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ORIGINAL ARTICLE

Pressure ulcer preventionin Australia: the roleof the nurse practitionerin changing practice andsaving livesMargo Asimus, Lorna MacLellan, Pui (Iris) Li

Asimus M, MacLellan L, Li P. Pressure ulcer prevention in Australia: the role of the nurse practitioner in changingpractice and saving lives. Int Wound J 2011; 8:508513

ABSTRACTThis paper reports on a successful nurse practitioner-led Pressure Ulcer Prevention Program (PUPP), established withmembers from nursing, allied health and senior management, within a regional area health service in Australia.The aims of PUPP were to quantify the prevalence of pressure ulcers within the health organisation, evaluate thepolicy compliances, identify cost effectiveness by implementing appropriate pressure redistributing surfaces andraise awareness of pressure ulcer prevention amongst all levels of clinical staff. The strategies include annual pointprevalence study across 41 facilities, mattress replacement and online education program. The prevalence surveydata were collected by skin inspection and chart audits by the trained surveyors. Since this quality improvementprogram commenced in 2008, it has demonstrated a reduction in pressure ulcer prevalence by 16.4%, increased

pressure ulcer risk assessment by 7.9% and use of appropriate pressure-relieving devices by 46.5%, which led tocost saving of AUD 500 000. This paper highlights the patient and organisation benefits that management andclinicians can accomplish through a systemic collaborative approach, in particular with strong support from theArea Executive Team of the health organisation.

Key words: Cost Management Pressure ulcers Prevalence Quality improvement

INTRODUCTION

Pressure ulcers are painful, socially unaccept-

able and costly, and are considered to be a

Authors: M Asimus, NP, STN, RM, RN, Cert IV of Assessment

and Training. Greater Newcastle Cluster, Hunter New England

Local Health District, NSW, Australia; L MacLellan, MN, MNP,

RN, SCM, School of Nursing and Midwifery, The University of

Newcastle, Callaghan, NSW, Australia; Pui (Iris) Li, MN, RN, Cert

IV of Assessment and Training, Nursing and Midwifery Services,

Hunter New England Local Health District, NSW, Australia and

School of Nursing and Midwifery, Faculty of Health, University

of Newcastle, NSW, Australia

Address for correspondence: M Asimus, Hunter New

England Local Health District, Wallsend Health Campus, Booth

Building, Longworth Ave, Wallsend, NSW 2287, Australia

E-mail: [email protected]

key indicator of the quality of nursing care (1).

Despite pressure ulcers being recognised as a

largely preventable adverse event, they remain

a major problem for patients in all health care

settings and can lead to increased morbid-

ity particularly for the chronically ill and the

elderly (2). In some instances, pressure ulcers

are complicated by infection, patient deteriora-

tion and even death if strategies are not imple-

mented early in patients identified at risk (3,4).

Health economists worldwide are fully

aware of the financial burden of pressure

ulcers on society. An Australian study reported

a median of 95,695 cases of pressure ulcers

incurs a median opportunity cost of AUD

285 million (5). The Institution for Healthcare

Key Points

pressure ulcer is an adverse

event causing detrimental

impacts on individuals and

health care system.

a nurse practitioner-led pres-

sure Ulcer Prevention Program

(PUPP) in Australia has been

proven a success: decease inpressure ulcer prevalence and

cost saving.

an inter-professional project

team, led by a nurse practi-

tioner in wound management,

was established with members

from nursing, allied health and

senior management. The mem-

bers were chosen for their clin-

ical expertise and their ability

to provide strong leadership.

Medical staff contributed to

subgroup activities as keystake-

holders.

strategies included annual

surveillance study, appropriate

use of equipment and staff

education.

the key to success is the

strong support from the Exec-

utive sponsor from the health

organisation and the leadership

fromthe nursepractitioner,clin-

ical leader of the program.

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Pressure ulcer prevention in Australia

Improvement (IHI) estimated pressure ulcer

treatment to cost the US health care system US

$11 billion per year (4) and a study conducted

by the Society of Actuaries reported that

pressure ulcer is the most expensive medical

error in the USA (6). In 2007, the US Medicare

and Medicaid Services announced they wouldno longer reimburse facilities for hospital-

acquired Grades 3 and 4 pressure ulcers (4).

Thus, there is a financial incentive for health

care facilities in the USA to take pressure ulcer

prevention seriously and implement evidence-

based therapies to eradicate this major health

burden. This paper describes the steps taken by

an area healthservice in Australia to changethe

culture and improve the outcomes of patients

in its care.

BACKGROUND OF THIS PROJECTHunter New England Health (HNEH) is one

of the largest area health services in New

South Wales, Australia providing services to

840 000 people living in metropolitan and

regional areas as well as in rural and remote

communities.

