Literature Evaluation

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT SPB S6 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT Pressure ulcer prevention in hospitals:

a successful nurse-led clinical quality improvement intervention S usceptibility to wounds, including pressure damage, becomes more common after the age of 65, owing to thinning of the epidermis and diminishing immunity.

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As the UK has an ageing population, wound care is a public health concern. Posnett and Franks (2008) reported that one in five hospital inpatients in the UK has a pressure ulcer. Pressure ulcers are an area of concern in Denmark, which also has an ageing population. Odense University Hospital (OUH) is one of the four university hospitals in Denmark. All medical specialties are represented. OUH is one of the largest education and training centres in the Region of Southern Denmark, and has a close collaboration with the University of Southern Denmark. The hospital has two units: one in the city of Odense and one in Svendborg. In 2010, OUH conducted a prevalence study on pressure ulcers, which showed it to be 32.3% among inpatients. If category 0 pressure ulcers were excluded, the prevalence was 17.3% (Dorsche and Fremmelevholm, 2010). This result prompted action and in 2012 a quality improvement intervention was planned at OUH with the aim of reducing pressure ulcers at the hospital by implementing the recommendations from the Danish Safer Hospital Programme in clinical practice (Dansk Selskab for Patientsikkerhed, 2015a). Background Between 2010 and 2014 there was a focus on prevention of adverse events and patient safety at hospitals in Denmark.

The Region of Southern Denmark—one of 5 regional health authorities—and OUH had patient safety strategies, and one of the aims was the elimination of pressure ulcers (> category 0) during hospitalisation in the region by the year 2014 (Odense University Hospital, 2011). The Danish Safer Hospital Programme was introduced in 2010 with bundles of recommendations to improve patient safety in hospitals in various clinical areas. Five hospitals participated in the programme and one of the aims was to prevent pressure ulcers developing in hospitalised patients (Dansk Selskab for Patientsikkerhed, 2015b). The pressure ulcer bundle was incorporated in guidelines for the region but each hospital decided on its own quality improvement method. OUH was not one of the hospitals in the Danish Safer Hospital Programme. The hospital planned a quality improvement intervention by using the recommendations in the pressure ulcer bundle, and used its own quality improvement method.

Aim The aim of the quality improvement intervention was to reduce pressure ulcers by 50% at the hospital and have no pressure ulcers at category 3 (full thickness skin loss) or higher. Pressure ulcers were graded according to the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP) and Pan Pacific Pressure Injury Alliance system (EPUAP et al, 2014).

Method Inspired by different quality improvement methods, a quality improvement intervention for pressure ulcer prevention was planned at the hospital. A steering committee was established with leading nurses (executive director and three head nurses), a clinical nurse specialist in pressure ulcers and an experienced quality consultant. The elements of this quality improvement intervention are discussed below.

Establishment of a pressure ulcer specialist nurse A specialist nurse dedicated to pressure ulcer prevention was established at the hospital for a period of 2 years with funds from TrygFonden, a Danish foundation to promote safety. Together with the steering committee, the specialist nurse had overall responsibility for implementation of the ABSTRACT A pressure ulcer prevalence of 17.3% at Odense University Hospital in Denmark in 2010 prompted action and a quality improvement project was planned. This had two aims: to reduce pressure ulcers at the hospital by 50% and to have no pressure ulcers at or above category 3. An project was established with a steering committee, a pressure ulcer specialist nurse, local dedicated nurses and nurse assistants to implement a pressure ulcer bundle in clinical practice at all departments at the hospital. Six years later the pressure ulcer prevalence was down to approximately 2% and in 2018 only one stage 3 pressure ulcer occurred in the hospital. Pressure ulcer prevention is now incorporated into clinical practice in all departments at the hospital.

