BOARD OF DIRECTORS PAPER COVER SHEET Meeting Date: 1 st December 2010 Agenda Item: 9 Paper No: E Title: Management of Pressure Ulcers Purpose: For Information Summary: This paper provides a report on the management of pressure ulcers in quarter 2 of 2010-2011. Year on year the number and severity of acquired pressure ulcers is reducing however the number of inherited pressure ulcers is increasing. As numbers reduce the percentage of unavoidable pressure ulcers appears to be increasing. Recommendation: The Board of Directors is asked to note this Report. Prepared by: ANDREA GRAHAM Tissue Viability Nurse Specialist Presented by: MARTIN SMITS Director of Nursing & Patient Services This report is relevant to: (Please tick relevant box) Assurance Framework Risk Register I/D No. Healthcare Standards: Financial implications YES / NO Please specify which standard Monitor compliance Human Resources implications YES / NO Internal monitoring Legal implications YES / NO
POOLE HOSPITAL NHS FOUNDATION TRUST E Report to the Board of Directors- 1 st December 2010 MANAGEMENT OF PRESSURE ULCERS Quarterly Performance Report Quarter 2 July 2010 September 2010 1. INTRODUCTION This report provides the details of the Trust s performance on pressures ulcers during Quarter 2 of 2010-2011 2. SUMMARY Table 1 gives a summary of the quarter s pressure ulcers both acquired in the Hospital and inherited by the Hospital. Table 1 150 100 50 0 Jul-10 Aug-10 Sep-10 Grand Total acquired 12 10 15 37 inherited 34 45 56 135 3. PRESSURE ULCER INCIDENCE AND PREVALENCE Table 2 shows the incidence and prevalence of pressure ulcers in the first two quarters of 2010-2011. The definitions of prevalence and incidence are:- Prevalence Incidence The total number of people in a defined population with pressure ulcers at a specified time. The total number of people developing a new pressure ulcer who are admitted to hospital over a set period of time. Table 2 20010/11 Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Incidence Prevalence 1.11% 0.63% 0.49% 0.59% 0.49% 0.73% 3.13% 1.85% 2.82% 2.25% 2.69% 3.41%
4. MONITORING PERFORMANCE The requirement from the Primary Care Commissioners is a continuous improvement to reduce the number of avoidable pressure ulcers; in particular a reduction in avoidable Grade 3 and 4 hospital acquired pressure ulcers. The national paper from the Department of Health (DoH 2010) Your Skin Matters - High Impact Actions for Nursing and Midwifery, the Essential Collection has also had an impact upon how pressure ulcers are reported. Table 3 Acquired pressure ulcers by Specialty ACQUIRED CCG Acquired Specialty July-10 Aug-10 Sept-10 Grand Total Medical Elderly 4 5 1 10 Emergency Gen Med 2 5 7 Oncology 2 3 5 Medical Total 8 8 6 22 Surgery Critical Care 1 1 Gen Surg 1 1 3 5 Trauma 2 1 6 9 Surgery Total 4 2 9 15 Grand Total 12 10 15 37 Table 4 Acquired pressure ulcers adjusted per 1000 bed days per Specialty no. of sores per 1000 bed days no. of sores per 1000 bed days no. of sores per 1000 bed days total for QTR no. of sores per 1000 bed days Speciality July- 10 Aug- 10 Sept- 10 Elderly 4 0.99 5 1.31 1 0.28 10 0.87 Emergency 0 0 0 0 0 0 0 0 Gen Med 2 0.59 0 0 5 1.79 7 0.72 Oncology 2 2.16 3 2.85 0 0 5 1.65 Critical Care 1 3.76 0 0 0 0 1 1.23 Gen Surg 1 0.48 1 0.45 3 1.40 5 0.78 Trauma 2 0.96 1 0.46 6 2.89 9 1.42 Total for Hospital 12 0.79 10 0.62 15 0.97 37 0.79 Standard Deviation 1.28 1.05 1.14 0.55
Table 5 Number of acquired pressure ulcers summary No of pts who acquired pressure ulcers per 1000 bed days 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Reporting pressure ulcers in terms of per 1000 bed days is relatively new for many trusts within the UK, reported figures from acute trusts range from 0.94 up to 4.37, with targets in some trusts set at 3 on their dashboard. The trust wide figure for the QTR is 0.79 per 1,000 bed days, this demonstrates we are currently performing very well. Table 6 Acquired pressure ulcers by age group AGE Category July-10 Aug-10 Sept-10 Grand Total Patients who developed pressure ulcers (Acquired) 19-65 3 3 66 and above 9 10 15 34 acquired Total 12 10 15 37 