Annette Bartley, RN, MS MPHJanuary 2015

Getting to Zero

For the most part pressure ulcers are avoidable!Source: www.la4seniors.com/bedsores

Why is this work so important?

Facts

• Pressure ulcers are a common problem for patients who have limited mobility, or who sit or lie in one position for long periods of time.

• Pressure ulcers are painful, and can be devastating for patients leading to surgery and longer stays in hospital.

•• They can be potentially life-threatening.

• The total cost in the UK is £1.4–£2.1 billion annually (4% of total NHS expenditure) that’s 4p in every pound of the NHS budget!

• (Bennett et al 2003)

What Does the Evidence Tell Us?

• Risk is predictable• age immobility, incontinence, poor nutrition, sensory

problems, circulation problems , dehydration and poor nutrition

• Skin Integrity can deteriorate in hours• Frequent assessment prevents minor problems from

becoming major ulcers

• Wet skin is more vulnerable to skin disruption and ulceration

• But dry skin is a factor as well

• Continual pressure, especially over bony prominences, increases risk

• Pressure relieving surfaces work

Source: Reddy et al JAMA 2006;296: 974-84

First do no harm!

Fundamental Safety Principles

– Prevention

– Detection

– Mitigation

Simon Sinek http://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action.html

The key to success

Maintain the focus on patientsR

ela

tional

Transactional

Warm but chaotic Everything works

Unpleasant and inefficient

“Cold comfort farm”

Efficient but impersonal

Coordinated, integratedWarm, fed, watered “Battery chicks?”

Jocelyn Cornwell

Kings Fund Point of

Care

It’s all about making connections

Head (Knowledge-Ideas)

Heart

(Inspiration-

Will)

Hands (Wisdom-Execution)

Zero harm

Ascension Health

Nurses throughout the organization created and implemented care methods under the SKIN bundle

Reduced pressure ulcer incidence to about 1.4 per 1,000 patient days system-wide

Six hospitals had no pressure ulcers for 1 year

Almost all that did occur were Stage I or II

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Background- A Personal JourneyUSA- Transforming Care at the bedside IHI

Wales/UK

Introduced the SKIN bundle and QI to Tissue Viability in Led the development of QI methods and SSKIN bundle in Scotland

UCLH- Keep the Pressure Off campaign

South West QUPSIP

South Central Safer Care programme

IHI expedition

Danish Patient Safety Programme

Pressure Ulcers to zero -Ireland

Torbay and South Devon Healthcare

Scottish Patient Safety Programme

HMC

Tools

Atmos Air 9000

Reducing Variation in Practice

Desired - variationbased on clinical criteria, no individual autonomy to change the process,process owned from start to finish,can learn from defects before harm occurs, constantly improved by collective wisdom -variation

Current -Variable, lots of autonomynot owned,poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels

Terry Borman, MD Mayo Health System

Avoidable Pressure Ulcer

“Avoidable” means that the person

receiving care developed a pressure ulcer

and the provider of care did not do one of

the following: evaluate the person’s

clinical condition and pressure ulcer risk

factors; plan and implement interventions

that are consistent with the persons

needs and goals, and recognised

standards of practice; monitor and

evaluate the impact of the interventions;

or revise the interventions as

appropriate.”

Unavoidable Pressure Ulcer

“Unavoidable” means that the person receiving care developed a pressure ulcer even though the provider of the care had evaluated the person’s clinical condition and pressure ulcer risk factors; planned and implemented interventions that are consistent with the persons needs and goals; and recognised standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate; or the individual person refused to adhere to prevention strategies in spite of education of the consequences of non-adherence” The Department of Health (DH)

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Making the connections

15

Risk assessment

Communicate

Preventative action

Measure impact

Partner ship

with patient

Developing a systems-based approach to the prevention of adverse events

Risk Identification

Communication of Risk status

Risk Assessment

Appropriate preventative strategy implemented

Evaluation of outcome

What will success look like?

To eliminate

avoidable pressure

ulcers across HMC

by September 2016

Local Risk Identification

Reliable Risk Assessment

Reliable implementation

of the SSKIN bundle/

similar prevention

process

Identification, grading and

treatment of pressure

ulcers

MDT staff, patients and families work collaboratively to

understand and highlight pressure ulcer risk factors specific

and prevent harm.

Staff understand the risk factors affecting their patient

population (Immobility/poor nutrition/sensory impairment

devices etc.).

Staff effectively communicate risk to the wider team.

Patient/families

Utilise ‘At risk’ cards/systems to enable quick identification of

individuals at risk.

Provide timely risk assessment for ALL patients within a

maximum of four hours of admission.

