Pressure Ulcer Prevention – Enhancing Outcomes with Care Bundles

1. Pressure Ulcer Prevention – Using Care Bundles to Enhance OutcomesProfessor Zena MoorePhD, MSc (Leadership in Health Professionals Education), MSc (Wound Healing & Tissue Repair), FFNMRCSI, PG Dip, Dip First Line Management, RGNProfessor of Nursing, Head of the School of Nursing & Midwifery , RCSI. Director of the SWaT Research Centre, RCSI.Adjunct Professor, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia, Professor Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Honorary Professor, Lida Institute, Shanghai, China, Senior Tutor, University of Wales.

2. Outline • Definition of a clinical pathway • Rationale for the use of clinical pathways • SSKIN Bundle • Impact of PU Bundles • Conclusion

3. “A clinical pathway is defined as structured multidisciplinary care plan, which details essential steps in the care of patients with a specific clinical problem” Definition of “Clinical Pathway” Rotter T, Kinsman L, James EL,Machotta A, GotheH,Willis J, Snow P, Kugler J. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. CochraneDatabase of Systematic Reviews 2010, Issue 3. Art.No.:CD006632. DOI: 10.1002/14651858.CD006632.pub2.

4. “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.” Definition of “Care Bundle” Institute of healthcare Improvement. Evidence-based care bundles. Available from: http://www.ihi.org/Topics/Bundles/Pages/default.aspx

5. Outline • Definition of a clinical pathway • Rationale for the use of clinical pathways • SSKIN Bundle • Impact of PU Bundles • Conclusion

6. Support the implementation of evidence-based practice; • Improve clinical processes by reducing risk; • Reduce duplication through the use of a standardised tool; • Reduce variation in health service process delivery. Rationale for the use of care bundles Clinical Pathways, available from: https://clinicalexcellence.qld.gov.au/resources/clinical-pathways

7. One in 10 patients is harmed while receiving hospital care But………………………. Citation: WHO 10 Facts about Patient Safety; Available from: http://www.who.int/features/factfiles/patient_safety/patient_safety_facts/en/index8.html:

8. The greatest burden was exerted by pressure ulcers (13,780 DALYs); • The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death). Rationale for the use of clincal pathways in PU prevention Slawomirski L, Auraaen A, Klazinga N (2017) The economics of patient safety. OECD Health Division. Available from: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/P/Patientensicherheit/The_Economics_of_patient_safety_Web.pdf:

9. Hospital acquired PUs are, in the main, considered a preventable event. • International guidelines recommend: • Accurate and ongoing risk assessment; • Skin assessment & care; • Incontinence management; nutrition; repositioning and choice of the correct seating and mattress. • Unless applied consistently, incidence of PUs will likely continue to rise. Rationale for the use of care bundles in PU prevention Chaboyer W, Bucknall T, Webster J, McInnes E, Gillespie BM, Banks M, et al. The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. Int J Nurs Stud. 2016;64:63-71.

10. Outline • Definition of a clinical pathway • Rationale for the use of clinical pathways • SSKIN Bundle • Impact of PU Bundles • Conclusion

11. SSKIN • Skin assessment • Surface • Keep moving • Incontinence • Nutrition Gibbons W, Shanks HT, Kleinhelter P, Jones P Eliminating facility-acquired pressure ulcers at Ascension Health JtComm J Qual Patient Saf. 2006 Sep;32(9):488-96.

12. Risk Assessment • Conduct a structured risk assessment as soon as possible (but within a maximum of SIX hours after presentation and at first assessment in the community); • Use a structured approach to risk assessment that is refined through the use of clinical judgment and informed by knowledge of relevant risk factors; • Repeat the risk assessment as often as required based on assessment of the patient’s acuity. If the patient’s condition is unstable, then re-assess every 48-72 hours until stable; thereafter, weekly reassessment should be conducted; • Conduct a reassessment if there is any significant change in the patient’s condition. Office of Nursing and Midwifery Services Director (2018) HSE National Wound Management Guidelines 2018. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound-management-guidelines-2018.pdf

13. Who is at Risk?

14. Hierarchy of risk factors Prime cause of pressure ulcers Prime factor exposing individual to pressure & shear Factors influencing tolerance of pressure & shear Reference: MOORE, Z., COWMAN, S. & CONROY, R. M. 2011. A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J Clin Nurs, 20, 2633-44.

15. SSKIN • Skin • Surface • Keep moving • Incontinence • Nutrition Gibbons W, Shanks HT, Kleinhelter P, Jones P Eliminating facility-acquired pressure ulcers at Ascension Health JtComm J Qual Patient Saf. 2006 Sep;32(9):488-96.

16. Results • Silicone dressings may reduce pressure ulcer incidence (any stage), low-certainty evidence; downgraded for very serious risk of bias. • In the one trial rated as being at low risk of bias, there was no clear difference in pressure ulcer incidence between silicone dressing and placebo-treated groups, low-certainty evidence, downgraded for very serious imprecision. Moore  ZEH, Webster  J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD009362. DOI: 10.1002/14651858.CD009362.pub3..

