Reducing hospital-acquired pressure damage: an NHS acute trust initiative Joan Bedo ■■ Good
During 2009, Maidstone and Tunbridge Wells NHS Trust reviewed its pressure ulcer prevention strategy; this included patient interventions and equipment provision. Standard hospital mattresses were requiring replacement and dynamics were used frequently, while the overall prevalence of pressure damage remained high. Replacing the standard foam mattress with a non-powered pressure-redistributing system (AtmosAir) was proposed. The rationale for this was that by renewing all standard foam mattresses with the AtmosAir 4000, all patients would have immediate access to a pressure redistributing mattress. Training and education of staff was increased and the Trust redesigned documentation. The outcome of this approach was a significant reduction in hospital-acquired pressure damage. Key words: Pressure ulcers adjusting technology
■
Pressure redistributing mattress
■
Self-
M
aidstone and Tunbridge Wells (MTW) NHS Trust is a large 700-bed acute trust, comprising two hospitals 27 km (18 miles) apart, with a small 12-bed stroke rehabilitation unit located off site. The Trust provides a full range of services to a population of 500 000 people in the local area and specialist cancer services to 1.9 million people throughout Kent and Medway, and parts of East Sussex. Before 2009, static foam mattresses were used as the standard mattress in the Trust. Patients assessed as at risk of pressure ulceration had access to a replacement dynamic alternating therapy system. Patients with oedema, fragile friable skin, category 3 and 4 pressure ulcers (European Pressure Ulcer Advisory Panel (EPUAP), 2009) and uncontrolled pain management were placed on a rented low-air-loss mattress. Trust protocols for pressure ulcer prevention strategies were based on National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 29 (2005) and EPUAP guidance (2009). They comprised the following: ■■ Patient repositioning ■■ Nutritional support
Joan Bedo is Tissue Viability Clinical Nurse Specialist, Maidstone and Tunbridge Wells NHS Trust Accepted for publication: October 2013
S24
skin care with use of skin cleansing and rehydration products ■■ Continence management ■■ Use of preventive equipment, including pressureredistributing mattresses, cushions, electric profiling beds and manual-handling equipment. The Trust’s tissue viability nurse (TVN) delivered training and education on pressure ulcer prevention. This included some formal teaching sessions for the registered nurses and the clinical support workers, but was mainly opportunistic training and advice given on the wards. Tissue viability link nurse training days, held twice yearly, also focused on pressure ulcer prevention, with the expectation that this information would be cascaded down to ward level. Despite heavy use of the alternating dynamic systems and low-air-loss systems, rates of hospital-acquired pressure ulcers (HAPUs) remained high. In 2009, the annual HAPU prevalence and incidence rates were 23% and 12% respectively—above the national average. Clearly, the Trust needed to improve these clinical outcomes, while reducing costs and operational inefficiencies. The director of nursing, the tissue viability clinical nurse specialist (CNS) and the heads of nursing decided to review the Trust’s pressure ulcer prevention strategies.
Key areas for consideration The 2008–2009 mattress audit identified that a high number (25%) of static foam mattresses required replacement because of strikethrough, bottoming out or damage to the cover (before this date, annual audits had been undertaken and the need for replacement was found to be small; the stock of mattresses was coming to the end of its functional life). The prospect of further static foam replacements during the next financial year and the fact that the rental agreement relating to the dynamic mattresses was about to expire led the review board to consider the use of alternative pressureredistributing equipment. Talks with key stakeholders, including nurse managers, infection prevention leads and financial managers, identified that the pressure ulcer prevention equipment had to be evidence-based, sustainable, cost-efficient and comply with the Trust’s infection prevention policy. A key issue was access to pressure-redistributing systems out of hours, as anecdotal evidence indicated it took longer to find an appropriate support surface for high-risk patients at these times. Initially, the Trust explored the possibility of purchasing a number of replacement dynamic systems, but decided against this owing to decontamination requirements and storage issues.
© 2013 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights reserved.
