Narelle Marshall (AARCS Nurse) & Darlene Saladine (Acute Pain Service Nurse) November 2012

1. ‘A Multidisciplinary Approach to the Prevention of Pressure Areas on Patients with Hip Fractures at Armidale Rural Referral Hospital.’ Narelle Marshall (AARCS Nurse) & Darlene Saladine (Acute Pain Service Nurse) November 2012

2. Prize-winning project

3. Introduction • Wound dressing Inservice • Decision to trial the use of preventative wound dressings • Acknowledging a high prevalence of pressure ulcers in hip fracture patients. • Had an existing multidisciplinary pressure ulcer prevention working group

4. Aim • To determine whether the use of preventative dressings will reduce the incidence of hospital acquired pressure ulcers in patients who present with a hip fracture

5. Process • Strategies implemented by the Pressure Ulcer prevention Working Group demonstrated some improvement • However it was evident that there was still room for improvement particularly with regard to referrals to Dietitian and Occupational Therapists

6. Determining the extent of the Problem • Baseline data: - IIMS and coding identified the patient group • File audit to determine major contributing factors : • Injury to ED time • Injury to surgery time • Co-morbidities eg diabetes, anaemia, dementia, diarrhoea (incontinent)

7. The Extent of the Problem • 18 (22.2%) of the 81 hip fracture patients from 1st July 2009 – 30th June 2010 developed at least 1 pressure ulcer • Baseline audit indicated poor compliance with risk assessment on admission and timely referral to Dietitian and Occupational Therapist • 44% took more than 5 hours getting to ED and 72% waited more than 24hrs for surgery

8. Planning & Implementation • Consultation with management, NUMs and orthopaedic surgeons • Ascertain dressings to be used: • Allevyn heel (with silicone border) for sacral/buttock area • Mölnlycke Mepilex heel dressings (adhesive foam) • Templates to track the use of the dressings

9. Allevyn Heel with silicone border

10. Mepilex Heel

11. The dressings applied

12. Implementation cont. • Education to nursing staff of ED, surgical, ICU, operating theatres & rehab unit • OT’s, Dietitian’s, Physio’s and CSO’s informed of their roles • Commenced 1st September 2010 • Project monitored by Darlene Saladine on the wards to ensure compliance with application of dressings and completion of tracking sheets

13. Implementation cont. • Feedback provided to staff using a wall chart & staff meetings • Patient education re: rationale of the project

14. Outcomes & Evaluation • Follow up audit of all hip fracture patients presenting from the 1st September 2010 to 31st March 2011 • Incidence of pressure ulcers reduced from 22.2% to 8.8% with only 3 out of 34 having hospital acquired pressure ulcers during the project • These 3 patients all had multiple co-morbidities

15. Outcomes & Evaluation cont. • Once identified none of the pressure ulcers deteriorated further • 1 patient with bilateral heel stage 1 pressure ulcers who continued to use the Mepilex heel dressings was discharged with skin intact

16. Graphical data of reduced incidence of pressure ulcers

17. Variables • It is acknowledged that the reduction in pressure ulcers should not be wholly attributed to the use of preventative dressings as this project also resulted in raised awareness of, and compliance with existing strategies eg: the use of pressure reduction equipment, High Protein diet/supplements and increased repositioning

18. Our Multidisciplinary Team

19. Ongoing data • Latest audit of hip fracture presentations for the period 1/10/11 – 30/9/12 showed further reduction to 2.5% = 2 patients with pressure ulcers from 78 hip presentations (compared to the initial 22.2% in 2010 and 8.8% in 2011).

20. Flow on Impact • Staff now tend to apply preventative dressings to other high risk patients eg. Palliative care and frail elderly as a routine measure, however… • Still no evidence to demonstrate reduced incidence of hospital-wide pressure ulcers – but we now have more Stage 1 pressure ulcers and less Stage 2 & 3

21. Other observations we have made • When dressings were unavailable, the incidence of pressure ulcers increased which confirms our view that the dressings are effective in reducing pressure ulcers • All audits have shown that there is a definite correlation between the incidence of pressure ulcers and the time spent in transit from outlying towns, to access orthopaedic care.

22. More observations we have made • Men in the # NOF group seem to be at a greater risk of pressure ulcers than women; • Co-morbidities play a definite role in the incidence of pressure ulcers; • Time is of the essence when it comes to applying the dressings.

23. Sustaining the Change • Pressure Ulcer Prevention Working Group continues to monitor data monthly • Review of the hip fracture clinical pathway to prompt regular waterlow scoring, referrals to Dietitian and OT and application of preventative dressings on admission • The use of dressings for all high risk patients

24. Future Scope • Share information with internal transport and ambulance re the benefits of repositioning in transit • Share information with other Hospitals re the benefits of preventative dressings on high risk patients