Key words : Pressure ulcer ■ Prevention ■ Prevalence study ■ Quality improvement ■ Pressure ulcer specialist nurse Aase Fremmelevholm, Wound Specialist Nurse, Department of Plastic Surgery, Odense University Hospital, Odense, Denmark Knaerke Soegaard , Quality Consultant, Department of Plastic Surgery, Odense University Hospital, Odense, Denmark, Accepted for publication: December 2018 2019 MA Healthcare Ltd British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT SPB S8 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT guidelines in clinical practice in all 50 departments at the hospital and for the establishment of an internal organisation to support implementation. The specialist nurse also became a consultant that every nurse or nurse assistant at the hospital could contact for supervision and specialist advice in the prevention and treatment of pressure ulcers and other skin damage, such as incontinence-associated dermatitis. The pressure ulcer nurse was very visible in the departments at OUH and arranged training and bedside instruction in the treatment of pressure ulcers. In 2016, the role of pressure ulcer specialist nurse was made permanent.

Steering committee and dedicated local clinicians The steering committee supported the pressure ulcer specialist nurse and encouraged a focus on pressure ulcer prevention among leading nurses at the hospital, for example by initiating audits on documentation of pressure ulcer risk assessment.

The committee also supported a theme day on pressure ulcer prevention once a year, as well as establishing an internal structure with a nurse or nurse assistant dedicated to pressure ulcer prevention in all 50 departments at the hospital. These nurses and nurse assistants received one day of training in risk assessment, categorisation of pressure ulcers, and training in the pressure ulcer prevention guidelines from April to July 2012. Along with the leading nurse in their departments, their job was to secure implementation of the guidelines and pressure ulcer prevention by training their colleagues. The pressure ulcer specialist nurse planned meetings every third month for this group of dedicated nurses and nurse assistants to make time for networking, mutual inspiration and discussions of difficulties in implementation.

Guidelines for pressure ulcer prevention The pressure ulcer guidelines for the southern Denmark region are based on the Braden scale (1988), the pressure ulcer bundle from the safer hospital programme and the EPUAP guidelines (EPUAP, 2014). The guidelines prescribe early risk assessment of pressure damage and describes prevention methods and how to document observations and preventive actions (Region of Southern Denmark, 2016). The pressure ulcer bundle from the Danish Safer Hospital Programme (Dansk Selskab for Patientsikkerhed, 2015a) states:

■■ All patients must be risk assessed on admission ■■ Patients at risk must be risk assessed every day ■■ Patients at risk must be evaluated for nutritional risk and patients at nutritional risk must have a nutrition plan ■■ Patients at risk must be mobilised as much as possible by repositioning and the use of pressure-distributive aids must be considered.

By the end of the Safer Hospital Programme an analysis concluded that the use of the pressure ulcer bundle can reduce pressure ulcers in hospitals by 50% (COWI consulting group, 2014). Adhering to the programme is time- consuming, but time is saved if the patients develop fewer pressure ulcers.

Pressure ulcer prevention theme days Every year since 2014 the hospital has arranged a theme day with a focus on pressure ulcer prevention. The programme consists of presentations from different departments at OUH and presentations about clinical topics from the pressure ulcer specialist nurse. Since 2016 colleagues from primary care have been invited to attend, and during the past 3 years there have been presentations from primary care staff. In 2016 a theme day for clinicians from the other five hospitals and primary healthcare areas in the southern Denmark region was held. In 2018, OUH hosted a presentation by Professor Dimitri Beeckman, President-Elect of EPUAP.

Monitoring Between 2012 and 2015 the number of patients with documented risk assessments at admission and documented daily skin checks was counted in all departments at OUH.

The pressure ulcer incidence was difficult to measure due to a lack of consequent documentation of pressure ulcers. In Denmark there is a system to register adverse events but it is well known that not all adverse events are registered. OUH therefore monitors pressure ulcers in two ways; pressure ulcer prevalence and counting days with no pressure ulcers.

Pressure ulcer prevalence The overall pressure ulcer prevalence was examined once a year by the pressure ulcer specialist nurse to see if the prevalence would decrease year on year. Due to difficulties with documentation we decided to measure by prevalence knowing that the measurement method was not ideal.

Patients who already had pressure ulcers at admission were counted as well as those whose pressure ulcers developed during hospitalisation. The prevalence study was initially inspired by a method prepared by the Videncenteret for Sårheling—a wound healing knowledge centre at Bispebjerg Hospital in the Capital Region of Denmark (Bermark, 2009). Inpatients were examined using the following inclusion and exclusion criteria:

Inclusion criteria ■■ All inpatients of more than 15 years of age in all hospital departments, including intensive care units ■■ All patients who were self-sufficient in their personal care and all patients who were able to mobilise. Exclusion criteria ■■ Patients with dementia, who were unable to co-operate in the examination (this patient group may have an increased risk of pressure ulcers and so undergoes routine risk assessment) ■■ Patients who did not understand the Danish language ■■ Patients who did not wish to participate or where their inclusion was unethical for some reason.

