VOL: 96, ISSUE: 36, PAGE NO: 12
Claire Martin, BSc, RGN, DipPNS, is wound care clinical nurse specialist, Brighton Health Care NHS TrustUntil September 1997, pressure prevention and relief at Brighton Health Care NHS Trust was a mix of pockets of excellence and areas with no defined plan.
Until September 1997, pressure prevention and relief at Brighton Health Care NHS Trust was a mix of pockets of excellence and areas with no defined plan.
In the 1996-1997 financial year, expenditure on hired pressure-relieving equipment peaked at £200,000, a significant drain on ward resources. A number of companies were providing the equipment and wards were using various criteria to choose it, with no accurate monitoring system.
Clinical staff were confused by the variety of equipment on offer and the procedures for obtaining it, and uncertain about how to approach issues such as maintenance and cleaning.
In April 1996, I was appointed wound care nurse specialist at the trust. One of the priorities of my job was to coordinate a strategy to ensure the equitable distribution of equipment and the availability of education and advice to all staff and patients.
After a presentation to the management board and the formation of a multidisciplinary team, including a member of the finance department, the implementation of a trust-wide strategy to prevent and manage pressure damage began in earnest. One of the main objectives was to develop a protocol for the selection of equipment to ensure that provision was based on clinical need rather than availability.
An algorithm was developed to encourage a consistent and coordinated approach (Fig 1). The key components of the protocol and the rationale underpinning the guidance presented in this algorithm are discussed in this article.
Many risk-assessment tools have been criticised because there is little data to support their reliability and validity (Flanagan, 1997), but one was needed to reduce subjectivity and provide a standardised framework for the algorithm. The Waterlow score (1985) was chosen because it was already in use throughout the trust.
The team constantly review and update components of the algorithm, and as more research on the effectiveness of such tools becomes available it may be necessary to reconsider this choice (Lyne et al, 1999).
The educational workshops that accompanied the introduction of the algorithm emphasised the importance of using clinical judgement in conjunction with a risk assessment tool to guide decision-making. They also stressed that individual scores in each Waterlow category were as important as the overall score in directing care (Harding, 1999).
Patients at risk
A checklist was developed for nurses to use when assessing the needs of all patients, regardless of their risk of developing pressure damage. It includes an instruction to 'evaluate the care plan every shift and review the assessed needs of the patient as the general condition changes'.
Staff were also given information to encourage accurate and meaningful documentation (Box 1).
Waterlow score of 10 and above
A checklist was developed for patients with a score of 10-18, who could be at increased risk of pressure damage as a result of their underlying pathology (Fig 1).
Those with uncontrolled pain, restricted mobility and increased oxygen demands are particularly vulnerable (Bliss and Simini, 1999), as are those with advanced peripheral vascular disease.
Patients with diabetes, older people and those with a history of cigarette smoking are also at increased risk, particularly in the lower limbs. This may be the result of vascular changes caused by atherosclerosis.
Patients with complex underlying clinical problems should be referred to the clinical nurse specialist or the senior nurse on duty and the use of appropriate pressure-relieving equipment should be considered.
Choice of equipment
When selecting a support surface, its properties should match the needs of both the patient and staff. The factors to consider include interface pressure, friction and shear forces, moisture-vapour transmission rates, thermal insulation properties, indentation load deflection, density, ease of use, safety and patient comfort (Mulder et al, 1999).
Laurent (1999) points out that patient acceptability is an important factor in choosing appropriate pressure-relieving equipment. For example, any motor should be quiet enough not to disturb the patient's sleep.
After a literature search, multidisciplinary liaison and trials on the wards, we chose a layered foam mattress as standard rather than a conventional hospital mattress.
Dynamic pressure-relieving systems were selected for patients at high risk and those with existing pressure damage.
The input of all members of the multidisciplinary team is essential when assessing the most suitable pressure redistribution system for the patient. This should include an occupational therapist and physiotherapist, for ease of movement and rehabilitation, as well as the infection control department, for a decontamination protocol.
For dynamic pressure relief, we chose an overlay and mattress replacement. For patients who are unable to move and those admitted with grade-4 pressure damage, we chose a vacuum-assisted alternating-pressure mattress. Other professions were involved in these decisions (Box 2).
The algorithm meets the criteria for a good assessment tool as outlined by Flanagan (1993) because it:
- Acts as an aide-memoire to carers;
- Provides quantifiable data for audit;
- Provides evidence that preventive and treatment plans are based on objective criteria and a specific rationale;
- Allows the targeting of limited resources.
New clinical staff are introduced to the algorithm and regular educational updates are provided for all staff.
All patients admitted to the trust are assessed on admission, using a validated assessment tool. They are subsequently reassessed daily and have the use of at least a pressure-reducing layered foam mattress.
The algorithm ensures that patients are issued with the most appropriate equipment for them within a mean audited time of two hours. For staff, the benefits of the system include the allocation of equipment on an equitable basis and the use of a standard formula for assessments.