stop the pressure lincoln - 15 october 2013
DESCRIPTION
Presentations from the Stop the Pressure Lincoln event held for 500 student nurses and caremakers at The Engine Shed, Lincoln on 15 October 2013 This event supports Stop the Pressure, a campaign to raise awareness of pressure ulcers The hashtag used at this event was #stopthepressurelincolnTRANSCRIPT
#stopthepressure Lincoln15th October
2013
Welcome
Professor Sara Owen
Pro-Vice Chancellor
University of Lincoln
Introduction
Lyn McIntyreDeputy Nurse Director, Midlands and
EastCharlotte Johnston
Student Nurse, University of Lincoln
NHS Midlands & East
4
New grade 2, 3 and 4 pressure ulcers
5
• Midlands and East
• New numbers trend
Resources
NHS | Presentation to [XXXX Company] | [Type Date]6
NHS | Presentation to [XXXX Company] | [Type Date]7
The Swan’s Story
http://www.youtube.com/watch?v=IJ8FEhE561Y&sns=em
Pressure ulcer recognition and
preventionMark Collier
Tissue Viability Nurse Consultant
United Lincoln Hospitals NHS Trust
United Lincolnshire Hospitals NHS Trust
PRESSURE ULCER RECOGNITION AND PREVENTION..
Mark Collier, Lead Nurse/Consultant - Tissue Viability, United Lincolnshire Hospitals NHS Trust
Pressure Ulcers:Pressure Ulcers:Pressure Ulcers:
© Mark Collier
Current terminology?
• Bedsore• Pressure Sore• Decubitus Ulcer• Pressure Ulcer
What term do you use/prefer?
What is a Pressure Ulcer?
‘A pressure ulcer is a 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 significance of these factors is yet to be elucidated. (EPUAP 2009)
What is a Pressure Ulcer?
‘an area of localised damage to the skin which can extend to underlying structures such as muscle and bone. The damage is caused by a combination of pressure, shearing and friction forces and moisture’ (NICE, 2005)
‘Ulceration of the skin due to the effects of prolonged pressure, in association with a number of other variables’ (Collier 1995)
Pressure
External pressure will be transmitted from the skin to the underlying bone, compressing the tissues, including the smaller blood vessels, between these two structures.
When prolonged this pressure can lead to inadequate blood supply and cause tissue death.
Shear
A parallel force, shear damage occurs when deeper skin layers and skeleton move away from the upper skin layers. This causes stretching of the small blood vessels which, if unrelieved, will lead to inadequate blood supply leading to tissue death.
For example when a patient slides down the bed - the skin over the sacral area adheres to the bed sheets and remains in the sitting position as gravity forces the deeper underlying tissues and bone to slip down the bed.
Friction
Friction results form is the skin rubbing against another surface. Friction forces can contribute to the development of pressure ulcers by causing the skin layers to separate forming a blister, or by compromising the intact nature of the skin.
For example ill-fitting shoes or during poor moving and handling techniques, such as moving patients up the bed on a sheet .
Can you measure Pressure?..
‘a perpendicular load or force exerted on a unit of area’
Bennett and Lee (1985)
Force
Pressure = ---------------
Surface Area
Potential Sites for Pressure Ulcers
• Bony prominences
• Consider– Oxygen masks– Catheters and
tubing– Surgical appliances – Prosthesis
Factors that increase the risk of developing a pressure ulcer
Variables - ‘evidence based’
• Age
• Medical Condition
• Peripheral Vascular Disease (PVD)
• Drug Therapy
• Nutrition
• Medical Interventions
• Patient Support Surfaces
• Care being Given
Age
• Extremes of age• The skin of elderly patients is thinner, drier
and less elastic increasing the risk of damage.
• Neonates and young children are also at increased risk of skin damage because their skin is still maturing.
Nutritional Status
• Dehydration and malnutrition lead to poorly nourished, inelastic tissues that are more prone to damage.
• Consider– Likes and dislikes– Appetite– Chewing and swallowing difficulties –
dentures, sore throat/mouth– Physical ability to feed themselves?
BMI
• Very thin patients have less fatty tissue over the bony prominences to protect from pressure.
• Obese patients may have difficulty moving and therefore repositioning to relieve pressure.