17. Results • One trial reported no clear difference in pressure ulcer incidence when a thin polyurethane dressing was compared with no dressing. In the same trial pressure ulcer incidence was reported to be higher in an adhesive foam dressing compared with no dressing, very low certainty evidence, downgraded for very serious risk of bias and serious imprecision. • Trials reported that there was no clear difference in pressure ulcer incidence between the following comparisons: polyurethane film and hydrocolloid; dressing, Kang’ huier versus routine care, 'pressure ulcer preventive dressing' (PPD) versus no dressing. Very low certainty evidence, downgraded for very serious risk of bias and serious or very serious imprecision. Moore  ZEH, Webster  J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD009362. DOI: 10.1002/14651858.CD009362.pub3..

18. SSKIN • Skin assessment • Surface • Keep moving • Incontinence • Nutrition Gibbons W, Shanks HT, Kleinhelter P, Jones P Eliminating facility-acquired pressure ulcers at Ascension Health JtComm J Qual Patient Saf. 2006 Sep;32(9):488-96.

19. Surface • Select a support surface that meets the individual’s needs • Consider the individual’s need for pressure redistribution based on following factors: • level of immobility and inactivity • need for microclimate control and shear reduction • size and weight of the individual • risk for development of new pressure ulcers • number, severity, and location of existing pressure ulcer(s) Office of Nursing and Midwifery Services Director (2018) HSE National Wound Management Guidelines 2018. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound-management-guidelines-2018.pdf

20. Surface • Choose a support surface that is compatible with the care setting • Examine the appropriateness and functionality of the support surface on every encounter with the individual • Verify that the support surface is being used within its functional life span, as indicated by the manufacturer’s recommended test method (or other industry recognised test method) before use of the support surface • Continue to reposition individuals placed on a pressure redistribution support surface • Choose positioning devices and incontinence pads, clothing and bed linen that are compatible with the support surface Office of Nursing and Midwifery Services Director (2018) HSE National Wound Management Guidelines 2018. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound-management-guidelines-2018.pdf

21. Surface • Individualise the selection and periodic re-evaluation of a seating support surface and associated equipment for posture and pressure redistribution with consideration to: • body size and configuration • the effects of posture and deformity on pressure distribution • mobility and lifestyle needs • Select a stretchable/breathable cushion cover that fits loosely on the top surface of the cushion and is capable of conforming to the body contours • Assess the cushion and cover for heat dissipation • Inspect and maintain all aspects of a seating support surface to ensure proper functioning and meeting of the patient’s needs Office of Nursing and Midwifery Services Director (2018) HSE National Wound Management Guidelines 2018. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound-management-guidelines-2018.pdf

22. SSKIN • Skin • Surface • Keep moving • Incontinence • Nutrition Gibbons W, Shanks HT, Kleinhelter P, Jones P Eliminating facility-acquired pressure ulcers at Ascension Health JtComm J Qual Patient Saf. 2006 Sep;32(9):488-96.

23. Keep Moving • Repositioning of an individual is undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body and to contribute to comfort, hygiene, dignity, and functional ability. • Reposition all patients at risk of, or with existing pressure ulcers, unless contraindicated. • Determine repositioning frequency with consideration to the patient’s: • tissue tolerance • level of activity and mobility • general medical condition • overall treatment objectives • skin condition • comfort Office of Nursing and Midwifery Services Director (2018) HSE National Wound Management Guidelines 2018. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound-management-guidelines-2018.pdf

24. Keep Moving • Establish written pressure relief schedules that prescribe the frequency and duration of weight shifts. • Teach patients to do ‘pressure relief lifts’ or other pressure relieving manoeuvres as appropriate. • Regularly assess the patient’s skin condition and general comfort. Reconsider the frequency and method of repositioning if the patient is not responding as expected to the repositioning regimen. • Increase activity as rapidly as tolerated Office of Nursing and Midwifery Services Director (2018) HSE National Wound Management Guidelines 2018. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound-management-guidelines-2018.pdf

25. MOORE, Z., COWMAN, S. & CONROY, R. M. 2011. A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J ClinNurs, 20, 2633-44.

26. Repositioning – Summary More frequent repositioning vs less frequent repositioning 8% (221/2834) vs 13% (398/3050) OR 0.75 (95% CI: 0.61-0.90; p=0.003)

27. SSKIN • Skin • Surface • Keep moving • Incontinence • Nutrition Gibbons W, Shanks HT, Kleinhelter P, Jones P Eliminating facility-acquired pressure ulcers at Ascension Health JtComm J Qual Patient Saf. 2006 Sep;32(9):488-96.