Figure 1. The AtmosAir 4000
In 2007–2008, the tissue viability CNS had been shown a non-powered pressure-redistributing system that used SAT—a system of dynamic air chambers and cut-off valves that help to maximise body-weight displacement and minimise tissue-interface pressure by automatically adjusting the internal air pressures in response to body movement, altitude and temperature. This technology is used in the AtmosAir 9000 and AtmosAir 4000 (Figure 1) (both currently manufactured by ArjoHuntleigh). Both systems offer a high degree of pressure redistribution. The AtmosAir 4000 has four longitudinally positioned cells, which help protect the torso and sacral area. The AtmosAir 9000 offers a higher degree of protection because of its nine transversally positioned cells with SAT, which offer additional support under the shoulders, torso and seat through non-powered pressure redistribution and a sloping heel section that helps transfer weight off the delicate heel and onto the calf and thigh. Maintenance is minimal; yearly formal mattress audits would identify systems that required cover changes owing to damage or ingress of fluids. Internal foam cores and the cells could be replaced independently. Cleaning would be in line with local infection prevention guidance, with no need to remove the mattresses from the Trust for decontamination. In 2008, MTW had undertaken a small evaluation of the AtmosAir 4000 in an acute orthopaedic ward. It has been estimated that one third of patients with a hip fracture develop a HAPU (British Orthopaedic Association, 2007). The British Orthopaedic Association report (2007) estimated that approximately 70 000 patients present in the UK each
S26
year with a fractured neck of femur, with most being over 70 years of age. These patients are frequently admitted out of hours, and so can be at increased risk of HAPU because of the potential delay in accessing a pressure-redistributing support surface. However, according to Trust policy, patients with fractured neck of femur are fast-tracked through accident and emergency (A&E) onto the ward in order to reduce time spent on trolleys. In 2007, the incidence of HAPU on the orthopaedic ward had been 12%. For the evaluation, four patients admitted to the ward with a fractured neck of femur were placed on an AtmosAir 4000 mattress (four were loaned to the hospital for a month). None of the four patients developed pressure ulcers or skin damage. Evaluations from therapists and nursing staff indicated that another advantage was that the mattress edge remained stable when the patient started rehabilitation.
A new approach The review board developed a proposal to implement a Trust-wide pressure ulcer prevention strategy. As part of this proposal, it was recommended that the AtmosAir should be used as the standard mattress throughout the hospital to ensure that all patients would have immediate access on admission to a pressure-redistributing mattress (the exception was patients with spinal fractures, for whom the mattress is contraindicated). This meant that all patients, including those admitted via A&E with limb fractures, could be placed directly onto a pressure-redistributing system at admission. Education and training were considered prerequisites for achieving successful outcomes, and arrangements were made to ensure that communication channels with matrons
© 2013 MA Healthcare Ltd
Self-adjusting technology (SAT)
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights reserved.