Medical History
• Conditions causing reduced mobility & sensation.• Terminal illness due to multi-organ failure, poor
nutritional status & immobility. • Conditions affecting the circulation and
oxygenation of the blood.• Consider
– Heart disease– COPD and lung diseases– Peripheral vascular disease– Diabetes– Anaemia
Medication
• Anti-inflammatory drugs (including aspirin) and steroids may prevent healing.
• Chemotherapy drugs may damage healthy tissues.
• Sedative drugs may affect mobility and sensation.
Reduced Mobility
• Inability to move self in order to relieve the pressure.• Consider immobility/reduced mobility due to:
– #’s– Surgery– Epidurals– Traction– Pain– Paralysis– CVA– MS– Arthritis– Drains & tubing
Sensory Impairment/Reduced Consciousness
• Unaware of the need to relieve pressure.• Consider
– Unconsciousness – Sedation– Spinal Cord Injury– Diabetic neuropathy– Neurological Conditions egg MS, CVA
Moisture Lesions• A combination of moisture
and friction may cause moisture lesions in skin folds.
• A lesion that is limited to the natal cleft only and has a linear shape is likely to be a moisture lesion.
• Peri-anal discolouration / skin irritation is most likely to be a moisture lesion due to faeces.
Incontinence
• Urinary and faecal incontinence cause excoriation of the skin.
• Moisture causes maceration of the skin.• Consider
–Barrier creams/films
Skin Hygiene
• Excessive use of soaps will remove the skin’s natural protective oils and dehydrate it.
• Consider –Skin cleansers
Cost of Pressure Ulcers?
Additional treatment / management costs associated with an Orthopaedic patient with
one Grade 4 Pressure Ulcer equals….
£40,000 Sterling
Collier M (1993) Quality Report, Addenbrookes NHS Trust
from £1,214 (cat 1) to £14,108 (cat IV)
Dealey C, Posnett J et al (2012)
© Mark Collier
SSKIN - what does it stand for?
• S = Surface• S = Skin Inspection• K = Keep moving• I = Incontinence• N = Nutrition
Patient Support Surfaces available?
PRESSURE REDUCING?
PRESSURE RELIEVING?
Prevention and Management Support Surfaces
• Static foam mattresses• Huntleigh Rentals Contract
– Resource pack on intranet
• Nimbus III – alternating airflow, has heel guard
• Breeze – low air loss, light weight patients• Aura cushion• Consider when to step down!
© Mark Collier
Observation / Skin Assessment
Prevention and ManagementSkin Inspection
• At least daily, frequency will depend on vulnerability and condition of patient
• Pay particular attention to:– Areas of healed ulceration– Bony prominences
• Look for– Discolouration– Redness that doesn’t blanche with light pressure– Blisters– Localised heat– Localised oedema
Risk Assessment Tools
NICE Guideline No.7 Pressure Ulcer Prevention
‘Whilst there is little evidence to support one tool over another, there is evidence to suggest that an assessment process that incorporates a risk assessment tool improves the patients outcomes’
Which one do we use?
WATERLOW (2005)
Prevention and Management Positioning
• Regular repositioning to avoid pressure on bony prominences and existing pressure ulcers
• Turning/30 degree tilt• Avoid direct contact
between bony prominences to avoid friction and shear – consider use of pillows
• Consider– Seating– Spinal injuries– Bariatric patients
Prevention and Management
• Use of appropriate patient support surfaces• Skin assessment and good hygiene• Evidence based moving and handling
practice• Nutrition• Hydration • Incontinence
Categories (Grading) of Pressure Ulcers:
GRADE 1
GRADE 2
GRADE 3
GRADE 4 © Mark Collier
Pressure Ulcer CategoriesCategory 1
• Non-blanchable hyperaemia (of intact skin)
• Discolouration of the skin• Warmth• Oedema• Hardening
Pressure Ulcer CategoriesCategory 2
• Partial thickness skin loss or damage involving the epidermis and\or the dermis.
• The ulcer is superficial and presents clinically as an abrasion or a blister.
Pressure Ulcer CategoriesCategory 3
• Full thickness skin loss involving damage to or necrosis of subcutaneous tissue.
• This may extend down to but not through the underlying fascia.
Pressure Ulcer CategoriesCategory 4
• Extensive destruction and tissue necrosis or damage to bone, muscle or supporting structures with or without full thickness skin loss
Deep Tissue Injury• May appear as a purple,
deep bruise, often mistaken for a Grade 1 pressure ulcer
• Skin is intact• Occur over bony
prominences• Tissue damage that occurs
from the inside out• May quickly progress to
Grade 3 / 4 pressure ulcers
© Mark Collier
Guidelines within ULHT for….
