Post on 28-Nov-2014
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Pressure Injury Prevention: Continuum of Care from Hospital to Community Judith Barker RN BHlthSc (Nurs) MNP Nurse Practitioner – Wound Management Community Care Program ACT Health
Overview
ACT environment
Community Wound Management Service
Nursing and Allied Health referrals
Minimum data set - Wound types
Cost and governance
Implement evidence based systems
Continuum of Care from hospital to community
Standardisation of resources - managing practice change
Prevalence results - community
ACT Health Environment - Community
Canberra - 101 years old
Government
360,000 people
2 public hospitals
Canberra Hospital
Tertiary teaching, catchment for trauma from surrounding NSW
699 beds - 1000 beds
3000 nurses ACT Health
Community Care Program 5 community health centres
Tuggeranong Health Centre Phillip Health Centre
City Health Centre
Gungahlin Health Centre Belconnen Health Centre
Community Wound Management
Service
Wound Management in the Community
• Link team – after hour community nursing service
• Walk in centres – nurse led
• General practice
• Podiatry – private/public
• High risk foot clinic
• Orthotics
• Seating clinics
• OPD clinics private/public
• Share care with palliative care/podiatry
Private nursing care agencies
Residential Aged Care Facilities
Alexander Maconochie Centre
Schools/child care centres
Providing an Evidence Based Wound Care Service for the ACT Community
Well-defined wound management pathway
• Community nursing referrals and OOS
• Community Wound Management Service referrals
• Allied Health
• Home or clinic base
• Three Tier Wound Management System - link with the acute setting
• Collaboration and multidisciplinary focus
Wound types – Referrals to Community Wound Management Service
Wound types – incidence new and review
pressure injuries
skin tears
dehisence wounds
burns
leg ulcers
170 – 220 active referrals
40 new referrals each month
100 – 150 patient contacts per month
Pressure injuries 12%
Skin tears 13%
Dehiscence 4%
Burns 1%
Leg ulcers 70%
Wound type referrals in aged care
Wound types – incidence new and review
pressure injuries
skin tears
venous
arterial
Wound types Canberra Hospital
Wound types – incidence new and review
pressure injuries
skin tears
dehisence wounds
burns
chronic wounds
Pressure injuries
Major challenge for healthcare professionals and systems
Collier, Moore 2006, Ousey 2005
Nursing specific clinical indicator & indicator for the quality of care
Baharestani et al 2009
Large percentage of pressure injuries are considered to be preventable
EPUAP & NPUAP 2009
Pressure injuries were the fifth most costly, commonly occurring
preventable condition
Jackson et al 2011
Cost and Governance
Cost of Pressure Injuries in ACT Health
$US 18,948,996
Establishment of the National Safety and Quality Health Service - Standard 8
Preventing and management pressure injuries International guideline
Strategic framework
Policy and Standard Operational Procedure Graves N Zheng H (2014) Modelling the direct health care costs of chronic wounds in Australia. Wound Practice
and Research .Vol 22 No1,
Understanding the depth of the problem through data collection
ACT Health
Annual prevalence
Incidence reporting :Riskman – alerts to NP
Score card
Clinical review
Community
Incidence auditing clinical file – minimum wound data set
ACT Health Patient Administration System
Canberra Hospital
Tissue Viability Unit – minimum wound data set
Incidence auditing at ward level for pressure injury – Audit angels
Extract from RiskMan – wound extension module (WEM)
2014 International guidelines
EPUAP, NPUAP, PPPIA
Launched in August 2014
Special populations
- bariatric
- operating rooms
- SCI
- critically ill
- older adults
Evidence based systems: continuum of care
Risk assessment
Equipment – support services and surfaces – improve timely access
Experts and Education Acute and community focus
Resources for pressure injury prevention and management
Assessment
Waterlow - on discharge
Waterlow risk assessment – 1st visit
Wound assessment/digital photography/tracing
Care plan – trial PI
Resources in car
Waterlow - high risk - referral to OT
Stage 2 pressure injury and above – referral to OT and Nutrition
Communication/hand over
- Community to hospital
- GP
Equipment -Support surfaces
Community Equipment Scheme/service
Hiring of support surfaces – ACT Equipment Scheme
Rapid response service
2010 hospital wide mattress replacement
constant low pressure mattresses
2012 Establishment Central Equipment Store
Alternating air mattress / cushions -30mins – 1 hr
Heel tofts