5. CONTRACT NHS Bournemouth and Poole have set a target that the number of acquired pressure ulcers is reduced. The requirement last year was a reduction in the number of patients acquiring pressure ulcers (grade 2 and above) by 10% compared to the previous years baseline. For this quarter the paper bases the figures on the same target a 10% reduction against the previous year. This has been achieved with 37 patients developing pressure ulcers during the QTR, a 26% reduction. Number of patients who acquired pressure ulcers QRT 2 09/10 50 QRT 2 10/11 37 The number of patients admitted into the trust with existing pressure ulcers has increased when compared to 2009/10. Number of patients admitted to trust with existing pressure ulcer damage QRT 2 09/10 86 QRT 2 10/11 135
6. GRADE OF PRESSURE ULCER Predominately the acquired pressure ulcers were of a grade 2. Grade July-10 Aug-10 Sept-10 Total 2 12 9 14 35 Number of patients who 3 1 1 2 acquired pressure ulcers 4 Total 12 10 15 37 Unavoidable Acquired Grade 3 on Surgery A patient developed a Grade 3 pressure ulcer on B4, this was categorised as unavoidable. The patient is in the end stages of life and was on a Liverpool Care Pathway for 13 days prior to pressure ulcer development. It had taken time to control pain and therefore the patient was only repositioned for comfort, also during the time the patient was only able to eat and drink small amounts. All appropriate interventions were taken in accordance with patient choice and comfort. Avoidable Acquired Grade 3 on Medicine A patient developed bilateral Grade 3 pressure ulcers on Arne ward and Kimmeridge ward. Information from the Medical team is still required in order to complete the root cause analysis process however; from the nursing documentation it appears opportunities to implement preventative interventions were missed. Action plans have already been implemented on both wards. In comparison, the severity of pressure ulcers inherited into the trust has remained greater with 13 patients having Grade 3 and 4 pressure ulcers. Grade July-10 Aug-10 Sept-10 Total Number of patients 2 33 38 51 122 admitted to trust with existing pressure ulcer 3 1 6 4 11 damage 4 1 1 2 Total 34 45 56 135 7. TRENDS IN THE DATA A comparison to the previous QTRs show a reduction in pressure ulcers. Number of patients who acquired pressure ulcers QRT 1 09/10 70 QRT 2 09/10 50 QTR 3 09/10 36 QTR 4 09/10 65 QTR 1 10/11 46 QTR 2 10/11 37
The reduction in hospital acquired pressure ulcers is reflected across all the Clinical Services Divisions. The Medical Service Division continues to have the most hospital acquired pressure ulcers but still achieved a significant reduction. Number of patients who acquired pressure ulcers Medical QRT 2 09/10 32 QRT 2 10/11 22 Surgery QRT 2 09/10 18 QRT 2 10/11 15 Pressure ulcers increased on TAU in September; there is no data to understand this trend, looking at the figures last year only 1 pressure ulcer occurred on TAU in September 09. It is possible that patient acuity and dependence has increased but there is no data to support this suggestion. There has also been an overall increase in the number of reported pressure ulcers from the General Medical specialty, no one ward appears to be forming a trend within the data. Looking at figures from last year there were a total of 3 pressure ulcers for quarter 2 in 2009/10 compared to a total this quarter of 7 pressure ulcers. It is possible that patient acuity and dependence has increased but again there is no data to support this. The Elderly specialty has significantly reduced its pressure ulcers this QTR compared to the previous year; in 2009/10 a total of 25 pressure ulcers were reported and this QTR a total of 10 pressure ulcers have been reported. Reporting levels for the QTR have been maintained at 80% accuracy which is comparable to last year. 8. CONTRIBUTORY FACTORS Patient Age Across the trust the average age of patients developing pressure ulcers remains over 80 years with a range of 60 years to 99 years. Workload Without doubt the prevention of pressure ulcers is dependant upon physical nursing intervention and therefore man power. How increased workload from patient dependency and acuity affects pressure ulcer incidents is not currently measured. In addition the amount of and the severity of inherited pressure ulcers into the trust has increased the workload of the wards and the tissue viability service. Tissue viability Patient Contacts and Activity No. of patients No of visits seen July-10 81 146 Aug-10 57 100 Sept-10 86 157 Total 224 403