• Pressure Ulcer Prevention• Equipment Provision (Support
Surfaces)• Pressure Ulcer reporting (PUNT)• Pressure Ulcer Management
Current ULHT Documentation
• Patient assessment/admission documentation that incorporates all of the principles of SSKIN
• Waterlow Assessment Tool• Tissue Viability Care Pathway• PUNT (e-reporting tool on intranet) • Wound Assessment and Management Chart
ANY QUESTIONS?
Living with a pressure ulcer – a patient and
carer perspectiveBrian and Yvonne Rawson
In conversation with
Delia Muir
Patient and Public Involvement Lead
Institute of Clinical Trials Research University of Leeds
Brian and Yvonne Rawson - PURSUN UKDelia Muir - Patient and Public Involvement Officer, University of Leeds
Living With a Pressure Ulcer – a patient and carer perspective.
PURSUN UK
• A network of people with some personal experience of pressure ulcers or pressure ulcer prevention
• We work on pressure ulcer related research projects
• Our members are also involved in education and professional development projects
Patient Stories
• Real life stories are powerful and can create a common focus
• Patients and their families are often the only constant thing in their journey through services, therefore their perspective very valuable
• We hope that hearing about the impact that a pressure ulcer can have will help to drive home important prevention messages
Brian and Yvonne’s Story
For more information contact:Delia Muir (PPI Officer)[email protected]
www.pursun.org.ukTwitter @PURSUN_UK
Or talk to us over lunch
Comfort Break
SSKIN mini quiz
Mark Collier
Tissue Viability Nurse Consultant
United Lincoln Hospitals NHS Trust
United Lincolnshire Hospitals NHS Trust
STOP THE PRESSURE...SSKIN Mini-Quiz
Mark Collier, Lead Nurse/Consultant - Tissue Viability, United Lincolnshire Hospitals NHS Trust
Question 1
What does the second S of SSKIN stand for?
• Surface (green)
• Skin Inspection (red)
Question 2
What is the prime function of an alternating pressure mattress (APM), such as a Nimbus III?
• Pressure reduction (green)
• Pressure relief (red)
Question 3
Which of the following skin discolouration is the most important to identify and report when inspecting a patient’s skin?
• Blanching (green)• Non-blanching (red)
Question 4
How would you categorise?
• Pressure ulcer (green)• Moisture lesion (red)
Question 5
All pressure ulcers are preventable?
• True (green)
• False (red)
Question 5: Answer
Hibbs, P. (1988) suggested that 95% of all pressure ulcers are avoidable.
Although everybody would agree that ALL avoidable pressure ulcers should be prevented, there is now evidence in the literature to suggest that around 43% of all pressure ulcers can be deemed to be avoidable.
Dowie F, Guy H et al (2013) Are 95% of hospital acquired pressure ulcers avoidable? Wounds 9:3 16-22
Question 6
Who is responsible for the application of the principles that underpin SSKIN in clinical settings?
• Everybody (green)
• All healthcare professionals (red)
ANY QUESTIONS?
Impact of good nutrition and hydration on
pressure ulcer prevention and care
Dr Ailsa Brotherton
Director for Clinical Engagement and Leadership
NHS QUEST PMO
NUTRITION AND HYDRATION IN THE PREVENTION AND TREATMENT OF PRESSURE ULCERS
DEVELOPING HIGHLY RELIABLE NUTRITIONAL CARE
Ailsa Brotherton
BAPEN Secretary
B A P E N Malnutrition Matters
British Association for Parenteral and Enteral Nutrition
A multi-disciplinary charity committed to raising awareness of malnutrition and options for nutritional treatment, along with
consequent impacts on health outcomes, resource utilization, and health & social care budgets.