The examination was performed by two professionals: the pressure ulcer specialist nurse and the dedicated nurse or nurse assistant from the department. All the patients’ pressure- exposed areas were examined and pressure ulcers was categorised according to the EPUAP classification system (EPUAP, 2014; EPUAP et al, 2014). The data were recorded in a standard form and the patient record was checked to see if there was any documentation of risk assessment in 2019 MA Healthcare Ltd British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S11 S10 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT In 2012 and 2013 five category 3 pressure ulcers and one category 4 pressure ulcer were found during prevalence inspections in OUH. In 2016 and 2017 no pressure ulcers of category 3 or above were found during prevalence studies, but in 2018 there was one category 3 pressure ulcer. The departments at OUH have been counting days without pressure ulcers to keep a focus on prevention.

On a few occasions during the project a total count of days without pressure ulcers was made for all departments (Figure 2 ) . Discussion The pressure ulcer quality improvement intervention at OUH has involved nurses and nurse assistants (and their leaders) in all departments at the hospital. Activities such as an annual pressure ulcer theme day, audits and prevalence studies, along with celebrations of milestones, have secured a focus on pressure ulcer prevention. The pressure ulcer nurse specialist has supported all the local dedicated nurses and nurse assistants as well as their leaders to secure a focus on pressure ulcer prevention in clinical practice every day.

Networking between dedicated clinicians has inspired them and they have learned from each other. This quality improvement intervention showed that some departments were more successful than others. In departments with very ill and dependent patients, the job of pressure ulcer prevention was more difficult. However, staff had specialist knowledge of their own patient categories and their risk factors, which helped in pressure ulcer prevention. The pressure ulcer specialist nurse has been available for all nurses and nurse assistants to contact to secure specialist supervision when needed. This has continued after the intervention ended in 2015 and was made a permanent feature.

Conclusion The pressure ulcer project, the introduction of the pressure ulcer specialist nurse role and the various activities have led to a focus on pressure ulcer prevention at OUH. The aim was a 50% reduction in pressure ulcers at the hospital, and the results from the prevalence studies and from counting days without pressure ulcers, suggest that this goal has been surpassed. The managerial support was a major reason for this good result, but the increased focus on the pressure ulcer issue nationally, regionally and locally was also significant. Keeping the prevention of pressure ulcers on the hospital’s agenda in the future would benefit both patient wellbeing and the hospital’s economy.

Impact on clinical practice The introduction of a pressure ulcer specialist nurse role has, as a side effect, led to several smaller projects at the hospital such as the following:

■■ A focus on prevention of pressure ulcers in operating rooms at the OUH ■■ A pressure ulcer reduction among patients with a hip fracture from 15% to 4% by using a parking disc (a sign to remind staff when the patient is due to be turned) and an the patient’s file. All occurrences of pressure ulcers were investigated by the pressure ulcer specialist nurse. The departments were notified in advance of the date of examination in order to keep the staff and patients informed.

Counting days with no pressure ulcers Manual registration of days without pressure ulcers was established in each department. This method was dependent on the nurses and nurse assistants registering patients with pressure ulcers every day. Every time a department achieved 200, 300, 400 or 500 days without pressure ulcers, they celebrated the achievement (with a large cake). The celebration was shared on the hospital’s internet site with photographs to inspire staff in other departments. The aim of this method was not to compare the individual departments, because they had different patient populations with different risks.