Despite the organisation having established

a pressure ulcer prevention and manage-

ment policy in 2001, the nurse practitioner in

wound management (NPWM) noted a signifi-

cant number of clients were being discharged

from acute care facilities to community nursingservice in HNEH with serious pressure ulcers.

It was evident that the standard policy was

having little or no effect in reducing the inci-

dence of pressure ulcers. The policy was not

embedded into routine clinical practice and

a systemic approach to ensuring appropriate

pressure ulcer prevention was required. There-

fore, the proposal to establish a Pressure Ulcer

Prevention Program (PUPP) was supported by

the Area Executive Team (AET) and the quality

improvement project commenced.

THE PRESSURE ULCER PREVENTIONPROGRAMAn inter-professional project team, led by an

NPWM, was established with members from

nursing, allied health and senior management.

The members were chosen for their clinical

expertise and their ability to provide strong

leadership. Medical staff contributed to sub-

group activities as key stakeholders.

The overall aims of this project were to

decrease the prevalence of pressure ulcers by

improving quality of care and subsequently

reducing the overall health care cost caused by

pressure ulcers.

OBJECTIVES OF THE PROJECT1. To quantify the prevalence of pressure

ulcers within HNEH and provide tending

data for future

2. To evaluate the effectiveness of policy

implementation

3. To identify cost-effective strategies such

as implementing appropriate pressure

redistributing surfaces and reduction in

prevalence rate

4. To raise awareness of pressure ulcer

prevention and treatment among all

levels of nursing, medical and alliedhealth staff through compulsory online

educational modules.

STRATEGIESSurveillance studyAnnual pressure ulcer point prevalence study

was one of the important strategies in PUPP to

monitor the prevalence of pressure ulcers and

evaluate the policy compliances. The method-

ology of the prevalence study was developed

from Prentices study (7) conducted in hospital

settings in Victoria, Australia. All consenting

adult in-patients on acute and subacute wards,

including patients flagged for admission in

Emergency Department, on the 41 facilities on

thedaysof thestudyconducted were surveyed,

except paediatrics, psychiatrics, community,

operating theatres and day surgery. Prior to

the survey, all surveyors were provided with

education and were required to achieve com-

petency in the training. An independent, who

wasnot employed by theward being surveyed,

was allocated to each team. There were two to

three surveyors in a team, which dependedon numbers of patients being surveyed. The

survey team assessed each consenting patients

with the Waterlow risk assessment tool (8) for

analysis of risk factors and the appropriate-

ness of the equipment in place. The survey

tool captured the following data points by skin

inspection and medical chart audit:

Patient demographics and primary medi-

cal specialty

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Use of pressure ulcer risk assessment tool

and timing of risk assessment

Use of appropriate pressure-relieving

devices

Number of pressure ulcers including

anatomical location, stage and causes such

as device-related Documentation of sources of pressure

ulcer: hospital-acquired or pre-existing

Risk profile

Ethics approval was granted by the Hunter

New England Human Research Ethics Com-

mittee. All participants were fully informed of

the survey requirements before verbal consent

was requested and were also aware that each

data set would be anonymous.

The first HNEH point prevalence survey of

1407 in-patients, (excluding mental health in-

patients) was undertaken in 2008 across the 41facilities in HNEH. The prevalence rate was

29.4% in 2008. The survey was repeated in 2009

and 2010 with 1279 patients and 1331 patients

being included in the 2009 and 2010 survey,

respectively. The results were compared and

shown a substantial improvement.

Senior management engagement was vital

to support the study. On average, 200 staff

participated as surveyors in each of the studies.

Survey teams included all levels of nursing

staff from nursing students, local university

academic staff to the most senior nursing

clinicians.

Appropriate equipmentMattresses

An audit of three general ward areas was

undertaken to examine the condition of the

standard ward mattresses. It was found that

the quality of mattresses varied considerably,

with few of them being in a perfect condition

and some in a poor state of repair. It was

concerning that many of these mattressescould

be contributing to the incidence of pressure

ulcers as there was no system in place to

document the life of ward mattresses. This

information was collated and then reported

to the AET, who decided to replace all

vinyl-covered mattresses with superior high-

density foam mattresses with a two-way

stretch dartex cover. Approximately 600 old

mattresses in the Newcastle metropolitan area

have been replaced with these new high-

quality mattresses which are now coded

to enable a scheduled systematic mattress

replacement.

Rental equipment

The team investigated the frequency of use

and the costs associated with renting dynamic

bed surfaces for high-risk patients in the same

three general ward areas. Of the 96 patients

reviewed, 26 patients were found to have been

prescribed rented powered mattresses, at a

cost of AUD 22.83 per day. These patients

were then assessed for risk of pressure ulcers

using the Waterlow risk assessment tool (8).