© 2013 MA Healthcare Ltd
product focus
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 20
30 Pressure Ulcer Prevalence
and directorate heads would remain open to facilitate this. This was inspired by a paper by Bales and Padwojski (2009) detailing a strategic approach that enabled a USA hospital to reduce the prevalence of HAPUs from 9.5% to 0% in 1 year. As well as emphasising the need for education and training, Bales and Padwojski highlighted the need to support ward teams in delivering excellent nursing interventions and to deliver the fundamentals of nursing care in a timely manner. The aim was to nurture such a culture within the Trust. As such, it was vital to gain support from nursing and Trust board management for the pressure ulcer prevention strategies developed by the TVN. The proposal included a business case, presented to the Trust board, that purchase of the AtmosAir would reduce the number of HAPUs and eventually result in reduced financial outlay as fewer dynamic systems would be hired. It was also suggested that, by reducing the need to upgrade and downgrade mattresses, it would save nursing time. In-house testing of the mattresses was undertaken by the electrical engineering department, for the risk of entrapment with the Trust’s current bed frame and proposed new bed frames, to ensure that the mattresses complied with Medicines and Healthcare Products Regulatory (2006) guidance, identified no risks. The proposal was accepted and funding for the purchase of the AtmosAir was secured. A procurement order was placed with the manufacturer, and the Trust purchased 600 AtmosAir 4000s and 20 AtmosAir 9000s, based on calculations of patient need, drawn on previous experience of using dynamic mattress systems. Low-air-loss systems continued to be made available for patients requiring a higher level of pressure prevention (patients with high specific risks of pressure damage, unstable skin integrity owing to multi-organ failure, oedema or in significant pain). Patients requiring intensive care interventions continued to be nursed on dynamic alternating systems. Allocation to either the AtmosAir 9000 or 4000 was based on each individual patient’s pressure ulcer risk status and comorbidities. Patients with diseases such as motor neurone disease, multiple sclerosis and other complex limiting conditions were, at times, identified as requiring additional pressure prevention requirements of the 9000. These decisions were made by the multidisciplinary team. The proposal to purchase and install the AtmosAir mattresses had the support of the nursing teams, therapists and nurse managers. Health professionals, including nurses, physiotherapists and occupational therapists, were invited to training sessions about the system. The therapists, in particular, were very impressed by its firm perimeter; the stability provided seating support for the patient when starting rehabilitation. Nursing staff also commented that the firmness of the mattresses enabled effective and safe moving and handling. It was also noted that it would not require mechanical deflation in the event of a cardiac arrest. Patients and relatives were informed about the change in mattress provision, and the benefits it would bring. Following the installation of the AtmosAir mattresses, the incidence of HAPUs fell by 70% (November 2009 to January 2012). In the orthopaedic unit, the HAPU incidence
25 20 Overall prevalence Hospital acquired Trend
15 10 5 0
2009
2011
2012
Figure 2. Post-installation prevalence audit
Table 1. Pressure ulcer prevalence and incidence rates Prevalence
Incidence
January 2013
5.5%
2.5%
October 2012
5.4%
2.2%
January 2012
10.6%
3.6%
2011
22.7%
8%
2010
N/A
N/A
2009
23.2%
12%
fell from 16% to 12% in one year alone (2007–2008). Since installation in 2009, the Trust has averaged use of seven dynamic low air-loss replacement systems at any one time, a reduction of 90%. As the standard of base mattress improved, so too did patient self-reported comfort and satisfaction.
Prevalence audit In January 2010, the manufacturers of AtmosAir undertook a post-installation prevalence audit, which was verified and monitored by the tissue viability CNS. The results were encouraging, with a small reduction in HAPUs. However, because of anomalies in technical data collection and reporting, actual incidence figures are unavailable. However, subsequent incidence and prevalence audits undertaken in-house, with support, data collation and report writing from the Trust audit department, showed a dramatic reduction in the incidence of HAPUs (Table 1 and Figure 2). The prevalence audit was undertaken on one specified day. Staff from all wards were required to complete an audit tool (verified by the audit department as reliable) asking them to identify every patient with EPUAP category I–IV pressure ulcers. An auditing team comprising the tissue viability link nurses then assessed all of the identified patients to validate the cause of the pressure ulcer and its category. The TVN acted as the adjudicator when necessary. This approach ensured that moisture lesions were not included as pressure ulcers, which could have skewed the results. The audit department undertook the data analyses and report writing.
Supporting strategies to reduce HAPUs The reduction in HAPUs were a result of a multifaceted approach that, along with Trust-wide implementation of the AtmosAir, included better education, training, greater
S27
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights reserved.
