Art & science tissue viability supplement
Recording pressure ulcer risk assessment and incidence Plaskitt A et al (2015) Recording pressure ulcer risk assessment and incidence. Nursing Standard. 29, 46, 54-61. Date of submission: March 3 2015; date of acceptance: June 23 2015.
Abstract This article reports on the introduction of an innovative computer-based system developed to record and report pressure ulcer risk and incidence at an acute NHS trust. The system was introduced to ensure that all patients have an early pressure ulcer risk assessment, which prompts staff to initiate appropriate management if a pressure ulcer is detected, thereby preventing further patient harm. Initial findings suggest that this electronic process has helped to improve the timeliness and accuracy of data on pressure ulcer risk and incidence. In addition, it has resulted in a reduced number of reported hospital-acquired pressure ulcers.
Authors Anne Plaskitt Senior nurse quality improvement, Royal United Hospitals Bath NHS Foundation Trust, Bath, England. Nicola Heywood Tissue viability nurse specialist, Royal United Hospitals Bath NHS Foundation Trust, Bath, England. Michaela Arrowsmith Lead tissue viability nurse specialist, Royal United Hospitals Bath NHS Foundation Trust, Bath, England. Correspondence to: [email protected]
Keywords Electronic patient records, pressure ulcer, pressure ulcer incidence, Rapid Spread Methodology, risk assessment, technology
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines
PRESSURE ULCERS HAVE a negative effect on people’s emotional, mental, physical and social health (Spilsbury et al 2007, Moore and Cowman 2009). The cost to the UK of pressure ulcers is estimated at between £1.4 billion and £2.1 billion per year (Bennett et al 2004) and the cost of healing a category 4 pressure ulcer is estimated at £14,108 (Dealey et al 2012). Therefore, reducing hospital-acquired pressure ulcers is an essential quality target.
Rationale for developing the computer-based system Before the introduction of the computer-based system at the Royal United Hospitals Bath NHS Foundation Trust, two aspects of pressure ulcer documentation for adults were paper-based processes: risk assessment and incidence data collection. The organisation wanted to find innovative ways to streamline the data collection process for pressure ulcers and to record data in real time. This would ensure that all patients had an early pressure ulcer risk assessment and enable staff to commence appropriate management if a pressure ulcer was detected, preventing further patient harm. The organisation decided to adopt an electronic documentation process for pressure ulcer risk assessment and incidence, and the system described in this article was developed in response. It was anticipated that documenting pressure ulcer risk assessments electronically would ensure prompt assessment of patients in accordance with National Institute for Health and Care Excellence (NICE) (2014) guidelines. It was expected that such assessment would enable patients at high risk of developing a pressure ulcer to be identified and the pressure ulcer prevention pathway to be implemented promptly, preventing the development of avoidable pressure ulcers (Hibbs 1988, Downie et al 2013). Avoidable pressure ulcers occur when risk assessments, preventive actions and ongoing re-evaluations are not implemented. Documenting pressure ulcer development in real time allows
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pressure ulcers to be validated by a specialist nurse, so that each patient’s pressure ulcer care can be managed correctly to maximise healing and prevent further harm. Validation involves having the pressure ulcer category (Table 1) confirmed by a specialist nurse, usually a tissue viability nurse specialist. Validation by a specialist is important because the inter-rater reliability between non-specialists can be poor (Pedley 2004).
Paper-based pressure ulcer risk assessment and incidence reporting Before the implementation of the computer-based system, the pressure ulcer risk assessment was documented on a paper form. This form had sections on mobility, moisture and continence, sensory perception, cognitive function, nutritional status, skin condition and other risk factors. The risk was categorised as low, medium or high based on the assessment and the clinical judgement of the nurse or assessor. This process was difficult to monitor and audit at ward and organisational levels. Moreover, the process did not include a trigger for reassessment. Pressure ulcer incidence data were collected at ward level using a paper-based weekly pressure ulcer reporting form. For each patient with a pressure ulcer, staff recorded information on the category or stage and the site of the pressure ulcer, and whether it originated on that ward, on another ward or in the community. The form also included descriptions of the different categories of pressure ulcer (Table 1) to help establish the correct category in each case. Each ward then sent the form to the tissue viability team via fax or email. When the team received the forms, the data were manually transferred to a database. After a check of the database, any areas of the hospital that had not submitted forms were contacted and their data, once received, were transferred to the database. Once forms had been received from all wards, a pressure ulcer incidence report was generated from the database. At times, reports were generated with incomplete data. This process was onerous and inefficient, with potential for inaccuracies, for example the writing on the forms might be illegible or forms might be incomplete. The system achieved on average 60% compliance with timely return of completed pressure ulcer incidence forms, because nurses had to remember to complete the form and return it to the tissue viability team. Some wards returned completed pressure ulcer incidence forms every week; others every month. At times there was a month-long lag in data reaching the tissue viability team. There was a further time lag in
reporting, since data from the paper forms had to be entered into the database before a report could be generated. This process was time-consuming for all concerned. The time lag between data collection and data reporting also meant that the information was out of date, making it difficult for tissue viability nurses to implement care for patients at risk. For example, if a ward reported a large number of hospital-acquired pressure ulcers, this might not have been apparent to the tissue viability team until one month later. These time lags were frustrating for the specialist nurses because of the delay in initiating appropriate management for patients. Pressure ulcer incidence data were not always validated by specialist nurses. There were concerns that other wound types, such as trauma wounds and incontinence-associated dermatitis, were being reported as pressure ulcers. The differentiation between pressure ulcers and these other wound types can be problematic for non-specialist nurses (Defloor et al 2005, Houwing et al 2007). Patients may have been moved to another area of the hospital or discharged by the time the completed incidence forms reached the specialist team. Assurance could not be given about the accuracy of data reported internally and externally, since tissue viability nurses had not validated the pressure ulcers. An annual pressure ulcer prevalence audit demonstrated that 50% of reported pressure ulcers were wounds of another aetiology (Royal United Hospitals Bath NHS Foundation
TABLE 1 Pressure ulcer categories Category
Description
1
Intact skin with non-blanchable redness of a localised area; usually over a bony prominence. Darkly pigmented skin may not have visible blanching. Colour may differ from surrounding area.