It was identified accordingly that only ten of

these patients actually required the powered

air mattresses. By implementing an algorithm

to guide clinicians in the appropriate selection

of equipment and replacing existing hospital

mattresses in these 26 patients, a potential costsaving of $131 247 was made over 12 months.

Staff educationThe initial pressure ulcer prevention and man-

agement educational online program consisted

of four modules:

Understanding pressure ulcers

Staging of pressure ulcers

Risk assessment and reassessment

Developing a prevention plan

This program was developed to guide clin-icians in the best practice measures to reduce

pressure ulcer occurrence. It is aligned with

the HNE Health pressure ulcer prevention

and management policy. Clinicians were edu-

cated and encouraged to take responsibility for

pressure ulcer risk assessment of all admitted

patients and provide appropriate preventa-

tive measures for at risk patients according to

evidence-based protocols. Successful comple-

tion is recorded on the staffs learning record.

PROJECT OUTCOMESReduction in the prevalenceand severity of pressure ulcersArea-wide prevalence of all pressure ulcers

was reduced from 29.4% in 2008, to 23.8% in

2009 and 13.0% in 2010 (Figure 1). There was a

decrease in the prevalence of hospital-acquired

pressure ulcers, from 23.4% in 2008 to 17.2%

in 2009 and 8.0% in 2010. The total number of

pressure ulcers decreased from 884 (2008) to

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0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

2008 2009 2010

Prevalence

Hospital-

acquired PU

Prevalence

Figure 1. Changes in pressure ulcer prevalence and hospital-acquired pressure ulcer prevalence in the health organisation.

Table 1 Change in pressure ulcer prevalence in major hospitals with mattresses replacement

YearInstitute

John Hunter Belmont Royal Newcastle

Hospital Hospital Centre

2008 Number of consenting patients 312 68 54

Number of patients with pressure ulcers 98 28 22

Prevalence of pressure ulcers 314% 406% 407%

Prevalence of hospital-acquired pressure ulcers 282% 279% 389%









Change in hospital-acquired pressure ulcer prevalence from 2008 to 2010 21.1% 19.3% 31.0%

611(2009) and had a further reduction to 344 in

2010. The severity of pressure ulcers was also

reduced. The total number of the more serious

Stage 3 and 4 pressure ulcers decreased from

14.9% in 2008 to 13.9%in 2010. In 2008, 52.7%of

the patients were classified as very high risk

developed pressure ulcers, whereas there were

only 44.3% and 23.3% of the patients in this

category in 2009 and 2010, respectively.

There was a significant reduction in hospital-

acquired pressure ulcer prevalence in the

hospitals where the standard mattresses had

been replaced by high-density foam mat-

tresses. Table 1 indicates the reduction of

hospital-acquired pressure ulcer prevalence

rate of those three major hospitals with mat-

tresses replaced.

Risk assessment and pressure-relievingdevicesThere was an increase in compliance by clinical

staff to risk assessment from 78.9% of the

surveyed patients in 2008 to 79.2% in 2009 and

86.8% in 2010. Also, there was a substantial

increase in the prescribing of appropriate

pressure-relieving devices. In 2008, only 44.4%

of high-risk patients had been provided with

the correct devices, whereas this was increased

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to 71.5% of high-risk patients being provided

with appropriate devices in 2009 and there was

a further increase to 90.9% in 2010. This change

in practice was undoubtedly responsible for

the overall reduction in pressure ulcers in 2009

and 2010.

Cost saving from power air mattressrentalBecause of the mattress replacement and the

implementation of the equipment algorithm,

more appropriate equipment has been pre-

scribed by clinical staff. There has been a

significant reduction in hiring of powered mat-

tress systems, which has resulted in a cost

saving of over AUD 500 000 in the first year of

the program. This has been a positive outcome

for both the patients and for management who

continually struggle to balance the deliveryof quality patient care with budgetary con-

straints.

CHALLENGESThe key challenge we identified during

the implementation of the PUPP was the

geographical size of our health organisation,

which is as big as England. It was a huge

challenge to ensure messages have penetrated

to every level across 41 facilities. Therefore,

our program sponsor from AET becamethe key person to disseminate information.

Key stakeholders were also identified during

monthly senior nursing manager meetings to

facilitate communication. During the period

of the first prevalence study in 2008, the

PUPP team visited all the survey facilities

supervising the surveyors and ensured the

methodology was followed at every site.

The PUPP team prepared survey reports

together with recommendations for each ward

and facility, which helped facility managers

and Nurse Unit Managers understand how

well their ward performed. All reports wereuploaded on HNEH intranet. Over these

3 years, each facility has taken the ownership

in pressure ulcer prevention.

DISCUSSIONPressure ulcer prevention and management

were redesigned using small teams and an

inter-professional collaborative approach.