Results Prevalence studies have been conducted since 2012 at OUH in Odense and the unit in Svendborg. Figure 1 presents the improvements that have achieved over the subsequent 6 years. KEY POINTS ■ Establishment of a nurse-led project involving a pressure ulcer specialist nurse and dedicated nurses and nurse assistants led to quality improvement in pressure ulcer-related clinical practice in one hospital ■ Ongoing focus on prevention is a way to reduce pressure ulcers in clinical practice ■ Prevalence studies and daily monitoring of pressure ulcers helped clinicians to focus on a topic in a quality improvement project ■ The number of pressure ulcers occurring in a hospital can be reduced by systematic effort and leadership Figure 1. Prevalence of pressure ulcers at Odense University Hospital and Svendborg Hospital, Denmark, 2012 to 2018 2012 2014 2015 2016 2017 2018 15 12 9 6 3 0 OdenseSvendborg Percentage 2019 MA Healthcare Ltd British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S11 ordinary pillow placed under the patient’s legs to ensure that the heels are not in contact with the surface ■■ Testing dressings for pressure ulcer prevention in cardiac intensive care, resulting in a reduction of 24% ■■ A hospital-based health technology assessment (HTA) carried out within a clinical pilot test area in care of the elderly and orthopaedic units at OUH, where two types of static overlays were tested for 6 months. Incidence of pressure ulcers was investigated before and after the implementation ■■ Presentations by the specialist nurse at several national and international conferences.

The pressure ulcer quality improvement project was terminated at the end of 2015, but the work of the pressure ulcer specialist nurse, the local dedicated nurses and nurse assistants continues, as do the annual theme days, prevalence studies and audits. It is important to maintain the results achieved so far and to continue to focus on pressure ulcer prevention. BJN Declaration of interest: none Acknowledgement: the Danish safety foundation ‘TrygFonden’ has contributed to the quality improvement project by providing funds to establish the pressure ulcer specialist nurse role Braden B, Bergstrom N. The Braden scale for predicting pressure sore risk. 1988. (accessed 14 March 2019) Bermark SE. Seks prævalensundersøge lser for tryksår på danske hospitaler. [Six prevalence studies for pressure ulcers in Danish hospitals.] Sår. [Wounds.] 2009; 4:203–210. COWI consulting group. Evaluering af Patientsikkert Sygehus. [Evaluation of the Danish Safer Hospital Program.] Lyndby, Denmark: COWI; 2014 Dansk Selskab for Patientsikkerhed. [Danish Society for Patient Safety]. Patientsikkert Sygehus [Danish Safer Hospital Programme.] 2015a. (accessed 14 March 2019) Dansk Selskab for Patientsikkerhed. [Danish Society for Patient Safety.] Tryksårspakken. [The pressure ulcer bundle.] 2015b. y25gs3cf (accessed 14 March 2019) Dorsche KM, Fremmelevholm A. Forekomst af decubitus på hospital. Occurrence of pressure ulcers in a hospital. Ugeskrift for læger [Weekly note for Doctors]; 15 March 2010; 601-606 European Pressure Ulcer Advisory Panel. 2014 prevention and treatment of pressure ulcers: clinical practice guidelines. 2014. (accessed 14 March 2019) European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: quick reference guide. 2nd edn. 2014. (accessed 14 March 2019) Odense University Hospital Department of Quality, Research, Innovation and Development. Strategi for patientsikkerhed 2012-2014. [Strategy for patients safety 2012-2014]. Odense: Odense University Hospital; 2011 Posnett J, Franks PJ. The burden of chronic wounds in the UK. Nursing Times 2008; 104(3):44-45 Region of Southern Denmark. Tryksår – forebyggelse [Guideline: pressure ulcer prevention.] Vejle: Region of Southern Denmark; 2016 CPD reflective questions ■ Reflect on whether the method implemented in this project could be used as an inspiration for other quality improvement projects in your area ■ Think about how the establishment of local dedicated nurses and nurse assistants can support quality improvement in clinical practice ■ Think about how quality improvements in clinical practice in your area can be maintained over time Figure 2. Odense University Hospital departments with days without pressure ulcers: March 2015 and December 2017 Number of departments at OUH with days without pressure ulcers: ≥50 to ≥1500 days ≥50 ≥100 ≥200 ≥300 ≥400 ≥500 ≥600 ≥700 ≥800 ≥900 ≤1000 ≤1100 ≤1500 March 2015 December 2017 50 40 30 20 10 0 PRESSURE ULCERS 2019 MA Healthcare Ltd Copyright ofBritish Journal ofNursing isthe property ofMark Allen Publishing Ltdand its content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder’sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.

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