2
Partial-thickness loss of dermis; presents as a shallow open ulcer or as an intact, open or ruptured blister. This category is not used to describe incontinence-associated dermatitis, maceration or excoriation.
3
Full-thickness tissue loss; bone or tendon not exposed. Slough may be present but does not obscure depth of tissue loss. May include undermining and tunnelling.
4
Extensive destruction; with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunnelling.
Purple or maroon area of discoloured intact skin may indicate suspected deep tissue injury. (Adapted from National Pressure Ulcer Advisory Panel et al 2014)
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Art & science tissue viability supplement Trust 2010); therefore, the reported pressure ulcer incidence was higher than the actual incidence. This issue was pertinent since the national Commissioning for Quality and Innovation (CQUIN) payment (NHS England 2014) included national and local measures relating to pressure ulcer incidence.
Development of the electronic patient record Having decided to document pressure ulcer risk assessment and incidence electronically, the trust started using the Cerner Millennium healthcare information system in July 2011. This electronic patient record system provides an individual electronic care record for each patient and clinical tools for healthcare staff. Use of this system enables doctors, nurses, other healthcare professionals and managers to have secure access to reliable and current information at all times. It was determined that an electronic system to document pressure ulcer risk assessment and incidence could be created using the system. The primary aim was to design a system for recording pressure ulcer incidence that would allow tissue viability nurses to provide timely advice on and validation of the categories of pressure ulcers (National Pressure Ulcer Advisory Panel (NPUAP) et al 2014). A secondary aim was to design an electronic system to assess patients’ risk of developing a pressure ulcer. A team of tissue viability and quality improvement nurses designed the system, with contributions from the information technology (IT) team, the quality improvement team and the senior nurse for quality improvement. The system included pressure ulcer risk assessment using a modified pressure ulcer risk assessment tool (Bergstrom et al 1987) and allowed for assessment on admission and ongoing reassessment. This was part of creating a complete electronic patient record with a focus on significantly improving patient safety and standards of patient care, as mandated by the Health and Social Care Act 2012. The NHS Safety Thermometer (2014) introduced the concept of measuring harm caused to patients as a means of measuring progress in providing a harm-free care environment. Thus, the electronic record system was extended to record harm events relating to pressure ulcers. The idea was to record pressure ulcers present on admission on the initial risk assessment electronic form (e-form), which also included core aspects of nursing care, such as infection status, falls and mobility risk, communication needs and mental health assessment. A pressure ulcer that developed
during a hospital stay would then be recorded as a harm event during subsequent risk assessments. The quality improvement, tissue viability and IT teams at the trust implemented the complete electronic system for recording pressure ulcer risk assessment and incidence in May 2013. The system is password protected, and confidentiality is further protected by a hierarchy of permissions – for example, tissue viability nurses can view data that are unavailable to ward team members. It is also possible to track which users have viewed which data.
Use of the electronic patient record The changes to patient assessment and data collection were staggered. The initial risk assessments went live in July 2011, with the recording of harm events going live in May 2013 and the modified pressure ulcer risk assessment in May 2014.
Initial risk assessment
Patients have a pressure ulcer assessment on admission to the hospital. Nursing staff record the findings of this skin check on the initial risk assessment e-form on the electronic system, including pressure ulcer site, category, date it was noted and in what setting it developed – an important record of whether the pressure ulcer was present on admission or hospital acquired. The system allows ward staff to record these findings on the electronic patient record and make an immediate, direct referral to the tissue viability nurses if a patient has a pressure ulcer of category 2 or above (NPUAP et al 2014). Comment boxes are included on the form to allow nursing staff to record the reasons for referral and any relevant patient history.
Pressure ulcer risk assessment process
Training in the use of the modified pressure ulcer risk assessment tool occurred in a cascade process via the tissue viability link nurse network. The requirement is that an initial modified pressure ulcer risk assessment should take place within six hours of admission, followed by assessment whenever there is a change in clinical status (NICE 2014), or every 48 hours thereafter regardless of the level of risk, to simplify the reassessment system.
Pressure ulcer incidence: harm events
Any pressure ulcer present at admission would be recorded in the initial risk assessment, but a pressure ulcer that develops following admission is recorded as a harm event. The harm event e-form allows nursing staff to record the pressure ulcer site, category and date it was identified, and can generate
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Art & science tissue viability supplement a direct referral to the tissue viability team to enable a prompt response. An audit tool identifies the numbers of patients with pressure ulcers at any time and their locations in the organisation, allowing up-to-date analysis of data trends and timely implementation of preventive pathways.