PHYSICALDisease related malnutrition
Feeding
Swallowing
Low activity
Decreasedorgan reserve
Specificdisease
Multiple drugs(taste)
SOCIAL
Isolation
Poverty
PSYCHOLOGICAL
Depression/bereavement
Dementia
Alcohol
Mobility
Malnutrition in the UK
Poor breathing and cough from loss of muscle strength
Psychology – depression &
apathy Poor
Immunity and infections
Decreased Cardiac output
Hypothermia – decline in all functions
Renal function – limited ability to excrete salt and water
Loss of muscle and bone strength – Immobility, falls, fractures and VTE
Impaired gut integrity and immunity
Impaired wound healing and susceptibility to pressure ulcers
Liver fatty change, functional declinenecrosis, fibrosis
CONSEQUENCES OF MALNUTRITION (OCCURRING WITHIN DAYS)
Malnutrition is both a cause and a consequence of disease
The Malnutrition Carousel
HOSPITAL
NURSING HOME CARE
HOME
HOME
malnutrition
PRIMARY CARE dependency GP visits prescription costs hospital admissions
SECONDARY CARE complications length of stay readmissions mortality
B A P E N Malnutrition Matters
Nutrition support in adults 2006
February 2006
The effectiveness of Nutrition Support (Stratton et al)
0 10 20 30 40 50 0 5 10 15 20 25 30
30 RCT, n = 3258RR 0.59 (CI 0.48 to 0.72)
10 RCT, n = 494; RR 0.29 (CI 0.18 to 0.47)
Complications % Mortality %
Controls Controls
Treatment Treatment
>70% reduction in complications and >40% reduction in mortality
NICE ONS and length of stay
Standardised Mean diff.-3.45185 0 3.45185
Study % Weight Standardised Mean diff. (95% CI)
-0.32 (-0.83,0.20) {HARTSELL1997} 12.3
-0.49 (-0.78,-0.21) {PEARL1998} 12.7
-3.00 (-3.45,-2.55) {REISSMAN1995} 12.4
-0.03 (-0.39,0.33) Gist 2002 12.6
-2.54 (-2.93,-2.15) Gocmen 2002 12.5
-0.38 (-0.78,0.01) Burrows1995 12.5
-2.08 (-2.53,-1.63) Patolia2001 12.4
0.11 (-0.25,0.47) Weinstein1993 12.6
-1.09 (-1.91,-0.27) Overall (95% CI)
PRODUCTIVITYFINANCIAL COSTS
Over 3 million individuals malnourished or at risk of malnutrition in the UK
Public expenditure associated with disease related malnutrition 2003 - >£7.3 billion p.a
2007 - >£13 billion p.a.
NICE Cost Saving Guidance places malnutrition asa potential large cost saving to the NHS
2013 - ?? Costs being recalculated
PREVENTIONWE KNOW WHERE IT IS BUT DO LITTLE TO PREVENT IT
SECONDARY CARE complications length of stay readmissions mortality
CARE HOMES30-42% of recently admitted residents
HOSPITAL28% of admissions
PRIMARY CARE
hospital dependency GP visits prescription costs
SHELTERED HOUSING10-14% of tenants
HOMEGeneral population
(adults)BMI <20kg/m2 : 5%BMI <18.5kg/m2 : 1.8% Elderly: 14% Prevalence of
malnutritionin the UK
The Challenge:
We know what excellent nutritional care looks like
WE NEED HIGHLY RELIABLE SYSTEMS THAT WORK ACROSS ALL HEALTH SETTINGS
Malnutrition MattersMeeting Quality Standards in Nutritional Care
Ailsa Brotherton, Nicola Simmondsand Mike Stroudon behalf of the BAPEN Quality Group
The BAPEN Toolkit for Commissioners & Providers2010
THE FOUR BASIC TENETS OF GOOD NUTRITIONAL CARE
1) Identify those with malnutrition or risk of malnutrition by screening e.g. BAPEN’s MUST Tool and assessment as appropriate
2) Implement ‘individualised’ care pathways for the malnourished and those at risk, appropriate to the care setting
3) Provide training for all care staff on the importance of nutritional care appropriate to setting, profession and responsibilities
4) Ensure multidisciplinary structures to manage and monitor nutritional care
...but we struggle to deliver these reliably
THE CHALLENGE : TO ORGANISE THE DELIVERY OF GOOD NUTRITIONAL CARE IN A HIGHLY RELIABLE WAY
Reliability is not about what clinical care
should be given
Reliability is about the process of ensuring patients get best care consistently
‘Every patient, every setting, every day’
Local Improvement: Using standards and guidelines to drive
quality improvements in nutritional care
•Use the BAPEN toolkit which simplifies the plethora of standards and guidelines for improving nutritional care
• Design systems based on the four tenets of nutritional care
• Embed good nutritional care into everyday work flow
• Use evidence based tools and e-learning to support front line staff
• Work across organisational boundaries to ensure seamless nutritional care
• Ensure Trust Board Level engagement
•Identify a BAPEN rep in your organization
MUST Compliance
Mark BellasDivisional Lead Nurse
Critical Care/T&O
Royal Devon and Exeter NHS Foundation Trust have designed a highly reliable electronic system for nutrition screening using ‘MUST’
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PositionTarget
General Compliance with MUST Screening at Weekly
Review
Trajectory Results Trust-wide
IMPROVEMENT WORK: DESIGNING RELIABLE SYSTEMS
Design systems to screen
all patients
using ‘MUST’
Develop individua
lised nutritional care plans
Design reliable systems to deliver
care plans
Monitor ongoing nutrition
al intake / status
Screening alone is not enough
THANK YOU“You may never know what results come of your
action, but if you do nothing there will be no result”
CALL TO ACTION
Now is the time to deliver good nutritional care in the UK to deliver ‘harm free’ and eliminate avoidable pressure ulcers.