Key points n Maidstone and Tunbridge Wells NHS Trust prevention of HAPU strategy included the use of non-powered pressure redistributing mattresses n In line with the NHS Harm Free Care initiatives, 95% of all patients now have the pressure-redistributing equipment they need on arrival n The reduction in HAPU was a Trust-wide initiative and concomitant strategies had a key part to play in the sustained reduction of pressure ulcers n The installation of the AtmosAir mattresses has contributed to the sustained reduction of HAPUs
awareness of and more managerial support for pressure ulcer prevention, and improvements in care provision. One of the eight High Impact Actions (NHS Institute for Innovation and Improvement, 2009) is to prevent avoidable pressure ulcers. This motivated the Trust to focus on pressure ulcer prevention. The link-nurse study days were held twice a year and focused on prevention techniques, accurate categorisation of pressure damage, and how to differentiate moisture lesions from actual pressure damage. The link nurses were then required to communicate their learning down to ward or department teams, with local audits being undertaken on the wards to validate the learning. Essence of Care audits were also taken into consideration when reviewing ward activity. The moving and handling coordinator reviewed the training package to ensure that taught practices were consistent with the mattress in place. An E-reporting system was set up to distinguish between those patients admitted to hospital with skin damage and those who sustained HAPUs during their hospital stay. All patients admitted also had a fully documented skin inspection to determine skin damage, enabling the Trust to record HAPUs accurately. Accurate documentation and recording is an integral part of nursing and midwifery practice, being essential to the provision of safe and effective care (Nursing and Midwifery Council, 2009).Working with the Professional Standards Team, the TVN helped redesign the documentation to reflect the needs of patients at risk of pressure damage. A skin-bundle format was introduced using the initials SKIN (Surface, Keep moving, Incontinence and Nutrition) to form the basis of pressure ulcer assessment and management. Core care plans for prevention and management of pressure damage and moisture lesions were introduced, for use in conjunction with the skin-bundle tool. Subsequent audits of documentation have shown an improved accuracy and frequency of documentation.
The AtmosAir was shown to be effective in the prevention and treatment of pressure ulcers, contributing to an overall reduction in the prevalence and incidence of HAPUs. The addition of this mattress to the preventative programme within the Trust was a positive initiative, though it must be acknowledged that concomitant strategies put in place also had a key part in the reduction of HAPUs, and were part of a continuing programme in which the Trust has invested. The right mix of AtmosAir and dynamic system rentals and reduction in power spending contributed to the Trust’s costimprovement programme. In line with the NHS Harm Free Care initiatives (Department of Health, 2013), 95% of all patients now have the pressureredistributing equipment they need on arrival. The MTW NHS Trust has adopted a zero-tolerance policy to HAPUs. All HAPUs undergo a root cause analysis (RCA), and category III and IV pressure damage is declared as a serious incident, to be investigated by a formal panel chaired by the Deputy Chief Nurse and including the tissue viability CNS, safeguarding matron and a member of the patient-safety team. The panel determines whether the pressure damage was avoidable or unavoidable. The incidence of category III/IV HAPUs has significantly fallen since 2010. A trend has been identified in a number of HAPUs reviewed at the serious incident panel; the use of orthopaedic devices and non-invasive ventilation masks have been identified as a significant contributing factor to pressure ulcers. The trend has been addressed within the Trust with a multidisciplinary review of the identified devices and a revision of types of device used. Category II ulcers’ RCAs are reviewed by the TVNs with actions and comments discussed directly with the ward manager. It is imperative that the prevention of pressure damage remains high on the health agenda. Harm-free patient care BJN must remain a priority for all health professionals. Conflict of interest: the author has received no financial or other support from ArjoHuntleigh for the publication of this article.
