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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
9
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)
14
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
18
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
19
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
31
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?
35
Action planning
Plan your next steps
Build on the PDSA’s developed yesterday
Report out
Three things you take away
Structure
First PDSAs
36