Referral to tissue viability
Both the risk assessment and harm event forms can generate a referral to the tissue viability team. When a patient has a pressure ulcer of category 2 or above, the staff member can choose to refer them to the team. The system then generates an electronic referral, including all information relating to the pressure ulcer and the patient. The tissue viability team triages these, along with all other referrals, and validates all category 3, 4 and suspected deep tissue injury pressure ulcers as well as many category 2 pressure ulcers. The team is able to validate pressure ulcers in a timely manner and ensure that the reported pressure ulcer incidence is accurate.
This is important from a patient care perspective as well as a data collection and reporting perspective. The treatment and management of pressure ulcers differ from that of other wound aetiologies, such as moisture lesions or incontinence-associated dermatitis; pressure ulcer treatment focuses on avoiding pressure and shear (NICE 2014, NPUAP et al 2014), whereas the management of incontinence-associated dermatitis or moisture lesions focuses on continence (Beeckman et al 2009). Therefore, correct identification of the wound type is essential to ensure the correct treatment is implemented.
Results achieved with the electronic patient record The organisation has seen a reduction in the incidence of hospital-acquired pressure ulcers following the implementation of the electronic system for recording harm events and initial
FIGURE 1 Hospital-acquired pressure ulcer incidence (July 2011 to September 2014) 40 Category 2
Number of hospital-acquired pressure ulcers
35 Category 3 30 Category 4 25 Trendline 20 15 10 5
Jul 2011 Aug 2011 Sep 2011 Oct 2011 Nov 2011 Dec 2011 Jan 2012 Feb 2012 Mar 2012 Apr 2012 May 2012 Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 2013 Apr 2013 May 2013 Jun 2013 Jul 2013 Aug 2013 Sep 2013 Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Mar 2014 Apr 2014 May 2014 Jun 2014 Jul 2014 Aug 2014 Sep 2014
0
Initial risk assessments and pressure ulcer risk assessments introduced
Harm event e-form introduced
Rapid Spread Methodology implemented
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Art & science tissue viability supplement risk assessments (Figure 1). Other patient care initiatives, such as expanding the tissue viability link nurse network and small-scale quality improvement measures, have contributed to this. Improvements to the way data are obtained and the quicker response by the tissue viability team have been instrumental in reducing the number of pressure ulcers acquired. The reductions in pressure ulcer incidence after the introduction of the initial risk assessment in July 2011 and the harm event in May 2013 are shown in Figure 1. There were periods when there were increases in the number of category 2 pressure ulcers recorded, for example between September 2012 and March 2013 and July and August 2013. These increases may have been a result of the increased reporting through the electronic system. The electronic system captures 100% of pressure ulcer incidence forms, whereas only 60% of the paper forms used previously were received on time from wards. The increased incidence in July and August 2013 occurred after the harm event e-form was introduced, and this introduction may have been a factor in the increased number of pressure ulcers reported. There is an overall downward trend in the number of hospital-acquired pressure ulcers recorded from May 2013 to September 2014 (Figure 1). This is most evident in the number of category 2 pressure ulcers. There were up to four category 3 pressure ulcers and one category 4 pressure ulcer over the time period covered; however, no incidences of category 3 or 4 hospital-acquired pressure ulcers were recorded between December 2013 and September 2014.
Improved patient experience
The rapid response by tissue viability nurses to pressure ulcers reported using the electronic risk assessments has enabled care planning to be provided promptly by the specialist nurse. This ensures that the best treatment plan is in place to prevent further harm to patients.
Incident reporting
The electronic system provides easily accessible data from a live system. It provides accurate reports for all users from board to ward (for example, the ward scorecard, a daily measurement of quality standards throughout the organisation). Evaluation of how effectively ward staff are using the system can be made by cross-referencing the numbers of pressure ulcers recorded with those on the trust’s incident reporting system, which is used to report incidents internally and externally. Implementation of electronic recording of patient assessments has improved documentation compliance and enabled rapid audit and validation
of data. The system provides a snapshot of compliance in real time. It is important to record accurate data since pressure ulcers are a key quality target, indicating the quality of care in an organisation. The organisation is committed to providing safe care and minimising patient harm. The accurate recording of data enables early validation of pressure ulcers, as well as implementation of safe and effective prevention plans.
Audit data
The average completion rate for initial pressure ulcer assessments throughout the organisation was 98%. This is an improvement on 2011, when audits of the paper-based risk assessments found the average timely completion rate was around 45%. Data on the ongoing assessments of risk showed a minimum 96% compliance.
Referral process
Tissue viability nurses are now aware of pressure ulcer risk and harm events quickly after they are documented. This has improved the referral process, allowing prioritisation of patients and validation of pressure ulcers on the day they are reported. This process has allowed tissue viability nurses to address inaccurate classification, for example when a wound recorded as a pressure ulcer is actually incontinence-associated dermatitis. Training on pressure ulcer categorisation is provided to all nursing staff, and nurses are now more likely to refer patients to the tissue viability team because the process is simpler. Nurses receive online notification from the tissue viability team that the referral has been received and triaged and that appropriate action has been taken.