Bales I, Padwojski A (2009) Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 18(4): 137–44 British Orthopaedic Association (2007) The Care of Patients with Fragility Fracture. British Orthopaedic Association, London Department of Health (2013) Harmfreecare: a new mindset in patient safety improvement. http://harmfreecare.org/ (accessed 26 October 2013). European pressure ulcer advisory panel (2009) Pressure ulcer treatment – quick reference guide. http://tinyurl.com/ygjykjx (accessed 28 October 2013) Medicines and Healthcare Products Regulatory Agency (2006) Safe use of bed rails. http://tinyurl.com/mhvrsl (accessed 26 October 2013) National institute for Health and Care Excellence (2005) Clinical guidance 29 pressure ulcer prevalence and treatment. NICE, London NHS Institute for Innovation and Improvement (2009) High Impact Actions. http:// tinyurl.com/y964por (accessed 28 October 2013) Nursing and Midwifery Council (NMC) (2009) Record keeping: guidance for nurses and midwives. NMC, London. http://tinyurl.com/9w9eqoy (accessed 28 October 2013)
CALL FOR CLINICAL PAPERS Do you have a research, education or clinical issue you would like to write about? Send your manuscript to: The editor | British Journal of Nursing, MA Healthcare Ltd | St Jude’s Church | Dulwich Road | London SE24 0PB e: [email protected] | t: 020 7501 6702 S28
© 2013 MA Healthcare Ltd
Discussion
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights reserved.
During 2009, Maidstone and Tunbridge Wells NHS Trust reviewed its pressure ulcer prevention strategy; this included patient interventions and equipment provision. Standard hospital mattresses were requiring replacement and dynamics were used frequently, while the overall prevalence of pressure damage remained high. Replacing the standard foam mattress with a non-powered pressure-redistributing system (AtmosAir) was proposed. The rationale for this was that by renewing all standard foam mattresses with the AtmosAir 4000, all patients would have immediate access to a pressure redistributing mattress. Training and education of staff was increased and the Trust redesigned documentation. The outcome of this approach was a significant reduction in hospital-acquired pressure damage. Key words: Pressure ulcers adjusting technology
■
Pressure redistributing mattress
■
Self-
M
aidstone and Tunbridge Wells (MTW) NHS Trust is a large 700-bed acute trust, comprising two hospitals 27 km (18 miles) apart, with a small 12-bed stroke rehabilitation unit located off site. The Trust provides a full range of services to a population of 500 000 people in the local area and specialist cancer services to 1.9 million people throughout Kent and Medway, and parts of East Sussex. Before 2009, static foam mattresses were used as the standard mattress in the Trust. Patients assessed as at risk of pressure ulceration had access to a replacement dynamic alternating therapy system. Patients with oedema, fragile friable skin, category 3 and 4 pressure ulcers (European Pressure Ulcer Advisory Panel (EPUAP), 2009) and uncontrolled pain management were placed on a rented low-air-loss mattress. Trust protocols for pressure ulcer prevention strategies were based on National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 29 (2005) and EPUAP guidance (2009). They comprised the following: ■■ Patient repositioning ■■ Nutritional support
Joan Bedo is Tissue Viability Clinical Nurse Specialist, Maidstone and Tunbridge Wells NHS Trust Accepted for publication: October 2013
S24
skin care with use of skin cleansing and rehydration products ■■ Continence management ■■ Use of preventive equipment, including pressureredistributing mattresses, cushions, electric profiling beds and manual-handling equipment. The Trust’s tissue viability nurse (TVN) delivered training and education on pressure ulcer prevention. This included some formal teaching sessions for the registered nurses and the clinical support workers, but was mainly opportunistic training and advice given on the wards. Tissue viability link nurse training days, held twice yearly, also focused on pressure ulcer prevention, with the expectation that this information would be cascaded down to ward level. Despite heavy use of the alternating dynamic systems and low-air-loss systems, rates of hospital-acquired pressure ulcers (HAPUs) remained high. In 2009, the annual HAPU prevalence and incidence rates were 23% and 12% respectively—above the national average. Clearly, the Trust needed to improve these clinical outcomes, while reducing costs and operational inefficiencies. The director of nursing, the tissue viability clinical nurse specialist (CNS) and the heads of nursing decided to review the Trust’s pressure ulcer prevention strategies.