Effectively communicate risk status to all

Reassess patients risk status at least daily or whenever a

patient’s condition/needs change.

Sustain compliance with risk assessment at 95% or greater.

Staff/patients/family.

Reliably Implement the SSKIN prevention bundle/ or similar

prevention process/intervention (compliance >95%)

Surface: ensure the appropriate surface/support when

seated/ lying in bed.

Skin inspection: regular inspection of skin.

Keep patients moving

Increased moisture/continence: Ensure patients are kept

clean and dry

Nutrition / hydration: right diet & fluids

Inspect skin daily.

Use safety briefing to highlight issues/risk

Utilise standardised grading tool

Utilise local tissue viability nursing expertise

Initiate and maintain correct and suitable treatment

Provide staff education with an emphasis on prevention

Educate staff regarding available resources/ validated risk

assessment/ staging tools/bundle (HMC guidance)

Educate the patient and family members regarding how to

minimise risk (include advice on optimising nutrition

Provide Patient/Carer information leaflet

Share learning from harm incidents across teams.

Education and training

Outcome Primary Drivers Secondary Drivers

What Exactly Is ‘A Bundle’?

IHI developed the concept of “bundles” to help health care

providers more reliably deliver the best possible care for

patients undergoing particular treatments with inherent risks.

A bundle is a structured way of improving the processes of

care and patient outcomes: a small, straightforward set of

evidence-based practices — generally three to five — that,

when performed collectively and reliably, have been proven to

improve patient outcomes.

Slide “stolen shamelessly” from Carol Haraden, IHI

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Bundles

The power of a bundle comes from the body of science behind it and the method of execution: with complete consistency. It’s not that the changes in a bundle are new; they’re well established best practices, but they’re often not performed uniformly, making treatment unreliable, at times idiosyncratic. A bundle ties the changes together into a package of interventions that people know must be followed for every patient, every single time.

Institute for Healthcare Improvement www.ihi.org

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20

SSKIN Bundle Elements

1. Surface: make sure your patients have the right support/surface.

2. Skin inspection: early inspection is early detection3. Keep: keep your patients moving 4. Increased moisture and incontinence: keep patients

clean and dry5. Nutrition/hydration: right diet and fluids

First Steps

Ask 5

Randomly ask 5 members of your team to describe the steps in the pressure ulcer prevention process in your setting

Different responses will highlight the variation in practice and the need for a more clearly defined process

Take Five

Take five patients notes and check risk assessment process

Did it happen? YES or NO?

Was it timely? YES or NO?

Was the risk status clearly communicated? YES or NO?

Was a prevention plan put in place YES or NO?

Was it reliably completed? YES or NO?

Safety Calendar

1 2 3 4 5 6

7 8 9 10 11 12

13 14 15 16 17 18

19 20 21 22 23 24

25 26 27 28 29 30

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Colour Code Details

No new PU cases

Patient

transferred with

PU from other

care setting

New PU case

identified

Grade 2

Right buttock

No cushion in

place

Patient Name

Date

Time 12am 4am 8am 12pm 4pm 8pm

Surface1 therapulse

2 roho cushion

Keep Moving1 skin assessed

Right Side

Left Side

Incontinence1 catheter patent

2 clean & dry

Nutrition1 protein drinks

2 fluid balance chart

WATERLOW 18

Surface = Therapulse bed 2 minute pulse, Roho Cushion for the chair

Keep Moving = Pressure areas to be assesed am, pm and night plus on return to bed from chair

Incontinence = catheter patency, record bowel action and ensure patient is kept clean and dry

Waterlow = Daily or increase if dependancy increases

Nutrition = dietician referral, protein drinks x3, maintain daily fluid balance chart

SKIN Bundle Communication tool for Pressure Ulcer Prevention

18/04/2008 19/04/2008

13/04/2008 Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Surface

Keep moving

Incontinence

Nutrition

Waterlow

20/04/2008 Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Surface

Keep moving

Incontinence

Nutrition

Waterlow

27/04/2008 Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Surface

Keep moving

Incontinence

Nutrition

waterlow

Patient Name

Weekly compliance chart

Skin Bundle

Compliance

Small Rapid Scale Tests of Change

One ward

One day / shift

One patient

One nurse

Preventing Pressure Ulcers-Simultaneous testing Potential PDSA’s

Communication of Risk status (visual cue)

Risk AssessmentCompliance

SSKIN bundle Engaging patients

ABM U LHB

658 days without a

pressure Ulcer

Winners of “Improving Quality through better use of resources” NHS awards 2009

The SKIN care bundle, which won an NHS Wales award in 2009, won the Patient Safety in Clinical Practice section of the Health Service Journal/Nursing Times Patient Safety Awards 2010.

