Taking the pressure off NHS Resources

Pressure ulcers cost the National Health Service (NHS) tens of millions of pounds each year in wasted resources – wasted because these wounds require additional resources and are deemed largely preventable if appropriate operational and clinical resources are in place. And yet despite this waste, pressure ulcers have never had the attention that other ‘preventable’ conditions such as MRSA seem to receive.

One NHS Trust in Walsall, however, is determined to buck this trend, and has for the last 12 months been working with ArjoHuntleigh on an imaginative Pressure Ulcer Prevalence Quality Management initiative, a clinical audit that is making a real, measurable difference to the quality of care delivered to Trust patients.

The story goes back to Summer 2008 when a visit by the Care Quality Commission (CQC) identified issues in the way that the Trust approached this subject matter. Brigid Stacey, the Trust’s Director of Nursing and no stranger to the subject of pressure damage, took immediate action, securing funding for an equipment contract and appointing a Lead Nurse, Helen Shoker, to support a dedicated Tissue Viability Service team.

Reporting of pressure ulcers through the clinical incident system was promoted, Helen explains: “There was now a real desire for change,” she says. “We found that the number of patients reported with pressure damage exceeded other incidents and therefore action was needed to change this situation.

“Although this was a major concern for the organisation, it was the first time that there was real visibility of the extent of the problem, and therefore the extent of the challenge.”

Desire for change
The hospital’s desire for change coincided with the latest development within ArjoHuntleigh’s Assessment Service, a clinical quality assessment that provides a holistic approach to the prevention of pressure ulcers: “We had an existing contract with ArjoHuntleigh and within that was a commitment to provide an auditing service,” Helen continues.

“I didn’t believe that simply describing or counting the number of pressure ulcer incidents was enough. I just thought ‘and now what?’ The emphasis should be on what preventative and treatment measures we have in place, and how we audited the quality and timeliness of the care we delivered. Only through implementing key, targeted actions could any change be achieved, otherwise it was simply a counting exercise. These thoughts coincided with ArjoHuntleigh’s own work in developing its Pressure Ulcer Prevention & Outcome Assessment, and when I saw the first draft audit document, it was exactly what I had in mind.”

As a pilot for this Assessment Service initiative, Walsall Hospitals NHS Trust undertook a thorough clinical assessment alongside experienced clinical teams from ArjoHuntleigh. A Link nurse was appointed for each ward, responsible for completing the assessment documentation. A 10 per cent sample of these documents was then re-checked as part of the validation process.

The report was presented to the Director of Nursing, the Heads of Nursing and the Trust Board. On the one hand, it confirmed that the strategy that Helen and her team were following was the right one; on the other, it put further detail around the ‘significant gaps’ in care to which Helen had previously alluded: “In emergency admission areas, we found that on some occasions staff were not able to assess the clinical needs of the patient for 48 hours, which simply wasn’t timely for implementing preventative strategies,” she says.

“Faster assessment means prompter care. Prompter care means that patients return home sooner with a lower risk of healthcare associated complications. That in turn means there is less cost to the hospital, the patient ‘experience’ is improved, and the reputation of the hospital is enhanced.”

It also identified gaps in education and training: “Nurses and doctors assess patients in a particular way and skin integrity seldom features as part of their base-line assessment,” she adds. “Historically skin assessment and pressure ulcer risk assessment has had a low profile, so changing staff perceptions and practice has been very important.”

The Pressure Ulcer Prevention & Outcome Assessment not only gave the clinicians pause for thought, however. It was also able to put an accurate figure on the cost of hospital-acquired Pressure ulcers to satisfy those controlling the budgets. In this case, the figure stood at around £3 million for the hospital-acquired pressure damage.

Since the new assessment  was started, there have been some major changes in the care delivered. New education strategies have been put in place; patients are now assessed upon arrival to emergency areas so that care regimes can be implemented sooner; and a new awareness programme, ‘Your Turn’, has been launched for patients and their relatives to involve them more actively in the process.
The ongoing nature of the initiative means that the audit is essentially a ‘live’ document, and that has allowed for a Quarterly Dashboard to be created so that the Trust’s performance can be continually monitored, and the results of its improvements clear to all.

Financial imperative
The timing of the Trust’s actions could not have been better. Now there is a quality and financial imperative for improvements. From April 2010, new commissioning targets came into being to reduce the effects of pressure ulcers. Failing to meet those targets could mean financial penalties, and budgets being withdrawn. The target set for Walsall is for a 10 per cengt reduction in the incidence of hospital-acquired pressure ulcers over the next 12 months, and to achieve the quality standards in 77 per cent of cases in the first year.
An impossibly high target would serve no purpose, Helen explains: “The targets might seem relatively modest, but what is important is to make progress step-by-step, to see real improvements, benchmark our performance, and then aim to achieve more the following year,” she says.

“This is about an improvement process involving many within our organisation, with changes in operational systems, staff perceptions and actions and should not be simply a burdensome audit or target. The positive results seen within infection prevention and the reduction of acquired infections took time, commitment and energy to deliver; we need to consider pressure damage in the same manner, with a supported, consistent and appropriate response.”

The utopian world of zero cases may never be achieved, since certain patient types will always be more vulnerable than others. “What we can do,” says Helen, “is demonstrate that we have the measures in place, and an improved delivery of care, to keep incidents as low as possible.”

Comparisons between NHS organisations is probably inevitable; however this needs to be undertaken with caution, Helen says: “Methodology, case mix adjustment and comparison to national data sets should be fundamental, as is offered through the Pressure Ulcer Prevention & Outcome Assessment. Tissue Viability services and the NHS approach to pressure ulcer prevention and management has not received much attention in previous years,” she adds, “but with the identification of Skin Matters, one of the High Impact Actions, this will provide an impetus for change.”

In this she has the complete support of the Trust Board: “They have been supportive from the start,” she says, “and understand that we must keep the patient at the centre of our service.

“Today, things are improving. Pressure ulcers will follow MRSA as one of the last major issues for healthcare settings to resolve, and the investment that we have made so far will have a positive impact on our local community which we hope can act as an example of good practice for other NHS organisations.”

For more information:
www.walsallhospitals.nhs.uk
www.arjohuntleigh.com