Key areas for consideration The 2008–2009 mattress audit identified that a high number (25%) of static foam mattresses required replacement because of strikethrough, bottoming out or damage to the cover (before this date, annual audits had been undertaken and the need for replacement was found to be small; the stock of mattresses was coming to the end of its functional life). The prospect of further static foam replacements during the next financial year and the fact that the rental agreement relating to the dynamic mattresses was about to expire led the review board to consider the use of alternative pressureredistributing equipment. Talks with key stakeholders, including nurse managers, infection prevention leads and financial managers, identified that the pressure ulcer prevention equipment had to be evidence-based, sustainable, cost-efficient and comply with the Trust’s infection prevention policy. A key issue was access to pressure-redistributing systems out of hours, as anecdotal evidence indicated it took longer to find an appropriate support surface for high-risk patients at these times. Initially, the Trust explored the possibility of purchasing a number of replacement dynamic systems, but decided against this owing to decontamination requirements and storage issues.
© 2013 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights reserved.
Figure 1. The AtmosAir 4000
In 2007–2008, the tissue viability CNS had been shown a non-powered pressure-redistributing system that used SAT—a system of dynamic air chambers and cut-off valves that help to maximise body-weight displacement and minimise tissue-interface pressure by automatically adjusting the internal air pressures in response to body movement, altitude and temperature. This technology is used in the AtmosAir 9000 and AtmosAir 4000 (Figure 1) (both currently manufactured by ArjoHuntleigh). Both systems offer a high degree of pressure redistribution. The AtmosAir 4000 has four longitudinally positioned cells, which help protect the torso and sacral area. The AtmosAir 9000 offers a higher degree of protection because of its nine transversally positioned cells with SAT, which offer additional support under the shoulders, torso and seat through non-powered pressure redistribution and a sloping heel section that helps transfer weight off the delicate heel and onto the calf and thigh. Maintenance is minimal; yearly formal mattress audits would identify systems that required cover changes owing to damage or ingress of fluids. Internal foam cores and the cells could be replaced independently. Cleaning would be in line with local infection prevention guidance, with no need to remove the mattresses from the Trust for decontamination. In 2008, MTW had undertaken a small evaluation of the AtmosAir 4000 in an acute orthopaedic ward. It has been estimated that one third of patients with a hip fracture develop a HAPU (British Orthopaedic Association, 2007). The British Orthopaedic Association report (2007) estimated that approximately 70 000 patients present in the UK each
S26
year with a fractured neck of femur, with most being over 70 years of age. These patients are frequently admitted out of hours, and so can be at increased risk of HAPU because of the potential delay in accessing a pressure-redistributing support surface. However, according to Trust policy, patients with fractured neck of femur are fast-tracked through accident and emergency (A&E) onto the ward in order to reduce time spent on trolleys. In 2007, the incidence of HAPU on the orthopaedic ward had been 12%. For the evaluation, four patients admitted to the ward with a fractured neck of femur were placed on an AtmosAir 4000 mattress (four were loaned to the hospital for a month). None of the four patients developed pressure ulcers or skin damage. Evaluations from therapists and nursing staff indicated that another advantage was that the mattress edge remained stable when the patient started rehabilitation.
A new approach The review board developed a proposal to implement a Trust-wide pressure ulcer prevention strategy. As part of this proposal, it was recommended that the AtmosAir should be used as the standard mattress throughout the hospital to ensure that all patients would have immediate access on admission to a pressure-redistributing mattress (the exception was patients with spinal fractures, for whom the mattress is contraindicated). This meant that all patients, including those admitted via A&E with limb fractures, could be placed directly onto a pressure-redistributing system at admission. Education and training were considered prerequisites for achieving successful outcomes, and arrangements were made to ensure that communication channels with matrons
© 2013 MA Healthcare Ltd
Self-adjusting technology (SAT)
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights reserved.