Quality assurance
Tissue viability nurses and senior sisters can monitor standards of care and quality indicators via pressure ulcer incidence reports, and monitor completion of e-forms for each ward from their computers. For example, a ward manager can view all of a ward’s pressure ulcer risk assessments on one screen and easily identify which patients require reassessment. Another important benefit to patients is that the organisation can provide the evidence (data) that risk is being assessed. These data can be obtained from any computer.
Clinical guidance
When entering details of a pressure ulcer into the electronic patient record, nurses can access reference information on the system, including NPUAP et al (2014) guidance on the categories of pressure ulcer. This guidance includes descriptions
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of the categories of pressure ulcer, photographs of examples in each category, and details of the nursing care and actions that should be taken to manage the different categories.
Education and shared learning from clinical incidents
The tissue viability nurses have accurate trust-wide information on patients who are at risk of developing pressure ulcers and those with pressure ulcers that have been reported as a harm event. The ability to readily identify areas with a higher incidence and greater risk of pressure ulcers enables the specialist nurses to focus their resources and provide support to wards through specialist intervention. It also enables them to share learning from clinical incidents, potentially avoiding harm to other patients.
Future developments With an effective system in place for accurate recording of pressure ulcer risk assessments and incidence data, the organisation can focus on ensuring that best practice is followed. A Rapid Spread Methodology for pressure ulcer prevention was implemented in June 2014 (Figure 1), with the aim of achieving zero avoidable hospital-acquired pressure ulcers (Department of Health 2011).
Information on the Rapid Spread Methodology is provided in the second article in this tissue viability supplement (Heywood et al 2015). Following the success of this initiative, an electronic system for falls harm has been implemented and electronic recording of other events, such as insertion of a urinary catheter and safeguarding, is being developed.
Conclusion Introducing an electronic system for recording pressure ulcer risk and incidence has enabled staff to obtain real-time data on hospital-acquired pressure ulcers and enabled them to make improvements to patient care and minimise patient harm. The system has improved the referral process for tissue viability nurses and ward nurses, allowing more efficient use of their time, the ability to focus on pressure ulcer prevention and to spend more time with patients. Reductions in reported pressure ulcer incidence reflect the early access to specialist advice as well as an increased awareness of pressure ulcer risk and the need for prevention on the wards. The authors would recommend this electronic system to other healthcare organisations as an accurate way to record pressure ulcer risk assessment and incidence NS
References Beeckman D, Schoonhoven L, Verhaeghe S, Heyneman A, Defloor T (2009) Prevention and treatment of incontinence-associated dermatitis: literature review. Journal of Advanced Nursing. 65, 5, 1141-1154. Bennett G, Dealey C, Posnett J (2004) The cost of pressure ulcers in the UK. Age and Ageing. 33, 3, 230-235. Bergstrom N, Braden BJ, Laguzza A, Holman V (1987) The Braden scale for predicting pressure sore risk. Nursing Research. 36, 4, 205-210. Dealey C, Posnett J, Walker A (2012) The cost of pressure ulcers in the United Kingdom. Journal of Wound Care. 21, 6, 261-266. Defloor T, Schoonhoven L, Fletcher J et al (2005) Statement of the European Pressure Ulcer Advisory Panel – pressure ulcer classification: differentiation
between pressure ulcers and moisture lesions. Journal of Wound, Ostomy and Continence Nursing. 32, 5, 302-306. Department of Health (2011) Defining Avoidable and Unavoidable Pressure Ulcers. tinyurl.com/cprcnn6 (Last accessed: June 12 2015.) Downie F, Guy H, Gilroy P, Royall D, Davies S (2013) Are 95% of hospital-acquired pressure ulcers avoidable? Wounds UK. 9, 3, 16-22. Heywood N, Brown L, Arrowsmith M, Poppleston A (2015) A quality improvement programme to reduce pressure ulcers. Nursing Standard. 29, 46, 62-70. Hibbs PJ (1988) The Economic Benefits of a Prevention Plan for Pressure Sores. Conference presentation. Fourth National Pressure Sore Symposium. April 20, Bath.
Houwing RH, Arends JW, Canninga-van Dijk MR, Koopman E, Haalboom JR (2007) Is the distinction between superficial pressure ulcers and moisture lesions justifiable? A clinical-pathologic study. Skinmed. 6, 3, 113-117. Moore M, Cowman S (2009) Quality of life and pressure ulcers: a literature review. Wounds International. 5, 1, 58-65. National Institute for Health and Care Excellence (2014) Pressure Ulcers: Prevention and Management of Pressure Ulcers. Clinical guideline No. 179. NICE, London. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Cambridge Media, Perth. NHS England (2014) Commissioning for Quality and Innovation
(CQUIN): 2014/15 Guidance. tinyurl.com/p52f6s5 (Last accessed: June 12 2015.) NHS Safety Thermometer (2015) NHS Safety Thermometer. It’s Not Just Counting, It’s Caring. www. safetythermometer.nhs.uk/ (Last accessed: June 12 2015.) Pedley GE (2004) Comparison of pressure ulcer grading scales: a study of clinical utility and inter-rater reliability. International Journal of Nursing Studies. 41, 2, 129-140. Royal United Hospitals Bath NHS Foundation Trust (2010) Annual Pressure Ulcer Prevalence Audit. Royal United Hospitals Bath NHS Foundation Trust, Bath. Spilsbury K, Nelson A, Cullum N, Iglesias C, Nixon J, Mason S (2007) Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. Journal of Advanced Nursing. 57, 5, 494-504.
