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Nurses face new focus on reducing pressure ulcers

Hospital nurses could face extra pressure to hit targets on tissue viability under new rules linking them to trust funding.

NHS trusts will face financial penalties if they fail to halve the number of pressure ulcers in their organisation during the next financial year, under the Department of Health’s Commissioning for Quality and Innovation scheme.

Hospitals and community services already measure pressure ulcer incidence using the NHS Patient Safety Thermometer audit tool. It also pools data on falls, urinary infections in patients with catheters and treatment for venous thromboembolism.

Under the CQUIN scheme, trusts have lost out on income this year if they failed to report a full set of data from the thermometer. However, from April, trusts will also be required to agree a target to reduce pressure ulcers.

New guidance has recommended organisations are challenged to cut grade 2 to 4 pressure ulcers by a minimum of half or risk losing out on part of their funding. A trust with a £300m annual turnover could lose up to £375,000 a year if they fail to meet the target.

Latest data shows 6.6% of patients developed a pressure ulcer between April and July 2012.

Julie Vuolo, senior lecturer in tissue viability at Hertfordshire University, told Nursing Times she hoped a target would bring extra focus on reducing pressure ulcers.

But she warned it might also lead to extra pressure on nurses and managers “finger pointing at staff”. “I worry about the burden on nurse specialists, who is going to be responsible when the target is not met,” she said.

Latest data shows 6.6% of patients had a pressure ulcer between April and July 2012, making them the biggest single cause of avoidable harm to patients while in NHS care. Just 1.2% of patients suffered harm due to a fall and 4.7% from a new urinary infection.

Previous data from the safety thermometer has demonstrated that an average reduction in pressure ulcer prevalence of 42% was possible through correct equipment, intentional rounding and ensuring adequate hydration and nutrition.

  • Join the NTClinical chat on 7 February, 4pm, on nursingtimes.net with Vanessa McDonagh and Amy Oldfield discussing their 100 Days Free initiative to reduce pressure ulcers at University Hospitals Coventry and Warwickshire Trust

 

Readers' comments (14)

  • The developement of decubitus ulcers is multi-factorial and can almost never (in my experience) be simply be attributed to "poor" nursing care.

    For example - An old lady who falls at home may spend several hours on the floor before being found. This lady will almost inevitably develope one or more ulcers. Nothing can be done to alter this inevitability! - although it may be true that the damage can be limited.

    The rise in the numbers of obese patients and those with dementia also present challeges to nurses as these patients are at a high risk of developing ulcers.

    None of the currently available "assessment
    tools (Norton, Waterlow,Braden) accuratley predict ulcer development in patients admitted to hospital.

    Much of the existing "research" into the prevention of decubitus ulcers is of poor quality and provides little assistance in formulating a prevention stratagy and some recommendations border on lunacy (ie Sitting time should be limited in "at risk" patients ---ever tried placiing a patient suffering CCF or COPD in a supine or prone postion ?)

    Before any demand is made of nurses to reduce the incidence of "pressure sores" there must be investment in high qualty reseach, designed to provid answers to the many unanswered questions about the "pr essure sore" problem. Until such answers are avaiable nurses of course must do their best with the limited tools available. The emergence of a pressure sore is not an excuse to indulge in the "blame" game.

    Nurses must beware of being made scapegoats for the occurance of "pressure sores"

    There is little in the way of high quality guidence, protocol or procedure to assist.




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  • I well remember an orthopaedic Ward Sister who gave sterling advise to the many young men with fractured femures treated in those (old days) by traction. She would say " Move your backside or it will drop off ! --dont expect me to pick up the pieces" She was loved , respected and non of her patients had pressure sores !

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  • Maybe the CNO(England) could do something useful.
    She could start by getting out of the office and demonstrating how her rediculous 6C's will reduce the incidence of pressure sores by 50%
    Wouldnt you all love to witness her in charge of a ward !
    Are you all holding your breath ? -----mistake !