Incidence reduced from near 15% to >1%

>50% reduction in pressure ulcers in all pilot wards

• Abertawe pilot unit has gone 7 years with only 1 grade

2 pressure ulcer

• 93 ward-four hospital system spread

• Many units have reached >600 days

• System wide results – Community/care homes/homes

Celebrating Success

Change 1: Real Time Education

Change 2: PURA & SSKIN in Admission Forms

Ward 11

Chg 1

Chg 2

0%10%20%30%40%50%60%70%80%90%

100%4

/21

/10

5/5

/10

5/2

6/1

0

6/1

4/1

0

6/2

9/1

0

7/1

4/1

0

7/2

7/1

0

8/1

0/1

0

8/2

4/1

0

9/7

/10

9/2

0/1

0

10

/8/1

0

10

/16

/10

10

/25

/10

11

/15

/10

11

/29

/10

12

/13

/10

12

/27

/10

1/1

0/1

0

1/2

4/1

1

2/7

/11

2/2

1/1

1

3/7

/11

3/2

1/1

1

Co

mp

lian

ce P

erc

en

tage

Date

NHS Borders ScotlandRisk Assessment Compliance

April 2010 – March 2011

Change 1: Real Time Education Change 4: Real Time Education (I element being missed)

Change 2: PURA & SSKIN in Admission Forms Change 5: Real Time Education (I element being missed)

Change 3: Visual Cues Change 6: Visual Cues

Ward 11

Chg 1

Chg 2

Chg 3

Chg 4 Chg 5

Chg 6

0%10%20%30%40%50%60%70%80%90%

100%4

/21

/10

5/5

/10

5/2

6/1

0

6/1

4/1

0

6/2

9/1

0

7/7

/10

7/2

7/1

0

8/1

0/1

0

8/2

4/1

0

9/7

/10

9/2

0/1

0

10

/8/1

0

10

/16

/10

10

/25

/10

11

/15

/10

11

/29

/10

12

/13

/10

12

/27

/10

1/1

0/1

0

1/2

4/1

1

2/7

/11

2/2

1/1

1

3/7

/11

3/2

1/1

1Pe

rce

nta

ge C

om

plia

nce

Date

Spread to SCOTLANDSSKIN Compliance

April 2010 – March 2011

Intended

Direction

Ward 11

0

83

2541

156

212

0

50

100

150

200

2504

/21

/10

6/2

/10

6/2

7/1

0

8/7

/10

8/2

2/1

0

8/2

8/1

0

3/2

8/1

1

Day

s B

etw

ee

n

Date

NHS BordersDays Between Preventable Pressure Ulcers

April, 2010 - March 2011

• Recorded on Safety Calendar – no evidence in notes• Recorded on Safety Calendar – no evidence in notes• Patient on Care Pathway for the Dying (PC) G2• Patient refusing to turn – (PC) G1• Patient not receiving optimal nutritional support (S) G2• Reviewed Operational Definition

SC SC

G 2

G 1

G 2 UP UPUP

0

1

2

3

4/2

1/1

0

5/5

/10

5/2

6/1

0

6/1

4/1

0

6/2

9/1

0

7/7

/10

7/2

7/1

0

8/1

0/1

0

8/2

4/1

0

9/7

/10

9/2

0/1

0

10

/8/1

0

10

/16

/10

10

/25

/10

11

/15

/10

11

/29

/10

12

/13

/10

12

/27

/10

1/1

0/1

1

1/2

4/1

1

2/7

/11

2/2

1/1

1

3/7

/11

3/2

1/1

1

Date

Quality Improvement ScotlandNHS Borders

Preventable Pressure Ulcer CountApril 2010 – March 2011

Repeated Use of the PDSA Cycle

Hunches TheoriesIdeas

Changes That Result in Improvement

A P

S D

A P

S D

Test SSKIN Bundle with 1 nurse and 1 patient

Test with 3 nurse and 3 more patients

Test with day staff Mon-Fri

Test with all night staff

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Test at weekends

Engaging Heart & Minds

‘If you want to build a ship do not gather men together and assign tasks. Instead teach them the

longing for the wide endless sea’ (Saint Exupery, Little Prince)

Getting started

Driver diagrams are dynamic tools

Review the driver diagram

Can you see your role in this?

How does it align with current practice?

What is missing?

What is not necessary?

How can you adapt it to fit your setting/patient

population?

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Action planning

Plan your next steps

Build on the PDSA’s developed yesterday

Report out

Three things you take away

Structure

First PDSAs

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