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Recording pressure ulcer risk assessment and incidence Plaskitt A et al (2015) Recording pressure ulcer risk assessment and incidence. Nursing Standard. 29, 46, 54-61. Date of submission: March 3 2015; date of acceptance: June 23 2015.
Abstract This article reports on the introduction of an innovative computer-based system developed to record and report pressure ulcer risk and incidence at an acute NHS trust. The system was introduced to ensure that all patients have an early pressure ulcer risk assessment, which prompts staff to initiate appropriate management if a pressure ulcer is detected, thereby preventing further patient harm. Initial findings suggest that this electronic process has helped to improve the timeliness and accuracy of data on pressure ulcer risk and incidence. In addition, it has resulted in a reduced number of reported hospital-acquired pressure ulcers.
Authors Anne Plaskitt Senior nurse quality improvement, Royal United Hospitals Bath NHS Foundation Trust, Bath, England. Nicola Heywood Tissue viability nurse specialist, Royal United Hospitals Bath NHS Foundation Trust, Bath, England. Michaela Arrowsmith Lead tissue viability nurse specialist, Royal United Hospitals Bath NHS Foundation Trust, Bath, England. Correspondence to: [email protected]
Keywords Electronic patient records, pressure ulcer, pressure ulcer incidence, Rapid Spread Methodology, risk assessment, technology
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines
PRESSURE ULCERS HAVE a negative effect on people’s emotional, mental, physical and social health (Spilsbury et al 2007, Moore and Cowman 2009). The cost to the UK of pressure ulcers is estimated at between £1.4 billion and £2.1 billion per year (Bennett et al 2004) and the cost of healing a category 4 pressure ulcer is estimated at £14,108 (Dealey et al 2012). Therefore, reducing hospital-acquired pressure ulcers is an essential quality target.
Rationale for developing the computer-based system Before the introduction of the computer-based system at the Royal United Hospitals Bath NHS Foundation Trust, two aspects of pressure ulcer documentation for adults were paper-based processes: risk assessment and incidence data collection. The organisation wanted to find innovative ways to streamline the data collection process for pressure ulcers and to record data in real time. This would ensure that all patients had an early pressure ulcer risk assessment and enable staff to commence appropriate management if a pressure ulcer was detected, preventing further patient harm. The organisation decided to adopt an electronic documentation process for pressure ulcer risk assessment and incidence, and the system described in this article was developed in response. It was anticipated that documenting pressure ulcer risk assessments electronically would ensure prompt assessment of patients in accordance with National Institute for Health and Care Excellence (NICE) (2014) guidelines. It was expected that such assessment would enable patients at high risk of developing a pressure ulcer to be identified and the pressure ulcer prevention pathway to be implemented promptly, preventing the development of avoidable pressure ulcers (Hibbs 1988, Downie et al 2013). Avoidable pressure ulcers occur when risk assessments, preventive actions and ongoing re-evaluations are not implemented. Documenting pressure ulcer development in real time allows
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pressure ulcers to be validated by a specialist nurse, so that each patient’s pressure ulcer care can be managed correctly to maximise healing and prevent further harm. Validation involves having the pressure ulcer category (Table 1) confirmed by a specialist nurse, usually a tissue viability nurse specialist. Validation by a specialist is important because the inter-rater reliability between non-specialists can be poor (Pedley 2004).
Paper-based pressure ulcer risk assessment and incidence reporting Before the implementation of the computer-based system, the pressure ulcer risk assessment was documented on a paper form. This form had sections on mobility, moisture and continence, sensory perception, cognitive function, nutritional status, skin condition and other risk factors. The risk was categorised as low, medium or high based on the assessment and the clinical judgement of the nurse or assessor. This process was difficult to monitor and audit at ward and organisational levels. Moreover, the process did not include a trigger for reassessment. Pressure ulcer incidence data were collected at ward level using a paper-based weekly pressure ulcer reporting form. For each patient with a pressure ulcer, staff recorded information on the category or stage and the site of the pressure ulcer, and whether it originated on that ward, on another ward or in the community. The form also included descriptions of the different categories of pressure ulcer (Table 1) to help establish the correct category in each case. Each ward then sent the form to the tissue viability team via fax or email. When the team received the forms, the data were manually transferred to a database. After a check of the database, any areas of the hospital that had not submitted forms were contacted and their data, once received, were transferred to the database. Once forms had been received from all wards, a pressure ulcer incidence report was generated from the database. At times, reports were generated with incomplete data. This process was onerous and inefficient, with potential for inaccuracies, for example the writing on the forms might be illegible or forms might be incomplete. The system achieved on average 60% compliance with timely return of completed pressure ulcer incidence forms, because nurses had to remember to complete the form and return it to the tissue viability team. Some wards returned completed pressure ulcer incidence forms every week; others every month. At times there was a month-long lag in data reaching the tissue viability team. There was a further time lag in
reporting, since data from the paper forms had to be entered into the database before a report could be generated. This process was time-consuming for all concerned. The time lag between data collection and data reporting also meant that the information was out of date, making it difficult for tissue viability nurses to implement care for patients at risk. For example, if a ward reported a large number of hospital-acquired pressure ulcers, this might not have been apparent to the tissue viability team until one month later. These time lags were frustrating for the specialist nurses because of the delay in initiating appropriate management for patients. Pressure ulcer incidence data were not always validated by specialist nurses. There were concerns that other wound types, such as trauma wounds and incontinence-associated dermatitis, were being reported as pressure ulcers. The differentiation between pressure ulcers and these other wound types can be problematic for non-specialist nurses (Defloor et al 2005, Houwing et al 2007). Patients may have been moved to another area of the hospital or discharged by the time the completed incidence forms reached the specialist team. Assurance could not be given about the accuracy of data reported internally and externally, since tissue viability nurses had not validated the pressure ulcers. An annual pressure ulcer prevalence audit demonstrated that 50% of reported pressure ulcers were wounds of another aetiology (Royal United Hospitals Bath NHS Foundation
TABLE 1 Pressure ulcer categories Category
Description
1
Intact skin with non-blanchable redness of a localised area; usually over a bony prominence. Darkly pigmented skin may not have visible blanching. Colour may differ from surrounding area.
