Visit by Lesley Griffiths AM Minister for Health & Social Services Pressure Ulcer Prevention :: Zero Tolerance 7Th February

Briefing Pressure Ulcer Prevention :: Zero Tolerance Within ABM University Health Board Visit by Lesley Griffiths AM Minister for Health & Social Services 7th February 2013 Morriston Hospital, Swansea Pressure Ulcer Prevention Within ABM University Health Board Background Before 2008, like most NHS hospitals we were seeing a high pressure ulcer prevalence in our hospitals. A culture had developed that pressure ulcers were an inevitable consequence of hospitalisation. This led to patient mortality, prolonged hospitalisation, avoidable pain and distress and cost; estimated at £2.7M per year for ABMU alone using the Department of Health productivity tool. ABM University Health Board consists of four acute and several community hospitals, with a total of 2300 beds providing: secondary, tertiary, community, Mental Heath, learning disability and hospice care. What did we do? In early 2009, as a pilot site for NHS Wales, ABM University Health Board developed a bundle of interventions and an approach which we have subsequently been successfully able to roll out across all inpatient areas within the Health Board and through the 1,000 lives pro- gramme across the NHS in Wales to prevent hospital acquired pressure ulcers. The work was developed and piloted on one ward within Morriston Hospital (Anglesey) before spreading to over 100 wards and departments. The initial pilot work took a year before we were assured that we had the required assessments, training, systems and processes to achieve the required results of preventing the development of pressure ulcers within inpatient areas. Regular audits were undertaken with the nurses of patient’s pressure areas to derive pressure ulcer incidence and prevalence rates. We measured the reliability of pressure ulcer and nutritional risk assessment in our patients. A spot audit undertaken in the previous Swansea NHS Trust in March 2008 identified an incident rate of 13%. Further audit work undertaken in 2009 identified that the reliability of pressure ulcer risk assessments was only 70% and nutritional risk assessment was only 60%. The frequency of adverse events meant that proper root cause analysis (RCA) of pressure ulcers was not being undertaken. Interviews with clinical staff identified that pressure ulcers were seen as inevitable in our patient/client group (high frailty and acuity). Staff knew what caused pressure ulcers and how to prevent them but were not identifying consistently those at risk or intervening to stop ulcers. The pilot ward used the Deming’s “Model for Improvement” with repeated PDSA cycles and process changes to improve reliability of risk and nutritional assessments to exceed 95%. We developed a group of interventions (the “SKIN bundle”), based on Ascension Health. A multi-professional project board was established with patient and executive membership was established from the outset. After the package was deemed to be fit for purpose the Project Board spread the SKIN bundle out to all 100 inpatient areas. The initial roll out was to three wards, again undertaken through PDSA cycles to ensure the bundle was ‘fit for purpose’. Within critical care and A&E areas more intensive further development and PDSA cycles were required to ensure the bundle fully met the unit and patient needs and most importantly was effective in eliminating hospital acquired pressure ulcers. The SKIN bundle was adjusted to increase acceptance and reliability. The original pilot ward team were re- leased to support the Tissue Viability Nurses in the provision of training, education and ‘on the job’ support for ward based staff during the roll out period. We involved all other staff groups, patients and visitors through a bed-end communication tool. Some patients called it a “contract of care”. We posted visual prompts prominently on the ward and a safety cross in the ward entrance. Priority was given to responding to high risk or nutritional scores and accessing equipment to support prevention, including chair cushions. We met weekly with all ward staff to maintain a high profile. Safety crosses, care metrics and incident reports and repeated audits were used to capture, record and analyse pressure ulcers, which were reported monthly using run charts at ward, hospital and Health Board level. We used occurrences and also “days since ...” as measures. We have changed the thinking about pressure ulcers which are now considered nearly always avoidable. They have become very uncommon and can be investigated properly. Some of these are still avoidable. Creating belief took time but has been achieved. A number of our Ward Sisters take pride in being able to say ‘pressure ulcers do not occur here’. What is the package of Care? The package of care that has been developed centres on reliably undertaking the initial risk assessment of the patients susceptibility to developing pressure ulcers and then the immediate implementation of a package of care using the SKIN Bundle format that is also tailored to meet that patients individual needs as well as communicating to the patient