bundle updated daily Is (Position patient below continent of faeces (at bladder, time of No Care more Rounding) than Bowel 2/3 full, function Connections monitored intact) Would you like a drink? Ensure fluids are within easy reach Fluid Balance Chart (updated if in use?) When did you last eat? Position catheter below the bladder/ no more than 2/3 full/ connections intact Observe bowel function and Update daily B Breakfast, L Lunch, D Dinner, S Snack, NBM Nil by Mouth. ( Food Chart to be updated if applicable ) Oral Hygiene Performed Appropriate Footwear? Walking aid available if applicable Area de-cluttered falls Bed rails in use? U up, D Down, N/A Are you in pain? Analgesia Given Pain Are you comfortable? PVC/ Cannula observed Observe for signs of inflammation / swelling at every CR session. Bundle to be updated daily Anything else I can do for you? Buzzer within easy reach Will be back in specify hrs Personal Care? circle & specify time(s): Bed Bath, Shower, Bath, Basin Wash, Shave, Hairwash, Initials Declined Skin Surface Keep moving Incontinence Nutrition
2014 2016 - HSCP and Community Focus Care rounding for DNs PDSA process incl. testing 1) Document layout 2) Implementation strategy 3) Roll out across Lothian Baseline findings: Inconsistency Gaps in screening tools Variance in assessments Led to Assessment booklet being developed
Staff Experience - Community D/N Managers We have made good progress, including the core documents made it more acceptable and user friendly for practitioners. The document will allow staff to record interventions smoothly and will provide evidence of good record keeping. D/N Potential to improve and standardise documentation. Pleasantly surprised myself with the usefulness of the tool Patients are saying that they really like Care Rounding
Where Pressure Ulcers developed 2016-2017 Grade 2-4 All Pressure Ulcers Reported 01/04/16-31/03/17 250 100% 90% 200 80% 70% 150 60% 50% 100 40% 30% 50 20% 0 In Hospital Own Home - Not known Own Home - Known Nursing Home/Care Home Another hospital outwith NHS Lothian Pressure Ulcer Developed In 10% 0% Total Cumulative %
2016 - Community Focused PU Reviews 41 patients documented PU Reviews Community 1st Jan - 30th April 2016 52 PUs (Grade 1-4) 17 on DN caseload 8 new wounds 9 deteriorations 15 not on DN caseload 10 24% 4 10% 1 3% 26 63% Own home Care Home Hospital Not recorded 3 seen during other assessments
2016 2017 Community - Deteriorating Patient work 90% of PU incidents linked to deterioration as Primary factor Aims: 1. Improve recognition and management of deteriorating patients 2. Reliable: i. Recognition, assessment and care delivery ii. Screening, NEWS and SIRS iii. Communication and escalation 3. Prevent Hospital admissions
2017 2018 Community - Deteriorating Patient work Learning: Wound related sepsis PU secondary to bed rest/recovery from infection at home Chronic deterioration - increased frailty, recurrent infections Testing identified: Acute presentation of new illness Exacerbation of chronic illness Outcome Regular physiological assessment
Community - Current Challenges and Solutions Challenge Patients Report no concerns with skin Non-concordant with intervention Staff No evidence of skin checked Prolonged periods with no formal assessment (Waterlow) No written evidence that: Patient information had been provided Extra documents had been initiated Solutions Cognitive impairment screening tools Care Rounding questions: Concern with cognition? Have you assessed the person for new, existing or deteriorating skin condition? Does the person report any skin concerns? If at risk clarify what information provided to patient Record date of last Waterlow
2016 - Acute Focused PU work New Target 50% reduction Grade 2-4 PU in-patients Consistent reporting on Datix SAE Template for PU in testing Adapted Red Day Review Tool includes community Share learning on individual hospital sites
2016-2017 Acute Challenges Electronic patient assessments and records (Trak) Paper lite vs. Paperless vs. Paper PU developing in wards who have made improvements Led to : Project initiation document for focused PU work in Lothian to test improvement ideas
Acute - Driver Diagram and Pareto Reliable care processes Availability of equipment Patient & staff involvement Learning for improvement DRIVERS Risk assessment Skin assessment Care planning Care Rounding Transfer of information Standardised and reliable process for obtaining equipment Timely delivery to the patient process map from identification to patient receipt, including times from one stage to the next, and experience information Opinions are sought from patients that lead to improvements Patient Information Reliable use of the Red Day Review Tool Robust learning from an event (and expert support) Rapid feedback from an event on ward
2017 2018 Acute Short-term focused work 4 Wards 2 hospital sites Medicine of Elderly x 2 Medical Admission Unit x 1 Intensive Care x 1 Review of 5 sets of notes Patient experience Staff education analysis Equipment process mapping Patient journey mapping Datix reviews Themes What is fed back to staff
Short-term focused work - 3 month findings (4 Wards) 1) Risk Assessment Waterlow 79% of patients assessed within 6 hours of admission 90% completed but 84% not accurate 2) Care Rounding - 53% repositioning linked to risk level 3) Care planning - 47% had an electronic Care Plan 4) Staff education lacking in confidence 5) Equipment Access and availability issues 6) Patient/carer involvement - 0% pressure ulcer prevention leaflet
Equipment Bed turnover Timely availability of mattresses Decontamination/cleaning requirements Pillows for maintaining patient position People Patient Acutely unwell/sick Lack of mobility Co-morbidities Concordance Contraindicated risk of movement Process Waterlow - issues with accuracy of score Care Rounding frequency not matching risk SSKIN Bundle incomplete Reliability of position changes Fishbone Factors Need for specialist equipment Ordering various options Knowledge of available equipment (API/static mattresses) Lack of patient/family involvement Nursing Time pressures Competing priorities Ward/unit acuity Workload Staffing levels Care planning interventions not reliably undertaken Pressure Ulcer Development Patient turnover Misunderstanding of SSKIN elements IT inability to see previous assessment Lack of information No regular feedback Availability of PC s for documentation Handover Under appreciation of risk of seriousness Patient flow Transfer Lack of awareness re: pressure ulcer recording Evaluation of risk assessment/care plan Discharge Lack of education (Learnpro NES module) Predominately nurse-led assessment Patient leaflet Lack of awareness of tissue viability website Management Communication Knowledge
2017 2018 Current Challenges Roll out of Trak EPR assessment and documentation SSKIN elements - Lack of knowledge Less PU developing = Reduced skills in grading Busy wards - reduced staffing levels, increased patient acuity Patient/carer involvement new leaflet ready for launch on Stop PU day (16 th Nov) Information not transferring with patient
Run chart: 22% reduction in PU rate since Dec 2014
Next Steps 2017-18 Focused work continuing Identify gaps Use PDSA to test improvement ideas If improves practice spread to other wards Review if improvement sustainable after work stops Share learning across sites Testing Top tips for Waterlow Check Skin visual aid at bedside Promote Prevent PU leaflet Equipment processes Education for staff on skin assessment and care planning SSKIN bundle knowledge