Skin IQ microclimate
Rapid Response
Occupational therapy referral service
40 new referrals each month
Monday – Friday service
Respond and action within 48hrs
Pressure relieving equipment
Hospital bed
Palliative care
Bariatric
Wound clinicians across the health service
2012 Growth in networking within our acute and community and
residential aged care
2008 Nurse Practitioner Wound Management – community
2010 CNC Wound Management – Canberra Hospital
2010 OT Rapid Response Service
2012 Establishment Tissue Viability Unit
4th rotation of 2 RNs for 6 months
2013 Diabetic High Risk Foot Clinic ( Multidisciplinary)
2014 CNC Wound Management - Community
Regular review multidisciplinary referrals
Nutrition, occupational therapist, physiotherapist
Numerous medical teams
2014 Expert Resources
Patient Centred Wound Services
Nurse Practitioner –
Wound Management Community ACT Health
Staff Development
Unit
Education
Clinical Nurse Consultant-
Wound Management
Community
Central Equipment
Store Canberra Hospital
5 Community Health Centres
2 Registered Nurse - months
rotation in TVU - CH
Allied Health rapid response
High Risk Diabetic Foot
Clinic
ACT Equipment Hiring Service
Clinical Nurse Consultant
Tissue Viability Unit
Education
Staff Development Unit – ACT Health
Focus on pressure injury prevention
4 e-learning modules
6 wound days/annually
11 wound afternoon sessions/annually
80 community nurses complete WoundsWest PIP module prior to annual prevalence
Practice development program - community/nurses/AH
Include AWMA (ACT) – Twilight Educational Evenings, Symposium and Conferences
Resources
Standardisation of product range from hospital to community
Foam dressings - meplix boarder sacral & heel dressings
Conveen skin care range - cleanser and creams
Removal of kylies - Touch Dry disposal
Review of Incontinence management and products - pads range for areas and education
Nutritional supplements
Pressure Injury Prevalence in the Community
Wound awareness week
2014 - 361 patients surveyed
80 community nurses
Prevalence over 1 week
All patients seen during this week – home and clinic visits
Manual data collection
Prevalence by year
Documenting patient education
56
92
43
66
38
85
0
10
20
30
40
50
60
70
80
90
100
Canberra Hospital Community
Compliance to Documenting Patient Education by Year
2012
2013
2014
%
Hospital acquired pressure injuries
4
0
5
10
15
20
25
30
35
40
CHCACT
Patients with Hospital Acquired Pressure Injuries by Year
2010
2011
2012
2013
2014
Age of patients
Referral to Multidisciplinary Team
HA Pressure injuries
Canberra Hospital Community Care
Stage 1 52% 80%
Stage 2 24% 20%
Stage 3 0% 0%
Stage 4 0% 0%
Unstageable 4% 0%
DTI 20% 0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Perc
ent
Classification of Hospital Acquired Pressure Injuries by Facility 2014
Challenges
High risk patients
Educating/supporting paid carers
Long term pressure injuries
Bariatric patients
Aged population
Co morbidities
Turning regime for the high risk patient
Equipment – maintenance
Purchasing/funding for new equipment
Future direction
Risk assessment in out patient settings
e – records – ongoing collation of data
Coding of pressure injuries
Increased bariatric equipment and services
Improve timely access to equipment for high risk patients
Summary
Targeting pressure injury prevention in the community
Targeted resources for our health environment
Practice changes – implemented evidence based practice
Standardised products and resources from hospital to community
Continuum of care from hospital to community
Reduced the prevalence of pressure injury
Data - earlier identification of stage 1 and strategies implemented
THANK YOU
Judith Barker
judith.barker@act.gov.au
Collier M & Moore Z (2006) Etiology and risk factors. In M. Romanelli (Ed), Science and practice of pressure Ulcer Management (pp. 27-36). London Springer
Ousey K (2010) Pressure area care. Oxford: Blackwell Publishing
Baharestani MM, Black JM, Carville K, Clark M ,Cuddigan JE ,Dealey C et al (2009) Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus. International Wound Journal,6(2), 97-104
European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel. Prevention and Treatment of pressure ulcers. Washington DC: national Pressure Ulcer Advisory Panel: 2009
Jackson T, et al. (2011) Marginal costs of hospital-acquired conditions: information for priority-setting for patient safety programmes and research. Journal of Health Services Research and Policy. Vol 16 No 3 July
Graves N Zheng H (2014) Modelling the direct health care costs of chronic wounds in Australia. Wound Practice and Research .Vol 22 No1,
References