Prevention Strategies for Pressure Ulcers in Denmark's Hospitals

1. Prevention of pressure ulcersDenmark State of the art A A R H U S U N I V E R S I T Y Aarhus University Hospital, Skejby Department of Cardiology

2. BackgroundPressure ulcer • Are caused by • Localised pressure -> • Deformation of skin and soft tissues -> • Distorting cells, reducing blood flow -> • Inducing ischemia and necrosis. • Takahashi M, Wounds International, 2010 A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

3. Backgroundwhat is going on? Tissue distortion due to pressure • Roaf R, J Tissue Viability 2006 A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

4. Backgroundwhat is going on? • Pressure and duration that are likely to result in tissue damage. • Takahashi M, Wounds International, 2010 A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

5. BackgroundAre pressure ulcers still a challenge in Danish Hospitals? • Six resent Danish cross sectional, in hospital, studies have shown a pressure ulcer prevalence of 14 – 66% • More than 5% of these were category 3 – 4 ulcers. • Nationwide this correspond to the use of ap. 1.500 man-years on treating pressure ulcers. • Bermark, S, vol2: 2010 EWMA J • Dumiel-Peeters I, 2006; J Clin Nurse A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

6. Challenges • Identifying persons at risk • How, when, how often? • How to monitor the frequency of pressure sores? • Prevalence / incidence? • Effective evidence-based prevention strategy? • Clinical guidelines? Generic or disease specific • Implementation of strategies • How A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

7. Challenges • Adoption of the strategies (guidelines) • Who is responsible? • Education and equipment? • How to maintain? • Documentation of risk and preventive actions • How? • When? • What is sufficient? A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

8. State of the artRisk assessment = Identifying persons at risk • Many different risk assessment instruments have been develop and used during the past 20 years • Their ability to indentify persons at risk of having pressure ulcers have though not been convincing • Pancorbo-Hidalgo PL et al. Journal of Advanced Nursing 2006; 54(1):94-110. • Schoonhoven L et al . Medical Journal 2002; 325(7368):797-800. • Seongsook RNJ et all. Journal of Nursing Studies 2004; 41(2):199-204. • Defloor T, Grypdonck MF. Journal of Clinical Nursing 2005; 14(3):373-382. A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

9. State of the artRisk assessment = identifying persons at risk • Vogelsang AB, 2004, research • Purpose • To conduct a valid prognostic index/risk assessment instrument (Adhoc) • To evaluate the prediction validity of Adhoc versus the Braden assessment scale • Vogelsang AB, Bladet SÅR, 2004 A A R H U S U N I V E R S I T E T Aarhus University Hospital Department of Cardiology

10. State of the art: Risk assessmentAdhoc • Considered at risk are only persons who are not self-reliant • Exception: Persons with diabetes • Score and risk category • 0 point No risk • 1 - 4 points Low risk • 5 - 8 points Moderate risk • 10 - 11 points High risk A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

11. State of the art: Risk assessmentAdhoc • State the degree of limitation in activity performance • 0 NONE or negligible limitation ( 0 – 4%) • 1 SLIGHTLY limited ( 5 – 14%) • 2 MODERATE limited (15 – 49%) • 3 STRONGLY limited (50 – 94%) • 4 Activity CAN NOT be performed (95 – 100%) • Do the person have both the ability and consent to mobility? • 0 Yes • 1 Yes, partly • 2 No A A R H U S U N I V E R S I T E T Aarhus University Hospital Department of Cardiology

12. State of the art: Risk assessmentAdhoc • Is friction reducing material used when moving or repositioning the person? • 0 Yes • 1 Yes, in average every second time • 2 No • Has the person been exposed to pressure at the same part of the body for more than 1½ running hour during the past 24 hours? • 0 No • 1 Yes, once • 2 Yes, twice • 3 Yes, more than twice A A R H U S U N I V E R S I T E T Aarhus University Hospital Department of Cardiology