2
Partial-thickness loss of dermis; presents as a shallow open ulcer or as an intact, open or ruptured blister. This category is not used to describe incontinence-associated dermatitis, maceration or excoriation.
3
Full-thickness tissue loss; bone or tendon not exposed. Slough may be present but does not obscure depth of tissue loss. May include undermining and tunnelling.
4
Extensive destruction; with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunnelling.
Purple or maroon area of discoloured intact skin may indicate suspected deep tissue injury. (Adapted from National Pressure Ulcer Advisory Panel et al 2014)
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Art & science tissue viability supplement Trust 2010); therefore, the reported pressure ulcer incidence was higher than the actual incidence. This issue was pertinent since the national Commissioning for Quality and Innovation (CQUIN) payment (NHS England 2014) included national and local measures relating to pressure ulcer incidence.
Development of the electronic patient record Having decided to document pressure ulcer risk assessment and incidence electronically, the trust started using the Cerner Millennium healthcare information system in July 2011. This electronic patient record system provides an individual electronic care record for each patient and clinical tools for healthcare staff. Use of this system enables doctors, nurses, other healthcare professionals and managers to have secure access to reliable and current information at all times. It was determined that an electronic system to document pressure ulcer risk assessment and incidence could be created using the system. The primary aim was to design a system for recording pressure ulcer incidence that would allow tissue viability nurses to provide timely advice on and validation of the categories of pressure ulcers (National Pressure Ulcer Advisory Panel (NPUAP) et al 2014). A secondary aim was to design an electronic system to assess patients’ risk of developing a pressure ulcer. A team of tissue viability and quality improvement nurses designed the system, with contributions from the information technology (IT) team, the quality improvement team and the senior nurse for quality improvement. The system included pressure ulcer risk assessment using a modified pressure ulcer risk assessment tool (Bergstrom et al 1987) and allowed for assessment on admission and ongoing reassessment. This was part of creating a complete electronic patient record with a focus on significantly improving patient safety and standards of patient care, as mandated by the Health and Social Care Act 2012. The NHS Safety Thermometer (2014) introduced the concept of measuring harm caused to patients as a means of measuring progress in providing a harm-free care environment. Thus, the electronic record system was extended to record harm events relating to pressure ulcers. The idea was to record pressure ulcers present on admission on the initial risk assessment electronic form (e-form), which also included core aspects of nursing care, such as infection status, falls and mobility risk, communication needs and mental health assessment. A pressure ulcer that developed
during a hospital stay would then be recorded as a harm event during subsequent risk assessments. The quality improvement, tissue viability and IT teams at the trust implemented the complete electronic system for recording pressure ulcer risk assessment and incidence in May 2013. The system is password protected, and confidentiality is further protected by a hierarchy of permissions – for example, tissue viability nurses can view data that are unavailable to ward team members. It is also possible to track which users have viewed which data.
Use of the electronic patient record The changes to patient assessment and data collection were staggered. The initial risk assessments went live in July 2011, with the recording of harm events going live in May 2013 and the modified pressure ulcer risk assessment in May 2014.
Initial risk assessment
Patients have a pressure ulcer assessment on admission to the hospital. Nursing staff record the findings of this skin check on the initial risk assessment e-form on the electronic system, including pressure ulcer site, category, date it was noted and in what setting it developed – an important record of whether the pressure ulcer was present on admission or hospital acquired. The system allows ward staff to record these findings on the electronic patient record and make an immediate, direct referral to the tissue viability nurses if a patient has a pressure ulcer of category 2 or above (NPUAP et al 2014). Comment boxes are included on the form to allow nursing staff to record the reasons for referral and any relevant patient history.
Pressure ulcer risk assessment process
Training in the use of the modified pressure ulcer risk assessment tool occurred in a cascade process via the tissue viability link nurse network. The requirement is that an initial modified pressure ulcer risk assessment should take place within six hours of admission, followed by assessment whenever there is a change in clinical status (NICE 2014), or every 48 hours thereafter regardless of the level of risk, to simplify the reassessment system.
Pressure ulcer incidence: harm events
Any pressure ulcer present at admission would be recorded in the initial risk assessment, but a pressure ulcer that develops following admission is recorded as a harm event. The harm event e-form allows nursing staff to record the pressure ulcer site, category and date it was identified, and can generate
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Art & science tissue viability supplement a direct referral to the tissue viability team to enable a prompt response. An audit tool identifies the numbers of patients with pressure ulcers at any time and their locations in the organisation, allowing up-to-date analysis of data trends and timely implementation of preventive pathways.