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  • The safety thermometer measure prevelence not incidence. To set a target to reduce prevelence may be achieved while increasing the number of patients (incidents and or incidence)harmed with a pressure ulcer.
    However which ever way you dress it up, this will make some organisation sit up and do things differently. For those organisations that have done the most to reduce their avoidable pressure ulcers will inevitably be hard pushed to achieve a 50% reduction

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  • The way the cQUIN payment is worked varies across the country. E.g.

    A. To reduce all grades of
    pressure ulcers
    B. To have no grade 4 pressure ulcers and a reduction in the percentage of grade 3 ulcers
    C. To maintain the low levels of grade
    3 and 4 hospital-acquired pressure ulcers
    D. A year on year reduction in newly acquired pressure ulcers of no less than 25% against the baseline
    E. A reduction in all preventable
    pressure ulcers

    This is yet again the danger of having people like me involved in agreeing this sort of thing. I haven't a clue. I didn't understand most of Jenny's post but I'm sure you all did.

    But do think about how much money this involves. cQUINs are up to 2.5% of trust outturn, so for a mid sized hospital this can be about £6m. But that's for all the cQUINs. What % is this? If it's say £300K perhaps you're thinking how many band 5 nurses that equates to, but it doesn't work like that. You only get the funding if you meet the target you've agreed locally. And the money is to be spent on delivering the target. It's like an extra bonus for doing something above and beyond. But as the previous poster says, the perverse incentive is if you're doing well already, raising the bar can penalise not reward you.

    Yet more reason nurses should be directly involved in negotiating clinical targets with commissioners.

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  • The Manager | 22-Jan-2013 8:38 pm

    Your post illustrates some of the risk associated with "targets".

    Exactly what is a "preventable pressure ulcer"? Such a statement impies that nurses have a means of identifying patients who will develope an ulcer if certain prescriptive measures are not taken. As far as I am aware no such tool exsists!

    "Guidlines" such as those issued by NICE are liberally hedged with caveats and avoid giving any "best pracise" advise ! These guidlines are good at arguing for the liberal use of "professional judgement" which interpreted means
    " We dont have a clue so its really all up to you "!

    I personally do not believe that the avoidence of pressure ulcers is entirly within the gift of the registered nurse. However, I do believe high quality, high power, research is urgently needed to support the laudable aim of reducing /eliminating the incidence of pressure ulceration.

    I am concerned that Trusts/Nurses may enter into contractual agreements which are not understood. The issue of pressure ulceration is complex and multi factorial.
    Nurses must not be accused of failing to achieve "targets" which are out of reach.

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  • Jenny Jones | 22-Jan-2013 11:31 pm

    Absolutely! This is the guidance we have to work to
    http://tinyurl.com/b7kptql
    I'd be interested to hear what you think of page 19, which shows how numbers vary in different settings.
    We've asked our tissue viability nurse to lead the thinking on the evidence base behind this, and make sure we don't sign off any numbers until she's seen and approved them. I do all the number crunching (pivot tables and things) but I'm also trying to make sure she manages the funds that we get so that we do e.g. spend it on more staff/ equipment. Our first look at the data showed we're doing quite well so I don't want us agreeing to completely unachievable numbers. I'd like to link in with the community/ care homes too so that we have some idea of risk and case mix, and how we can work together.

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  • So many good points raised in the above posts; the various comments show just how complex this subject is. I think the targets may be just we need to focus everyone's attention on this issue (and there is an national issue even if your own trust or home is perfoming well). However, targets must be applied to local context so that they are realistic and achievable rather than demoralising and punitive. This is the intention but as The Manager says it is dependent on people understanding what they are signing up to. So to reduce the numbers of avoidable pressure ulcers we must have focussed research to ensure we know what best practice is, we must have a 'safe' working environment where it is ok to acknowledge when things aren't right, we must have genuine organisational ownership of the problem, there must be appropriate investment in training, resources and staffing and we must have local expertise such as the tissue viability nurses provide to advise on clinical issues but (and it is a big but) we also need something else that is never mentioned and that is a strategic change management approach to reducing pressure ulcers. I know many Tissue viability specialists and I know the high level of expertise they bring to the job but not many have the kind of influence or power-base or the change management skills required to make the massive changes required in some organisations. It can be done and many TVNs and many trusts have done it, but it is not a given that everyone can do it, and where the organisation is failing in other respects too the chances are that a lone TVN will be fighting a losing battle.

