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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
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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
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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
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Tuggeranong Health Centre Phillip Health Centre
City Health Centre
Gungahlin Health Centre Belconnen Health Centre
Community Wound Management
Service
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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
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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
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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%
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Wound type referrals in aged care
Wound types – incidence new and review
pressure injuries
skin tears
venous
arterial
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Wound types Canberra Hospital
Wound types – incidence new and review
pressure injuries
skin tears
dehisence wounds
burns
chronic wounds
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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
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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,
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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
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Extract from RiskMan – wound extension module (WEM)
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2014 International guidelines
EPUAP, NPUAP, PPPIA
Launched in August 2014
Special populations
- bariatric
- operating rooms
- SCI
- critically ill
- older adults
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Prevalence by year
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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
%
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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
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Age of patients
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Referral to Multidisciplinary Team
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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
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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
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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
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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
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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