Table 7 Tissue Viability workload by type Patient contacts by wound type 120 100 80 60 01/09/2010 01/08/2010 01/07/2010 40 20 0 Foot Ulcer Leg Ulcer Moisture Lesion Not a sore Pressure ulcer Surgical Wound Trauma Wound Other 8. WHAT HAS BEEN LEARNED AND ACTION PLAN Early intervention The tissue viability team has heightened awareness to keep pressure ulcer prevention high on the clinical agenda. This has been achieved via the Pressure Ulcer Reporting Hotline and the development and introduction of the new Pressure Ulcer Prevention Strategy care plan (PUPS). Both the Hotline and PUPS have been shown to facilitate the early detection of patients who are at risk and triggered appropriate and specific care interventions. Both have prevented pressure ulcers and limited pressure ulcer severity. The tissue viability team see all patients who acquire pressure ulcers and all patients with inherited pressure ulcers of grade 3 and 4. Staff Education Knowledge on how pressure ulcers occur and how to prevent them reduces the incidents of pressure ulcers. Education on pressure ulcer prevention has from April 2010 been provided to clinical staff on induction. Education on pressure ulcers is currently provided via the ward link nurse (ANT) and opportunistically on patient consultation by the tissue viability team. An open learning education package is being developed but education on tissue viability and therefore pressure ulcers is not currently mandatory for clinical staff. 9. CHALLENGES As a result of cost efficiency savings the tissue viability service has been reduced by a total of 12 hours. The Tissue Viability team aim to categorise all acquired pressure ulcers as avoidable or unavoidable, this will increase the amount of time spent upon investigation of grade 2 pressure ulcer incidents.
The tissue viability service now follows up all patients who hospital acquired pressure ulcers including Grade 2; this has increased the clinical workload significantly, but has proved to be beneficial in the prevention of increased pressure ulcer severity. A simple measure of comparing pressure ulcer incidents to patient acuity and/or ward workload has not as yet been realised. There has been an increased demand for tissue viability activity in complex wound (non-pressure ulcer) management; this activity deflects the pro-active interventions in pressure ulcer prevention. Additional Tissue Viability Activity The tissue viability service has identified savings across the trust in terms of wound management products/dressings; this is part of the ongoing work on the wound management formulary. 10. ACTION PLAN The Tissue Viability Team is working to the following plan in quarter 3: Pressure Ulcer Reporting Hotline to continue to support reporting across all wards and departments within the trust. Tissue Viability team to categorise all acquired pressure ulcers as avoidable or unavoidable. A means of comparing pressure ulcer incidents to patient acuity and/or ward workload warrants further investigation. The Department of Health High Impact Skin Matters needs further consideration and implementation. How to inform wards on their performance on pressure ulcer incidents needs to be finalised. The NICE CG 29 Prevention and Treatment of Pressure Ulcers is currently being reviewed and the new clinical guidance is expected to be published in February 2011 this will need evaluation and implementation. It is planned to repeat the PCT commissioners audit on pressure ulcers in November 2010. To complete the update on the Trust s pressure ulcer prevention policy. Andrea Graham Nurse Consultant Tissue Viability 19 th November 2010 Martin Smits Director of Nursing & Patient Services