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  • Julie has presented a very balanced and reasoned view. I am fortunate to be able to say that in Midlands and East we have made a significant investment in supporting front line staff with change management skills - and we have seen the results, even if that is not consistent across the whole of the SHA (it's a very large area!), a start has been made and staff have been equipped with skills that will help them with many other changes.

    Perhaps one of the issues that has not been addressed with the ST prevalence being used in this way is that if you count prevalence you count all the PU that exist (both new and old) therefore to reduce your prevalence you not only need to prevent but also to heal existing ones more quickly. Therefore the focus is also on early identification of damage plus good management should damage occur - and as several people have identified sometimes damage is unavaoidable.

    Locally set targets are the only way this can be sensibly managed. Those organsiations that have already done great work and reduced their incidence (not prevalance) right down can not be set the same targets as others who have high incidence figures. But there are always targets that can be usefully set - if the right people are involved in the process. The incentive monies are to support delivering the targets therefore that is what they should be used for. It has also been interesting to see how the focus on PU has reduced the prevalence of falls, VTE and Catheter associated UTI - but then again why wouldn't it? If you ensure patients are mobilised properly, well fed and well hydrated, you are regularly inspecting their skin and keeping it clean and dry as well as giving them an appropriate bed / mattress / chair / cushion (the elements of the SSKIN bundle) then you should prevent or minimise a whole range of complications.

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  • Totally agree with Jacqui and Julie's views. The problem as they say is that, in many cases, it has fallen onto the TVN to achieve these targets (usually with no additional resources). Furthermore, some Trusts may manipulate the data if there are financial implications. I have experienced this personally where an avoidable pressure ulcer was deemed "unavoidable" in my absence. Pressure ulcer prevention is a BASIC nursing skill and needs to be re-entrenched within nursing like BRIGHTON within a stick of rock!!! Nevertheless, the majority of TVNs welcome this initiative as it brings TV and pressure ulcer prevention into the forefront.

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  • Pressure Ulcer prevention is a basic nursing skill and a good nurse should be able to look at a patient and realise the risk that the patient presents for developing a pressure ulcer. Unfortunately, we have to fill in risk assessments on every patient and the results of which are NOT put into practice.
    30 degree tilts, regular changing of position, good nutrition, education to staff and patient , appropriate use of pressure reducing devices and good knowledge of wound care ,dressing and healing is essential. This is all basic nursing. Unfortunately, as a student ,I have not been inspired by any qualified nurse in this area...

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  • I live in San Antonio, TX. I have been retired from wound ostomy nursing 2 years. This conversation is exhilarating and sounds like so many sharp and dedicated persons have nailed the problem. The sad thing is that the issues seem to remain the same for the last 20 years!
    Bottom line: educate the staff; hire enough staff; purchase the appropriate positioning aids and good support surfaces; expect and perform good diligence as nurses.
    Hooray for nursing sisters across the sea!

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  • Sorry, I forgot the bit about taking care of the whole body and person as pressure ulcers are symptoms.

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  • I think we need to cut the red tape (c*ap), and simplify reporting on a national (not international or european) level, there are too many egos within tissue viability all doing their own thing - and yes I am one of them - a tissue viability nurse! Take the current grading, catagorising, staging!!! system for instance... does it really matter what we call it *sigh* I spend most of my day differential diagnosing tissue injuries - wouldn't it be simpler to say superficial, deep or suspected deep! I welcome the attention from CQUIN and ST as I hope investment will follow in what has always been a cinderella service (I have been in post for 20yrs). Nationally we need agreement I hope the new NICE guidance will bring on the revolution :)

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