Referral to tissue viability
Both the risk assessment and harm event forms can generate a referral to the tissue viability team. When a patient has a pressure ulcer of category 2 or above, the staff member can choose to refer them to the team. The system then generates an electronic referral, including all information relating to the pressure ulcer and the patient. The tissue viability team triages these, along with all other referrals, and validates all category 3, 4 and suspected deep tissue injury pressure ulcers as well as many category 2 pressure ulcers. The team is able to validate pressure ulcers in a timely manner and ensure that the reported pressure ulcer incidence is accurate.
This is important from a patient care perspective as well as a data collection and reporting perspective. The treatment and management of pressure ulcers differ from that of other wound aetiologies, such as moisture lesions or incontinence-associated dermatitis; pressure ulcer treatment focuses on avoiding pressure and shear (NICE 2014, NPUAP et al 2014), whereas the management of incontinence-associated dermatitis or moisture lesions focuses on continence (Beeckman et al 2009). Therefore, correct identification of the wound type is essential to ensure the correct treatment is implemented.
Results achieved with the electronic patient record The organisation has seen a reduction in the incidence of hospital-acquired pressure ulcers following the implementation of the electronic system for recording harm events and initial
FIGURE 1 Hospital-acquired pressure ulcer incidence (July 2011 to September 2014) 40 Category 2
Number of hospital-acquired pressure ulcers
35 Category 3 30 Category 4 25 Trendline 20 15 10 5
Jul 2011 Aug 2011 Sep 2011 Oct 2011 Nov 2011 Dec 2011 Jan 2012 Feb 2012 Mar 2012 Apr 2012 May 2012 Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 2013 Apr 2013 May 2013 Jun 2013 Jul 2013 Aug 2013 Sep 2013 Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Mar 2014 Apr 2014 May 2014 Jun 2014 Jul 2014 Aug 2014 Sep 2014
0
Initial risk assessments and pressure ulcer risk assessments introduced
Harm event e-form introduced
Rapid Spread Methodology implemented
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Art & science tissue viability supplement risk assessments (Figure 1). Other patient care initiatives, such as expanding the tissue viability link nurse network and small-scale quality improvement measures, have contributed to this. Improvements to the way data are obtained and the quicker response by the tissue viability team have been instrumental in reducing the number of pressure ulcers acquired. The reductions in pressure ulcer incidence after the introduction of the initial risk assessment in July 2011 and the harm event in May 2013 are shown in Figure 1. There were periods when there were increases in the number of category 2 pressure ulcers recorded, for example between September 2012 and March 2013 and July and August 2013. These increases may have been a result of the increased reporting through the electronic system. The electronic system captures 100% of pressure ulcer incidence forms, whereas only 60% of the paper forms used previously were received on time from wards. The increased incidence in July and August 2013 occurred after the harm event e-form was introduced, and this introduction may have been a factor in the increased number of pressure ulcers reported. There is an overall downward trend in the number of hospital-acquired pressure ulcers recorded from May 2013 to September 2014 (Figure 1). This is most evident in the number of category 2 pressure ulcers. There were up to four category 3 pressure ulcers and one category 4 pressure ulcer over the time period covered; however, no incidences of category 3 or 4 hospital-acquired pressure ulcers were recorded between December 2013 and September 2014.
Improved patient experience
The rapid response by tissue viability nurses to pressure ulcers reported using the electronic risk assessments has enabled care planning to be provided promptly by the specialist nurse. This ensures that the best treatment plan is in place to prevent further harm to patients.
Incident reporting
The electronic system provides easily accessible data from a live system. It provides accurate reports for all users from board to ward (for example, the ward scorecard, a daily measurement of quality standards throughout the organisation). Evaluation of how effectively ward staff are using the system can be made by cross-referencing the numbers of pressure ulcers recorded with those on the trust’s incident reporting system, which is used to report incidents internally and externally. Implementation of electronic recording of patient assessments has improved documentation compliance and enabled rapid audit and validation
of data. The system provides a snapshot of compliance in real time. It is important to record accurate data since pressure ulcers are a key quality target, indicating the quality of care in an organisation. The organisation is committed to providing safe care and minimising patient harm. The accurate recording of data enables early validation of pressure ulcers, as well as implementation of safe and effective prevention plans.
Audit data
The average completion rate for initial pressure ulcer assessments throughout the organisation was 98%. This is an improvement on 2011, when audits of the paper-based risk assessments found the average timely completion rate was around 45%. Data on the ongoing assessments of risk showed a minimum 96% compliance.
Referral process
Tissue viability nurses are now aware of pressure ulcer risk and harm events quickly after they are documented. This has improved the referral process, allowing prioritisation of patients and validation of pressure ulcers on the day they are reported. This process has allowed tissue viability nurses to address inaccurate classification, for example when a wound recorded as a pressure ulcer is actually incontinence-associated dermatitis. Training on pressure ulcer categorisation is provided to all nursing staff, and nurses are now more likely to refer patients to the tissue viability team because the process is simpler. Nurses receive online notification from the tissue viability team that the referral has been received and triaged and that appropriate action has been taken.