© 2013 MA Healthcare Ltd
product focus
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 20
30 Pressure Ulcer Prevalence
and directorate heads would remain open to facilitate this. This was inspired by a paper by Bales and Padwojski (2009) detailing a strategic approach that enabled a USA hospital to reduce the prevalence of HAPUs from 9.5% to 0% in 1 year. As well as emphasising the need for education and training, Bales and Padwojski highlighted the need to support ward teams in delivering excellent nursing interventions and to deliver the fundamentals of nursing care in a timely manner. The aim was to nurture such a culture within the Trust. As such, it was vital to gain support from nursing and Trust board management for the pressure ulcer prevention strategies developed by the TVN. The proposal included a business case, presented to the Trust board, that purchase of the AtmosAir would reduce the number of HAPUs and eventually result in reduced financial outlay as fewer dynamic systems would be hired. It was also suggested that, by reducing the need to upgrade and downgrade mattresses, it would save nursing time. In-house testing of the mattresses was undertaken by the electrical engineering department, for the risk of entrapment with the Trust’s current bed frame and proposed new bed frames, to ensure that the mattresses complied with Medicines and Healthcare Products Regulatory (2006) guidance, identified no risks. The proposal was accepted and funding for the purchase of the AtmosAir was secured. A procurement order was placed with the manufacturer, and the Trust purchased 600 AtmosAir 4000s and 20 AtmosAir 9000s, based on calculations of patient need, drawn on previous experience of using dynamic mattress systems. Low-air-loss systems continued to be made available for patients requiring a higher level of pressure prevention (patients with high specific risks of pressure damage, unstable skin integrity owing to multi-organ failure, oedema or in significant pain). Patients requiring intensive care interventions continued to be nursed on dynamic alternating systems. Allocation to either the AtmosAir 9000 or 4000 was based on each individual patient’s pressure ulcer risk status and comorbidities. Patients with diseases such as motor neurone disease, multiple sclerosis and other complex limiting conditions were, at times, identified as requiring additional pressure prevention requirements of the 9000. These decisions were made by the multidisciplinary team. The proposal to purchase and install the AtmosAir mattresses had the support of the nursing teams, therapists and nurse managers. Health professionals, including nurses, physiotherapists and occupational therapists, were invited to training sessions about the system. The therapists, in particular, were very impressed by its firm perimeter; the stability provided seating support for the patient when starting rehabilitation. Nursing staff also commented that the firmness of the mattresses enabled effective and safe moving and handling. It was also noted that it would not require mechanical deflation in the event of a cardiac arrest. Patients and relatives were informed about the change in mattress provision, and the benefits it would bring. Following the installation of the AtmosAir mattresses, the incidence of HAPUs fell by 70% (November 2009 to January 2012). In the orthopaedic unit, the HAPU incidence
25 20 Overall prevalence Hospital acquired Trend
15 10 5 0
2009
2011
2012
Figure 2. Post-installation prevalence audit
Table 1. Pressure ulcer prevalence and incidence rates Prevalence
Incidence
January 2013
5.5%
2.5%
October 2012
5.4%
2.2%
January 2012
10.6%
3.6%
2011
22.7%
8%
2010
N/A
N/A
2009
23.2%
12%
fell from 16% to 12% in one year alone (2007–2008). Since installation in 2009, the Trust has averaged use of seven dynamic low air-loss replacement systems at any one time, a reduction of 90%. As the standard of base mattress improved, so too did patient self-reported comfort and satisfaction.
Prevalence audit In January 2010, the manufacturers of AtmosAir undertook a post-installation prevalence audit, which was verified and monitored by the tissue viability CNS. The results were encouraging, with a small reduction in HAPUs. However, because of anomalies in technical data collection and reporting, actual incidence figures are unavailable. However, subsequent incidence and prevalence audits undertaken in-house, with support, data collation and report writing from the Trust audit department, showed a dramatic reduction in the incidence of HAPUs (Table 1 and Figure 2). The prevalence audit was undertaken on one specified day. Staff from all wards were required to complete an audit tool (verified by the audit department as reliable) asking them to identify every patient with EPUAP category I–IV pressure ulcers. An auditing team comprising the tissue viability link nurses then assessed all of the identified patients to validate the cause of the pressure ulcer and its category. The TVN acted as the adjudicator when necessary. This approach ensured that moisture lesions were not included as pressure ulcers, which could have skewed the results. The audit department undertook the data analyses and report writing.
