Pressure ulcer prevention campaigns must engage and motivate clinical staff on an ongoing basis if they are to achieve long-term success
This article describes a campaign to eliminate avoidable grade 2-4 pressure ulcers at University Hospitals Coventry and Warwickshire Trust. The 100 Days Free strategy used traditional educational approaches along with ward-based power training and social media to engage staff and update practice. Root cause analysis has been vital in providing feedback to staff and identifying training needs.
Citation: McDonagh V (2013) Sustaining pressure ulcer prevention in practice. Nursing Times; 109: 15, 12-16.
Authors: Vanessa McDonagh is tissue viability clinical nurse specialist, University Hospitals Coventry and Warwickshire Trust.
- This article has been double-blind peer reviewed
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University Hospitals Coventry and Warwickshire Trust made a commitment to reduce hospital-acquired pressure ulcers in 2008.
To achieve its initial target to reduce avoidable pressure ulcers by 30% over two years, the tissue viability (TV) team, comprising of three full-time TV nurses, developed a structured approach to deliver preventive care (Box 1).
Box 1. Focus Points of the Strategy
- Introduction of incidence reporting
- Review of benchmarking framework
- Review of documentation
- Review of staff education programmes, from management to prevention
- Increased informal education
- Pressure ulcer prevention weeks
- Adopting avoidable and unavoidable definition of pressure ulcers
Awareness and reporting
As we began to raise awareness of pressure ulcer prevention, the reporting of inherited and acquired pressure ulcers also increased. This was followed by continuous reduction of both incidence and prevalence of avoidable hospital-acquired pressure ulcers of all grades. Fig 1 shows the figures for April 2010 to September 2012.
In April 2012, the chief nurse set a trajectory for a month-on-month reduction of all grades of pressure ulcers with a goal of zero avoidable pressure ulcers (Fig 2). Elimination of avoidable pressure ulcers has almost been achieved; only one grade 3 and two grade 2 ulcers were recorded in February 2013. This has been achieved through a variety of initiatives and changes to practice.
We began online incident reporting for pressure ulcers in April 2009. This provides accurate information on how many patients develop a pressure ulcer in hospital and how many were admitted with ulcers.
The TV team worked with the patient safety and quality department to implement, promote and refine the system for reporting and validating data.
Root cause analysis and performance review
Root cause analysis (RCA) is a method of investigating and analysing patient safety incidents so that effective ways of preventing similar incidents can be developed.
All grade 3 and 4 pressure ulcers are reported as serious untoward events and an RCA carried out. We developed a pro forma to facilitate the process and identify why pressure ulcers developed and which were unavoidable. The TV team works with ward managers and clinical staff to complete the RCA before the patient is discharged to ensure lessons are learnt and staff receive immediate feedback. All RCAs are reviewed for key themes and these have been used to drive specific training.
As soon as possible after the RCA, ward staff are invited to a performance review with the TV team and chief nurse or associate director of nursing. We discuss the incident, ensure learning is cascaded to all team members and identify any additional support.
Equipment gap analysis
All beds and bedside chairs have pressure redistribution mattresses and cushions; however, while dynamic pressure-relieving mattresses and seating are available, the RCA process identified delays in obtaining these.
A review of process identified that there was insufficient equipment to meet demand so a business case for more equipment was submitted, which resulted in the purchase of additional pressure-relieving mattresses and replacement covers to ensure efficient laundering processes. Rental mattresses are now held in stock to ensure staff can access them at any time.
In April 2012 we set a time frame of two hours from admission for patients to be placed on the pressure-relieving surface; this rose from 21% of patients on a mattress within two hours in April to 45% in June; our next audit will take place in April 2013, but the figure is expected to be similar.
All documentation and information relevant to pressure ulcer prevention has been adapted to incorporate the ASKIN acronym, which represents the five elements of pressure ulcer prevention (Box 2). This ensures a consistent message to all staff, patients and carers.
Box 2. The ASKIN tool
- Keep moving
The trust introduced intentional rounding in March 2012, and the TV team worked with a practice facilitator to incorporate ASKIN tool into the rounding tool. This was trialled on elderly care, orthopaedic, medical and stroke wards as well as the clinical decision unit, and redesigned after feedback from nursing staff. The rounding tool was then rolled out across the trust to all adult inpatient wards.
Initially, some staff were reluctant to carry out rounding as they did not understand the rationale behind it. This has now been resolved through dissemination of information and regular updates during all pressure ulcer prevention education.
An initial audit eight weeks after the introduction of intentional rounding showed that it was in place in 82% of areas, with 91% of these using it appropriately.
Patient information leaflets on pressure ulcer prevention have been updated to include the ASKIN acronym, along with and pictures and diagrams so that patients are aware of pressure ulcers and how they can help to prevent them.