Quality assurance
Tissue viability nurses and senior sisters can monitor standards of care and quality indicators via pressure ulcer incidence reports, and monitor completion of e-forms for each ward from their computers. For example, a ward manager can view all of a ward’s pressure ulcer risk assessments on one screen and easily identify which patients require reassessment. Another important benefit to patients is that the organisation can provide the evidence (data) that risk is being assessed. These data can be obtained from any computer.
Clinical guidance
When entering details of a pressure ulcer into the electronic patient record, nurses can access reference information on the system, including NPUAP et al (2014) guidance on the categories of pressure ulcer. This guidance includes descriptions
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of the categories of pressure ulcer, photographs of examples in each category, and details of the nursing care and actions that should be taken to manage the different categories.
Education and shared learning from clinical incidents
The tissue viability nurses have accurate trust-wide information on patients who are at risk of developing pressure ulcers and those with pressure ulcers that have been reported as a harm event. The ability to readily identify areas with a higher incidence and greater risk of pressure ulcers enables the specialist nurses to focus their resources and provide support to wards through specialist intervention. It also enables them to share learning from clinical incidents, potentially avoiding harm to other patients.
Future developments With an effective system in place for accurate recording of pressure ulcer risk assessments and incidence data, the organisation can focus on ensuring that best practice is followed. A Rapid Spread Methodology for pressure ulcer prevention was implemented in June 2014 (Figure 1), with the aim of achieving zero avoidable hospital-acquired pressure ulcers (Department of Health 2011).
Information on the Rapid Spread Methodology is provided in the second article in this tissue viability supplement (Heywood et al 2015). Following the success of this initiative, an electronic system for falls harm has been implemented and electronic recording of other events, such as insertion of a urinary catheter and safeguarding, is being developed.
Conclusion Introducing an electronic system for recording pressure ulcer risk and incidence has enabled staff to obtain real-time data on hospital-acquired pressure ulcers and enabled them to make improvements to patient care and minimise patient harm. The system has improved the referral process for tissue viability nurses and ward nurses, allowing more efficient use of their time, the ability to focus on pressure ulcer prevention and to spend more time with patients. Reductions in reported pressure ulcer incidence reflect the early access to specialist advice as well as an increased awareness of pressure ulcer risk and the need for prevention on the wards. The authors would recommend this electronic system to other healthcare organisations as an accurate way to record pressure ulcer risk assessment and incidence NS
References Beeckman D, Schoonhoven L, Verhaeghe S, Heyneman A, Defloor T (2009) Prevention and treatment of incontinence-associated dermatitis: literature review. Journal of Advanced Nursing. 65, 5, 1141-1154. Bennett G, Dealey C, Posnett J (2004) The cost of pressure ulcers in the UK. Age and Ageing. 33, 3, 230-235. Bergstrom N, Braden BJ, Laguzza A, Holman V (1987) The Braden scale for predicting pressure sore risk. Nursing Research. 36, 4, 205-210. Dealey C, Posnett J, Walker A (2012) The cost of pressure ulcers in the United Kingdom. Journal of Wound Care. 21, 6, 261-266. Defloor T, Schoonhoven L, Fletcher J et al (2005) Statement of the European Pressure Ulcer Advisory Panel – pressure ulcer classification: differentiation
between pressure ulcers and moisture lesions. Journal of Wound, Ostomy and Continence Nursing. 32, 5, 302-306. Department of Health (2011) Defining Avoidable and Unavoidable Pressure Ulcers. tinyurl.com/cprcnn6 (Last accessed: June 12 2015.) Downie F, Guy H, Gilroy P, Royall D, Davies S (2013) Are 95% of hospital-acquired pressure ulcers avoidable? Wounds UK. 9, 3, 16-22. Heywood N, Brown L, Arrowsmith M, Poppleston A (2015) A quality improvement programme to reduce pressure ulcers. Nursing Standard. 29, 46, 62-70. Hibbs PJ (1988) The Economic Benefits of a Prevention Plan for Pressure Sores. Conference presentation. Fourth National Pressure Sore Symposium. April 20, Bath.
Houwing RH, Arends JW, Canninga-van Dijk MR, Koopman E, Haalboom JR (2007) Is the distinction between superficial pressure ulcers and moisture lesions justifiable? A clinical-pathologic study. Skinmed. 6, 3, 113-117. Moore M, Cowman S (2009) Quality of life and pressure ulcers: a literature review. Wounds International. 5, 1, 58-65. National Institute for Health and Care Excellence (2014) Pressure Ulcers: Prevention and Management of Pressure Ulcers. Clinical guideline No. 179. NICE, London. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Cambridge Media, Perth. NHS England (2014) Commissioning for Quality and Innovation
(CQUIN): 2014/15 Guidance. tinyurl.com/p52f6s5 (Last accessed: June 12 2015.) NHS Safety Thermometer (2015) NHS Safety Thermometer. It’s Not Just Counting, It’s Caring. www. safetythermometer.nhs.uk/ (Last accessed: June 12 2015.) Pedley GE (2004) Comparison of pressure ulcer grading scales: a study of clinical utility and inter-rater reliability. International Journal of Nursing Studies. 41, 2, 129-140. Royal United Hospitals Bath NHS Foundation Trust (2010) Annual Pressure Ulcer Prevalence Audit. Royal United Hospitals Bath NHS Foundation Trust, Bath. Spilsbury K, Nelson A, Cullum N, Iglesias C, Nixon J, Mason S (2007) Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. Journal of Advanced Nursing. 57, 5, 494-504.
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