Supporting strategies to reduce HAPUs The reduction in HAPUs were a result of a multifaceted approach that, along with Trust-wide implementation of the AtmosAir, included better education, training, greater
S27
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights reserved.
Key points n Maidstone and Tunbridge Wells NHS Trust prevention of HAPU strategy included the use of non-powered pressure redistributing mattresses n In line with the NHS Harm Free Care initiatives, 95% of all patients now have the pressure-redistributing equipment they need on arrival n The reduction in HAPU was a Trust-wide initiative and concomitant strategies had a key part to play in the sustained reduction of pressure ulcers n The installation of the AtmosAir mattresses has contributed to the sustained reduction of HAPUs
awareness of and more managerial support for pressure ulcer prevention, and improvements in care provision. One of the eight High Impact Actions (NHS Institute for Innovation and Improvement, 2009) is to prevent avoidable pressure ulcers. This motivated the Trust to focus on pressure ulcer prevention. The link-nurse study days were held twice a year and focused on prevention techniques, accurate categorisation of pressure damage, and how to differentiate moisture lesions from actual pressure damage. The link nurses were then required to communicate their learning down to ward or department teams, with local audits being undertaken on the wards to validate the learning. Essence of Care audits were also taken into consideration when reviewing ward activity. The moving and handling coordinator reviewed the training package to ensure that taught practices were consistent with the mattress in place. An E-reporting system was set up to distinguish between those patients admitted to hospital with skin damage and those who sustained HAPUs during their hospital stay. All patients admitted also had a fully documented skin inspection to determine skin damage, enabling the Trust to record HAPUs accurately. Accurate documentation and recording is an integral part of nursing and midwifery practice, being essential to the provision of safe and effective care (Nursing and Midwifery Council, 2009).Working with the Professional Standards Team, the TVN helped redesign the documentation to reflect the needs of patients at risk of pressure damage. A skin-bundle format was introduced using the initials SKIN (Surface, Keep moving, Incontinence and Nutrition) to form the basis of pressure ulcer assessment and management. Core care plans for prevention and management of pressure damage and moisture lesions were introduced, for use in conjunction with the skin-bundle tool. Subsequent audits of documentation have shown an improved accuracy and frequency of documentation.
The AtmosAir was shown to be effective in the prevention and treatment of pressure ulcers, contributing to an overall reduction in the prevalence and incidence of HAPUs. The addition of this mattress to the preventative programme within the Trust was a positive initiative, though it must be acknowledged that concomitant strategies put in place also had a key part in the reduction of HAPUs, and were part of a continuing programme in which the Trust has invested. The right mix of AtmosAir and dynamic system rentals and reduction in power spending contributed to the Trust’s costimprovement programme. In line with the NHS Harm Free Care initiatives (Department of Health, 2013), 95% of all patients now have the pressureredistributing equipment they need on arrival. The MTW NHS Trust has adopted a zero-tolerance policy to HAPUs. All HAPUs undergo a root cause analysis (RCA), and category III and IV pressure damage is declared as a serious incident, to be investigated by a formal panel chaired by the Deputy Chief Nurse and including the tissue viability CNS, safeguarding matron and a member of the patient-safety team. The panel determines whether the pressure damage was avoidable or unavoidable. The incidence of category III/IV HAPUs has significantly fallen since 2010. A trend has been identified in a number of HAPUs reviewed at the serious incident panel; the use of orthopaedic devices and non-invasive ventilation masks have been identified as a significant contributing factor to pressure ulcers. The trend has been addressed within the Trust with a multidisciplinary review of the identified devices and a revision of types of device used. Category II ulcers’ RCAs are reviewed by the TVNs with actions and comments discussed directly with the ward manager. It is imperative that the prevention of pressure damage remains high on the health agenda. Harm-free patient care BJN must remain a priority for all health professionals. Conflict of interest: the author has received no financial or other support from ArjoHuntleigh for the publication of this article.
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British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 20
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