13. State of the art: Risk assessmentPrediction Risk at 1. registration compared to number of pressure ulcers at the 2. registration A A R H U S U N I V E R S I T E T Aarhus University Hospital Department of Cardiology

14. State of the art: Risk assessmentPrediction • Braden vs. Adhoc • Predicted presence of pressure ulcers correctly • Predicted absence of pressure ulcer correctly A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

15. State of the art: Risk assessmentConclusion • If the high predictive validity for Adhoc could be repeated in a new and independent population, Adhoc could be considered a valid instrument to identify patients at risk of developing pressure ulcer • The result from this and other studies leads to the conclusion that although the Braden scale predicts the occurrence of pressure ulcers to some extent, routine use of this scale has to be called into question A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

16. State of the art: Monitoring frequency • Up until now • All Danish studies but one are prevalence studies • We then do not know where and when the ulcers were produced! • Do we really measure quality? A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

17. State of the art: Implementation of strategies on equipment • Mattresses • Around 50% are placed on adequately pressure relieving mattresses • No one knows when the patient actually was located on the mattress. • Cushions • In average 30% of the patients are placed on adequately relieving cushions • Heal • One hospital did practice this procedure, the rest did not. • Bermark, S, 2010 EWMA J • Buttery J, 2010: EWMA J A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

18. Conclusion: Implementation of strategies on equipment • Use of preventive equipment are insufficient and may be introduced too late or perhaps not until the pressure ulcer is visible on the skin • Conversely, the use is not reduced as the need for preventive action decreases • Even the most simple recommendations are inadequately followed. A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

19. State of the art: Documentation of risk and actions • Preventive efforts • We do not know the degree of documentation, but the percentage is low • Categorising pressure ulcers • Less than 50% are registered in the nursing journal • Treatment plan??? • Bermark, S 2010 EWMA J • Buttery J, 2010: EWMA J A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

20. Conclusion: Documentation of risk and actions • Conclusion • Planned preventive actions is rarely documented and evaluated. • This all most certainly leads to staff spending to much time on the same process. • No one really knows if the most simple general recommendations are follow • The preventive effort is for certain not individualize corresponding the individual patient risk. A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

21. Future recommendations: Prevention of pressure ulcers • National guidelines should be defined and cleared • Local instructions should be available on the intranet and signed by the department leaders • Learning programs should be defined and available on the intranet A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

22. Future recommendations: Prevention of pressure ulcers • Support/education should be well organized • National indicators should be defined • Audit should be made on: • Pressure ulcer Incidence and Category • Percentage of E-learning passed • Percentage of patients placed on the right equipment at the right time. A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

23. Future ”Forebyggelse af liggesår vha. standardiseret screeningsmetode ogsensorlagner” • To ensure that appropriate preventive actions are documented and provided to the right patient in time • The effect of a simple implementation strategy will be tested in a new Danish project. • The interventions are based on a Danish clinical guideline for prevention of pressure ulcer including “Adhoc”. (Aarhus UniversitetshospitalSkeby, EWMA, OHMATEX) Projektleder Anne-BirgitteVogelsang A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology

24. Screening og indsats”Forebyggelseafliggesårvhascreeningsmetodeogsensorlagner”

25. Effect parameters”Forebyggelseafliggesårvhascreeningsmetodeogsensorlagner” • Independent measurements of • Number of new pressure ulcers (incidence) • Degree of documentation • Staff time spent • Staff satisfaction • Monitoring three times over a 4 weeks period : 1. Baseline 2. After education of the hole staff in: The screening method and how pre-specified preventive actions should be performed 3. Added censoring seats, visualizing pressure in a time perspective and added patient individual risk profile

26. Succes criteria”Forebyggelseafliggesårvhascreeningsmetodeogsensorlagner” • Time spent • Pressure frequency • Revalidated risk assessment “Adhoc” • Revalidated national clinical guideline • Cost Benefit analyses • User statements: • Patient • Staff • Interested parties A A R H U S U N I V E R S I T E T Aarhus University Hospital, Skejby Department of Cardiology