Mahatma Gandhi
Student nurse design for SSKIN
Charlotte Johnston
and student nurse colleagues
University of Lincoln
#stopthepressurelincoln#stopthepressure
SSKIN: For Students, BY Students.
University of Lincoln
S - Shadow• Important to spend time shadowing a Tissue Viability Nurse:
- When do you need their expertise?
- Learn from their experiences.
- Your responsibility to arrange to spend an insight day with TVN’s to supplement your university learning.
36. You must ensure any advice you give is evidence-based if you are suggesting healthcare products or services.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf Date Accessed: 07/10/2013
S – Signs/Symptoms• Understand and recognise the early signs of pressure ulcers or
potential/further damage:
- Start to form a care plan and ensure appropriate action is taken.
- To educate the patient and their families in ways to prevent potential/further damage.
- Also improves patient-centred care – by improving nurse-patient communication.
54. You must act immediately to put matters right if someone in your care has suffered harm for any reason.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf Date Accessed: 07/10/2013
K - Knowledge• As new guidelines are coming out, we know and understand how to apply these in
practice:
- Read, Read, READ!
- Challenge yourself and develop your own best methods of nursing based on your own evidence-based research.
- Training doesn’t stop at the end of a module, end of the year or the end of training.
40. You must keep your knowledge and skills up to date throughout your working life.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf Date Accessed: 07/10/2013
I – Innovate/Implement
• If you have any ideas to improve practice, share it!
- If you observe something that could be improved on, go and speak to your mentor/ward manager.
- Be the change you want to see.
22. You must work with colleagues to monitor the quality of your work and maintain the safety of those in your care.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf Date Accessed: 07/10/2013
N - NMC
• Nurses are accountable for all action:
- NMC Code of Conduct: YOU, as students, are accountable for all action/knowledge you have
- This is equally important for all healthcare professionals regardless of level, branch or speciality.
Page 1: We exist to safeguard the health and wellbeing of the public.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf Date Accessed: 07/10/2013
Change agents and boat rockers
Video: Dr Helen Bevan Introduced by
Lyn McIntyre
Deputy Nurse Director, Midlands and East
Ready, set -PLEDGE
Joe McCrea
Film maker and Strategic Adviser
NHS Change Day
Lunch
Lunch
……..and pledge, pledge,
pledge!
Tweets Can we trend?