The annual surveillance study, with the

sample sizes ranging from 1279 to 1407 and

the consenting rate between 82% and 87% over

these 3 years, has shown a huge reduction in

pressure ulcer prevalence rate of 16.4% over

the past 3 years. The severity of pressure ulcers

was also reduced. The validity of the studieswas strengthened by direct skin inspection,

allocating an independent to each survey team

and competence of the online training program.

Replacing vinyl mattress with high-density

foam mattress was one of the key factors

in to the reduction of the hospital-acquired

pressure ulcers, although mattresses were only

replaced in all the tertiary hospitals because of

the financial constraint.

The medical chart audits during the three

prevalence studies have identified an increase

in staffs compliances in pressure ulcer risk

assessment; approximately 46% increase in risk

assessment was evidenced. The surveillance

study itself was also an exercise facilitating

clinicians to gain better understanding of

policy requirements, evidence-based practice

and knowledge on pressure ulcer prevention

and management. With the support and

leadership from the local stakeholder, staffs

are encouraged to complete pressure ulcer

online education program. The increase in

the appropriate use of pressure-relieving

equipment was evidence of better knowledge

in pressure ulcer prevention.Monthly hiring cost of pressure-relieving

devices was evaluated for those hospitals

with high-density foam mattresses purchased.

There was AUD 500 000 of cost saving over

the first year after the implementation of

the equipment algorithm and staff education

program; more appropriate equipments have

been prescribed by clinical staff.

The strategies of PUPP have reduced

the number of pressure ulcers identified

in a repeat study and subsequently saved

significant amounts of the health budget

over the period of the study. The overall

outcomes would not have been achieved had

it not been for the combined efforts of all

teams and so their involvement is valued

and acknowledged. The data reveal evidence-

based, cost-efficient and sustainable strategies

were implemented. This is because of the

clinical staff having an increased knowledge

of pressure ulcer prevention and management

strategies. These figures also demonstrate the

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staffs commitment to improve clinical practice

and their adherence to policies in an effort to

reduce pressure ulcer prevalence in their area.

CONCLUSIONClinicians trained in pressure ulcer risk assess-

ment, prevention and treatment have the abil-

ity to contribute significantly to improving the

appropriate pressure ulcer prophylaxis and

reduce subsequent pressure ulcer complica-

tions. Pivotal in achieving positive outcomes

was the collaborative approach between clin-

ical staff and senior management. The data

demonstrate that there has been a substantial

improvement in the quality of care to patients

in HNEH over the last 3 years. This change

in culture has occurred because of the provi-

sion of educational modules and an increased

awareness of pressure ulcers and preventionstrategies. There has also been willingness by

each individual member of staff to make a con-

tribution to a positive outcome for the patients

in their care.

ACKNOWLEDGEMENTSWe acknowledge the support from the Exec-

utive sponsor of the program, Director of

Nursing and Midwifery Services, Mr Chris

Kewley, and Ms Felicity Williams, Nursing

and Midwifery Services and Pressure Ulcer

Prevention and Management Committees andsenior managers in Hunter NewEngland Local

Health District. Also, all clinicians participated

as a surveyor. This project was supported

by Nursing and Midwifery Services, Hunter

NewEngland Area Health Service. This project

won the Quality and Safety Award at the

HNE Health Awards and the Clinical Excel-

lence Commission Award for Improvement inPatient Safety at NSW Health Awards, both in

2009.

REFERENCES1 Angel D, Sieunarine K, Hunduma N, Clayton M,

Abbas M, Ponosh S. Postoperative pressure ulcers

in vascular patients after epidural analgesia: case

reports. Primary Intent 2004;12:348.

2 Lyder C. Pressure ulcer prevention and manage-

ment. JAMA 2003;289:2236.

3 Duncan K. Preventing pressure ulcers: the goal is

zero. Jnt Comm J Qual Patient Saf 2007;33:60510.

4 Bales I, Padwojski A. Reaching for the moon: achiev-ing zero pressure ulcer prevalence. J Wound Care

2009;18:137144.

5 Graves N, Birrell F, Whitby M. Effect of pressure

ulcers on length of hospital stay. Infect Control

Hosp Epidemiol 2005;26:2937.

6 Shreve J,van DenBos J,GrayT, Halford M,RustagiK,

ZiekiewiczE. The economic measurementof med-

ical errors. URL http://www.soa.org/files/pdf/

research-econ-measurement.pdf [accessed on 20

September 2010].

7 Prentice J, Stacey M, Lewin G. An Australian model

for conducting pressure ulcer prevalence surveys.

Primary Intent 2003;11:87109.

8 Waterlow JA. The use of the Waterlow pressure sore

prevention/treatment policy card. Primary Intent

1995;3:1421.

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7/29/2019 65382442

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