and family of the risks and what needs to be undertaken to reduce them. All inpatients must have a pressure ulcer risk assessment (Waterlow risk assessment) undertaken on admission to hospital. This is to be repeated as determined by the score or if the patients condition / needs change. Any patients who score 15 or greater on the risk assessment are deemed to be at risk and should be put on the SKIN bundle. This requires documented nursing intervention at least every two hours in the following areas to reduce likelihood of damage: Surface – ensure patient is on the right mattress, cushion, there are no creases or wrinkles Keep moving - encourage self movement, reposition patient and inspect skin Incontinence - meet patient’s toileting or continence needs Nutrition – keep well hydrated, meet patients nutritional needs An effective nutritional risk assessment on admission, repeated if patients condition changes and appropriate so that effective immediate dietary support can be provided is another key factor in reducing a patients susceptibility to developing pressure ulcers. The following measures are recorded across all wards every month in order that the focus on this work can be maintained: • Incidents of pressure ulcer development • % compliance with a Waterlow risk assessment on admission • % compliance with a repeat Waterlow risk assessment within agreed timeframe • % compliance with nutritional risk assessment on admission • % compliance with repeat nutritional risk assessment within agreed timeframe • % compliance with full completion of the SKIN bundle Current Situation The Health Board has gone from a pressure ulcer incident rate of 13% (2008) to <1% (2012), which equates to seeing over 450 incidences per month to only 2 during the month of December 2012. During 2012 the average monthly rate has been less than 8 with a continued downward trend. No severe ulcers (grade 4) have occurred. The majority of incidents have been a level 1 or 2 (redness or superficial damage). Every incident triggers a full review and a root cause analysis supported by a Tissue Viability Nurse. ABM University Health Board is now seeing a number of hospitals going extended periods of time without any incidents of patients developing pressure ulcers. Examples are the Neath Port Talbot Hospital site, which has not had an incident since August 2012 and Gorseinon Community Hospital (two Wards) has not had an incident since January 2010. At an individual ward level nine inpatient wards have not had an incident of a patient developing a pressure ulcer in their ward for over three years. These are: Morriston Hospital - Ward W (Trauma & Orthopaedics); Anglesey (Plastic Surgery) and Ward C (surgery) Singleton Hospital - Ward 8 (medicine) Gorseinon Hospital - East and West Ward (Community rehabilitation) Neath Port Talbot Hospital – Ward A (elective Surgery) Princess of Wales Hospital - Ward 11 (gynaecology) and the Clinical Decision Making Unit. In addition, a further seven wards have gone over two years since a patient developed a pressure ulcer. Spread across Primary and Commissioned Care Services During 2012 the Health Board has successfully rolled out the pressure ulcer reduction work across all Care Homes within the Neath Port Talbot Locality, and is planning some pilot work within Residential Home settings. The Health Board is now planning to spread this work out to all Care homes within Swansea and Bridgend Localities. In addition, the pressure ulcer reduction work has also been rolled out successfully to all District Nursing teams within Swansea Locality and the Health Board are planning the spread of this work within District Nursing Teams across Neath Port Talbot and Bridgend Localities. Both of these projects have required close multi-agency working, the provision of joint risk assessment processes and training. The projects have been very well received within all independent and public sector organisations that the Health Board has been working with and there has been no resistance to date. The outcomes so far are that no patients within the project teams or settings have developed new pressure ulcer damage. Very positive feedback has been received from patients, their carers and the public and independent sector partners. Pressure Ulcer Prevention ::: Zero Tolerance ::: Results to date Hospital Acquired Pressure Ulcers by Grade and month in 2300 beds across ABMU Health Board Results – February 2013 There has been a dramatic reduction in hospital acquired pressure ulcers 16 across ABMU Health Board. No of Incidents 14 From around 450 a month to less than 10. Many wards have gone hundreds 12 of days without a ulcer developing: 9 wards have had no incidents for over 3 years! 10 Grade1 8 Grade2 Pressure ulcer Incidence has decreased from 10% incidence to 0.1% since the introduction Grade3 of the new methods. 6 Grade4 4 Total Incidents Message for Others – 2 By maintaining a process that gives 100% compliance with risk assessments and managing them 0 in an appropriate manner will ensure a dramatic decrease in the incidence of pressure Ulcers and in some areas will eradicate them.

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