Lynnette Leman
Digital Communications Officer
NHS Improving Quality
Unique individuals that received a #stopthepressurelincoln tweet … 214,130
Total number of timeline deliveries… 1,610,570
Total number of tweets… 1,420
Stop the pressure and nutrition:
interactive sessionLyn McIntyre
Deputy Nurse Director
Midlands and East
Andy Yeoman
Focus Active Learning
Pressure ulcer conferenceLincoln University
15th October 2013
Introduction
• Each table will play either;- The Nutrition Game
or - Stop The Pressure Game
• Games last for 30 minutes • Each table splits into 2
teams
The Nutrition Game
• 1 board• 1 set of question
cards (face down)• 2 counters• 2 dice• 1 sand timer• 1 “Pee chart”
Starting to play
• Place counters on board
• Roll dice; highest score starts
• First team roll dice and move counter
• Land on square; opposite team picks up a question card
Answer questions
• Team answers question (use timer)
• Correct answer MOVE forward 2 squares
• Opposite team roll dice and move
• Repeat as before
Up Straws & Down Carrots
• Land on the bottom of a STRAW – move UP
• Land on TOP of carrot - move DOWN
• Do this before answering a question
Winning
• Get to FINISH firstOR
• Closest to FINISH
Stop the Pressure Game
• 1 board• 1 question pack• 1 SSKIN question
pack• 2 counters• 1 dice• 1 sand timer• 10 SSKIN tokens
Stop the Pressure Game
• Place counter on Start (green square)
• Roll dice; highest score starts
• First team roll dice and move counter
• Land on square; opposing team reads out a question
Stop the Pressure Game
• Team answers question (use timer)
• Correct answer MOVE 2 squares
• Opposing team roll dice and move
• Repeat as before
Stop the Pressure Game
• Team LAND on an SSKIN square
• Opposite TEAM picks up a SSKIN question card and reads out the question
Stop the Pressure Game
• Correctly answer WIN an SSKIN token
• TEAM places SSKIN token on board
Stop the Pressure Game
• Correctly answer WIN an SSKIN token
• TEAM places SSKIN token on board
• Place SSKIN token on board
Stop the Pressure Game
• Correctly answer WIN an SSKIN token
• Place SSKIN token on board
• Collect 5 tokens to WIN
• Facilitators will help and break up any fights
Enjoy
www.stopthepressure.com
Making a difference through practice led
pressure ulcer research
Professor Jane Nixon
Deputy Director
Institute of Clinical Trials Research
University of Leeds
© CTRU 2013
Making a difference through practice led pressure ulcer research
Jane Nixon PhD, MA, BSc(Hons) RGNProfessor of Tissue Viability and Clinical Trials Research
Clinical Trials Research Unit
School of Medicine
University of Leeds
© CTRU 2013
Impact of Pressure Ulcers on QOL
QOL Conceptual Framework
Symptoms
Pain & Discomfort
Exudate
Odour
Physical Functioning
Mobility
Daily activities
General malaise
Sleep
Psychological Well-being
Mood
Anxiety & Worry
Self-efficacy & Dependence
Appearance & self-consciousness
Social Functioning
Isolation
Participation
Source: Gorecki, C et al
© CTRU 2013
Critical mass Australia, Japan, Germany, the Netherlands, Belgium and USA
UK has 4 fundamental ingredients
1. Nursing research agenda2. Research funding through National Institute for Health Research
Large trials, Programme Grants, Research for Patient Benefit , Fellowships3. Clinical Research Networks – Research Nurse infrastructure4. Clinical Trials Units/Methodologists
UK world leading pressure ulcer prevention
clinical research
© CTRU 2013
Research areas/pathways- Leeds
QOL
Living with a PU
Conceptual Framework
Outcome Measure
Development
PUQOL Field Testing
PUQOL Instrument
Pain
Living with PU
QOL/Pain systematic
reviews
Epidemiology Prevalence
Epidemiology Risk Factor
Pain assessment
and management
Risk Factors
Erythema Imaging
Epidemiology Risk Factor
Studies
Systematic review
Risk Assessment
Mattress effectiveness
OR mattress
HTA Pressure
HTA PRESSURE
2
Early phase trial design
Severe Pu
Case studies
Clinical Practice – NHS
investigation
Clinical Practice Service
Development
© CTRU 2013
Pain and pressure ulcers
Living with a pressure ulcer
QOL and Pain systematic reviewsPain worst symptom of having a pressure ulcer. Pain impacts upon quality of life and is not addressed by hcps
Living with a pressure ulcer
Qualitative study Patients reported pain preceding PU development and said nurses ignored their concerns
© CTRU 2013
Pain and pressure ulcers
Extent of pressure area related pain
Prevalence hospital and community populations3397 hospital patients, 15.9%
pressure area pain
287 community
patients with PUs, 75.6%
reported pain
Severity not related to PU
Category
Pain reported on skin sites with no PUs
Mix of inflammatory
and neuropathic
pain
© CTRU 2013
Pain and pressure ulcers
Is pain important in predicting Category 2 PU development?
Cohort study hospital and community populations30+ centres, 634 patients
analysis population
602 .