Review of staff education
Over 500 nursing staff a year receive education through the TV team’s programme of formal education. This includes monthly study days, which cover all aspects of the ASKIN bundle and feature speakers from equipment providers, the handling and moving team, continence nurses and dietitians. We also provide study days for midwives, HCAs and newly qualified nurses. Ad hoc and bedside teaching is delivered in an informal manner on a daily basis.
We try to make education enjoyable and have met other specialist nurses to ensure the prevention message is consistent throughout the trust. Earlier in the programme, we delivered focused work in areas with high pressure ulcer numbers; this consisted of daily visits from the TV and handling and moving teams to audit documentation and ensure patients have the correct plans of care. The TV nurses also worked alongside staff delivering patient care, using it as a training opportunity. The trust currently has no areas where focused work is in place, as all teams are meeting the target to reduce pressure ulcers.
100 Days Free campaign
The 100 Days Free campaign was launched in March 2012. It set every ward and clinical department the target of achieving 100 days without a pressure ulcer.
Those remaining free from hospital-acquired avoidable pressure ulcers for 100 days achieve “100 Days Free” accreditation, which symbolises safety and demonstrates that the ward has reached a high standard in pressure ulcer prevention. Wards receive badges, certificates and coffee and cakes sponsored by ISS Mediclean, which provides support services including catering, cleaning and portering at the trust.
The emergency department and admissions unit received a separate target to identify 100 pressure ulcers as they came into the trust, which they met by early June. This work continues, with staff being proactive in screening patients for pressure ulcers, reporting and taking appropriate actions.
The TV team worked closely with the trust’s communications team to maximise staff engagement with the campaign, while the chief nurse wrote to all senior staff to provide executive endorsement for the campaign. Special 100 Days Free editions of the staff e-newsletter were produced, with articles on progress of pressure ulcer prevention and examples of good practice.
The campaign was formally launched with a TV link worker study day in March 2012, after which 90 link workers were asked to provide “power” training in their clinical areas. This involves short bursts of education focusing on the five elements of ASKIN; sessions take about 10 minutes and impart a consistent message, while allowing education to be delivered in wards and clinical areas at a time that is convenient for staff.
The sessions include the presentation of 10 slides, each focusing on an essential element of pressure ulcer prevention, as well as a patient case study to demonstrate the human and financial costs of pressure ulcers. In the first few weeks of the campaign over 500 staff attended a session with this number continuing to increase.
Wards submit updates reporting their progress on training and pressure ulcer-free days, and the TV team track progress and publish league tables showing the achievements of every ward and department (Fig 3).
Wards and departments that did not achieve the 100 Days Free target initially were not disqualified from the initiative but were set back on track with additional support from the TV team. We identified a lack of daily documented skin assessments in some areas, which has now been addressed with both formal and informal education.
Check and challenge
After receiving pressure ulcer prevention training, staff have been approached on wards and departments and asked about the key elements of pressure ulcer prevention by the TV team and modern matrons; this is known as a “check and challenge.” Each element of the ASKIN bundle has several related questions that staff may be asked; for example, one question under the Assess element is: “How frequently should a skin assessment be documented?”
Those with deficits in their knowledge are identified and additional support provided. The check and challenge tool also helps the TV team identify gaps in knowledge and this influences the format of the formal study days.
Use of social media
Social media offers health professionals an interesting and instant way of communicating professionally with each other and wider healthcare communities, to ask questions and share ideas. Although still relatively new to the NHS, social media and, particularly Twitter, is well established and supported by our trust.
The TV team has a Twitter account @TVN_UHCW, and tweet about best practice in pressure ulcer prevention and wound care. Twitter is useful because it gives direct access to nurses in our hospitals and beyond to deliver a consistent positive message about pressure ulcer prevention.
We also use social media to deliver the latest news on the 100 Days Free campaign and to celebrate and reward successes.
The challenge now is to sustain these achievements, but the trust is confident it has the procedures and processes in place to achieve this.
The drive to prevent pressure ulcers has had the full support of the board and pressure ulcer prevention is seen as a priority for all clinical staff. The TV team continue to be highly visible in clinical practice delivering informal education and supporting staff.
The focus on prevention and 100 Days Free is sustainable. The work of the TV team and link workers is being recognised locally and nationally, gaining several awards for pressure ulcer prevention, partnership working and the 100 Days Free concept.
- Pressure ulcers are a key quality indicator
- A variety of clinically focused initiatives are required to prevent pressure ulcers
- 100 Days Free campaign provides clinical teams with a goal for improvement
- Social media can be used to engage staff in clinical campaigns
- Appropriate pressure relieving equipment should be available within 2 hours of risk assessment
Department of Health (2011) The Operating Framework for the NHS in England 2012/13. London: DH.
Griffiths P et al (2008) State of the Art Metrics for Nursing: a Rapid Appraisal. London: National Nursing Research Unit.
NHS Institute for Innovation and Improvement (2010) High Impact Actions for Nursing and Midwifery – Your Skin Matters. Warwick: NHSIII.