28. Incontinence • For the prevention of IAD: conduct structured perineal skin care • including gentle cleansing with a product that has a balanced pH • and use of a skin protectant following each major incontinence episode • or skin protectants that do not require application after every incontinence episode. Office of Nursing and Midwifery Services Director (2018) HSE National Wound Management Guidelines 2018. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound-management-guidelines-2018.pdf

29. Incontinence • Clinicians should employ a skin care regimen that is consistently employed: • to remove irritants from the skin (cleanse); • to protect from exposure to irritant substances (protect); • to maximise the intrinsic moisture barrier function of the skin (restore). Office of Nursing and Midwifery Services Director (2018) HSE National Wound Management Guidelines 2018. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound-management-guidelines-2018.pdf

30. Citation: Beeckman D et al. Proceedings of the Global IAD Expert Panel. Incontinence associated dermatitis: moving prevention forward. Wounds International 2015. Available to download from www.woundsinternational.com

31. SSKIN • Skin • Surface • Keep moving • Incontinence • Nutrition Gibbons W, Shanks HT, Kleinhelter P, Jones P Eliminating facility-acquired pressure ulcers at Ascension Health JtComm J Qual Patient Saf. 2006 Sep;32(9):488-96.

32. Nutrition • Screen nutritional status for each individual at risk or with a pressure ulcer: • At admission to a health care setting • With each significant change of clinical condition and/or • When progress toward pressure ulcer closure is not observed • Use a valid and reliable nutrition screening tool to determine nutritional risk. • Adequate nutrition is essential to manage pressure ulcers with individualised dietary prescription based on thorough nutrition assessment. • Offer adults with a pressure ulcer a nutritional assessment by a dietitian or other health care professional with the necessary skills and competencies. Office of Nursing and Midwifery Services Director (2018) HSE National Wound Management Guidelines 2018. Available from: https://www.hse.ie/eng/services/publications/nursingmidwifery%20services/wound-management-guidelines-2018.pdf

33. Outline • Definition of a clinical pathway • Rationale for the use of clinical pathways • SSKIN Bundle • Impact of PU Bundles • Conclusion

34. Hospitals (clusters) were stratified and randomised to either a pressure ulcer prevention care bundle or standard care • The care bundle was theoretically and empirically based on patient participation and clinical practice guidelines • It was multicomponent, with three messages for patients’ participation in pressure ulcer prevention care: keep moving; look after your skin; and eat a healthy diet. • The primary outcome was incidence of new HAPU and pertained to both the individual patient and cluster. It was defined as number of new PU of any stage per 1000 patient follow up days Evidence of impact Chaboyer W, Bucknall T, Webster J, McInnes E, Gillespie BM, Banks M, et al. The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. Int J Nurs Stud. 2016;64:63-71.

35. Four clusters were randomised to each group and 799 patients per group analysed • The intraclass correlation coefficient was 0.035 (small effect) • After adjusting for clustering and pre-specified covariates the hazard ratio for new pressure ulcers developed (pressure ulcer prevention care bundle relative to standard care) was 0.58 (95% CI: 0.25, 1.33; p=0.198); 42% reduction (95% CI: 75% reduction to 33% increase) • No adverse events or harms were reported Evidence of impact Chaboyer W, Bucknall T, Webster J, McInnes E, Gillespie BM, Banks M, et al. The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. Int J Nurs Stud. 2016;64:63-71.

36. Direct costs were collected from trial data and supplemented by micro-costing data on patient turning and skin care from a 4-week sub-study (n = 317). • For the cost-effectiveness analysis, the primary outcome was the incremental costs of prevention per additional hospital acquired pressure ulcer case avoided. • The care bundle cost AU$144.91 (95%CI: $74.96 to $246.08) more per patient than standard care. The largest contributors to cost were clinical nurse time for repositioning and skin inspection. • The bundle was estimated to cost an additional $3296 (95%CI: dominant to $144,525) per pressure ulcer avoided. • A PUPCB consisting of multicomponent nurse training and patient education strategies may encourage good nursing practice but may not be cost-effective in preventing HAPU. Evidence of impact Whitty JA, McInnes E, Bucknall T, Webster J, Gillespie BM, Banks M, et al. The cost-effectiveness of a patient centred pressure ulcer prevention care bundle: Findings from the INTACT cluster randomised trial. Int J Nurs Stud. 2017;75:35-42.

40. What does it all mean for you?

41. Definition of a Pressure Ulcer “A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the primary of which is impaired mobility.” NATIONAL PRESSURE ULCER ADVISORY PANEL, EUROPEAN PRESSURE ULCER ADVISORY PANEL & PAN PACIFIC PRESSURE INJURY ALLIANCE 2014. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, Emily Hesler (ED.) Cambridge Media: Osborne Park, Western Australia.

42. N I K S S

45. Pressure Ulcer Prevention – Using Care Bundles to Enhance OutcomesProfessor Zena MoorePhD, MSc (Leadership in Health Professionals Education), MSc (Wound Healing & Tissue Repair), FFNMRCSI, PG Dip, Dip First Line Management, RGNProfessor of Nursing, Head of the School of Nursing & Midwifery , RCSI. Director of the SWaT Research Centre, RCSI.Adjunct Professor, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia, Professor Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Honorary Professor, Lida Institute, Shanghai, China, Senior Tutor, University of Wales.