Variable Odds Ratio p-valuePresence of category 1 PU(yes vs no) 3.25 <0.0001
Presence of skin alterations(yes vs no) 1.98 0.0014
Presence of pain on a normal, altered or Category 1 skin site(yes vs no)
1.56 0.0931
© CTRU 2013
Severe PU
• Inquiry style study (Laming Inquiry, 2003)• Innovative retrospective case study design to examine
whole system failures
Results: Clinicians fail to listen to patients/carers Clinicians fail to assess risk/respond to superficial PUs Co-ordination failures Current practice of investigation
does not include patient account
and as a result there are gaps
© CTRU 2013
Risk Assessment
Which of your patients are at risk?Multiple risk factors – which risk factors are most important?Only 0.34% of hospital patient admissions will develop a pressure ulcer.
© CTRU 2013
PU Risk Factor Systematic Review
Research Question: Which risk factors are independently predictive of PU development in surgical, medical and community-based populations?
Result15 Risk factor Domains46 Sub-DomainsHow useful is this for clinical practice?
5,462Abstracts/papers
retrieved
365 Potentially relevant,
obtained in full for further
scrutiny
Included54 Studies
34 Prospective cohort
9 Record Review
11 RCTs
5,097 Excluded – not
satisfying eligibility criteria
311 Excluded – not
satisfying inclusion criteria
Flow of studies:
© CTRU 2013
Key Risk Factor Themes included: Immobility Skin condition Perfusion (including diabetes)
Less consistently emerging themes included:
Moisture Body temperature
Nutrition Age
Gender Mental Status
Race Sensory Perception
Medication General Health Status
Haematological measures
PU Risk Factor Systematic Review
© CTRU 2013
Risk Assessment Framework
Phase 1Development of evidence base
PU Risk Factor Systematic Review to identify risk factors independently predictive of PU development
Pre-Clinical
Phase 2 Consensus study
Agree:- risk factors & assessment items for inclusion in draft risk factor MDS & RAF- Conceptual framework development
Pre-Clinical
Phase 3 Design & Pre-Test
- RAF Design- Assess & improve acceptability, usability, format, design, clarity, comprehension language & data completeness of draft RAF with clinical nursesClinical
Phase 4 Clinical Evaluation
- Evaluate reliability, data completeness, clinical usability, & validity (convergent & known groups) of preliminary RAF
Clinical
Phase 5 Long-term Implementation & Clinical Evaluation- Dissemination of RAF into routine NHS care- Predictive Validity testing- Multivariable modelling & revision of RAF
Clinical
Aim: to agree a pressure ulcer risk factor minimum data set (MDS) to underpin the development & validation of a risk assessment framework (RAF) for use in clinical practice.
© CTRU 2013
Consensus methods
QuestionnairesFace to face meetings
Risk Factor Progression
15 Risk factor domains & 46 sub-domains of the systematic review reduced to 26 risk factors following initial expert group meeting1. Immobility2. Existing PU3. Previous PU4. General skin status5. Chronic wound6. Friction & shear7. Sensory Perception8. Diabetes9. Pitting oedema10. Lowering BP11. Smoking 12. Cardiovascular disease13. Albumin14. Haemoglobin15. Skin moisture16. Dual incontinence17. Medication18. Acute illness19. Infection20. Body Temp21. General health status22. Nutrition23. Mental status24. Race25. Gender26. Age
Cycle 1:
Risk factor pre-meeting questionnaire
1. Immobility
2. Existing PU
3. Previous PU
4. General skin status
5. Diabetes
6. Nutrition
7. Sensory Perception
8. Dual incontinence
9. Skin Moisture
10. Acute Illness
11. Body Temp
12. Albumin
Cycle 1:
Risk factor post-meeting questionnaire
1. Immobility
2. Existing PU
3. Previous PU
4. General skin status
5. Perfusion
6. Diabetes
7. Nutrition
8. Sensory Perception
9. Skin Moisture
10. Dual incontinence
11. Albumin
Cycle 2:
Minor Refinement of Risk Factors (incorporated in pre-meeting questionnaire)
1. Immobility
2. Existing PU
3. Previous PU
4. General skin status
5. Perfusion
6. Diabetes
7. Nutrition
8. Sensory Perception
9. Moisture
Risk Factors for Screening & Full Assessment Stage of MDS and RAF
Screening Stage ImmobilityPU Status (existing & previous)
Full Assessment StageImmobilityPU Status (existing & previous)General skin statusPerfusionDiabetesSensory perceptionMoistureNutrition
© CTRU 2013
Initial draft of the RAF and underpinning MDS
© CTRU 2013
Pre-test - Focus Groups
Take home messages
at your patients skin
Ask and listen to patients
Problem solve for complex patients
ReferencesPain
Briggs M, Collinson M, Wilson L, Rivers C, McGinnis E, Dealey C, Brown JM, Coleman SB, Stubbs N, Stevenson R, Nelson EA, Nixon J (2013) The prevalence of pain at pressure areas and pressure ulcers in hospitalised patients BMC Nursing Vol 12 (1), p19 http://www.biomedcentral.com/1472-6955/12/19
Stevenson R, Collinson M, Henderson V, Wilson L, Dealey C, McGinnis E, et al. The prevalence of pressure ulcers in community settings: An observational study. International Journal of Nursing Studies 2013;DOI: http://dx.doi.org/10.1016/j.ijnurstu.2013.04.001.
Gorecki C, Closs J, Nixon J, Briggs M. (2011) Pressure ulcer pain: a mixed method systematic review. Journal of Pain and Symptom Management. Journal of Pain and Symptom Management Vol 42(3):443-59
Risk factors
Coleman S, Gorecki C, Nelson EA, Closs J, Defloor T, Halfens R, Farrin A, Brown JM, Schoonhoven L and Nixon J. Patient Risk Factors for Pressure Ulcer Development: Systematic Review International Journal of Nursing Studies Vol 50 (7) p974-1003 http://www.sciencedirect.com/science/article/pii/S002074891200421X
Nixon, J., Cranny, G. and Bond, S. (2007) Skin alterations of intact skin and risk factors associated with pressure ulcer development in surgical patients. International Journal Nursing Studies Vol 44: 655-663
Nixon, J., Nelson, E. A., Cranny, G., Iglesias, C., Hawkins, K., Cullum, N., et al on behalf of the Pressure Trial Group. (2006) Pressure Trial: Pressure RElieving Support SUrfaces: a Randomised Evaluation. Health Technol Assess Vol 10 (22).
ReferencesQOL
Gorecki C, Brown JM, Cano S, Lamping DL, Briggs M, Coleman S, Dealey C, McGinnis E, Nelson EA, Stubbs N, Wilson L, Nixon J (2013) Development and validation of a new patient-reported outcome measure for patients with pressure ulcers: The PU-QOL instrument. Health & Quality of Life Outcomes, DOI: 10.1186/1477-7525-11-95
Gorecki C, Lamping D, Alvari Y, Brown J, Nixon J (2013) Patient-reported outcome measures for chronic wounds with particular reference to pressure ulcer research: A systematic review. International Journal of Nursing Studies, DOI: 10.1616/j.ijnurstu.2013.03.004
Gorecki C, Nixon J, Madill A, Firth J, Brown JM (2012) What influences the impact of pressure ulcers on health-related quality of life? A patient-focused exploration of contributory factors. Journal Tissue Viability Vol 21: 3-12
Gorecki C, Closs J, Nixon J, Briggs M. (2011) Pressure ulcer pain: a mixed method systematic review. Journal of Pain and Symptom Management. Journal of Pain and Symptom Management Vol 42(3):443-59
Gorecki C, Lamping DL, Brown J, Madill A, Firth J, Nixon J. (2010) Development of a conceptual framework of health-related quality of life in pressure ulcers: a patient-focused approach. International Journal of Nursing Studies, 47: 1525-1534.
Gorecki CA, Brown JM, Briggs M, Nixon J. (2010) Evaluation of five search strategies in retrieving qualitative patient-reported electronic data on the impact of pressure ulcers on quality of life. Journal of Advanced Nursing, 66 (3): 645-652.
Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, Defloor T, and Nixon J on behalf of the European Quality of Life Pressure Ulcer Project Group (2009). Impact of pressure ulcers on quality of life in older patients: a systematic review JAGS 57: 1175-1183
Spilsbury K, Petherick E, Cullum N, Nelson EA, Nixon J and Mason S. (2008) The role and potential contribution of clinical research nurses to clinical trials. Journal of Clinical Nursing 17 (4), 549–557.
© CTRU 2013
Acknowledgement
PURSUN (Pressure UlceR Service User Network)
NIHR: This presentation presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (RP-PG-0407-10056). The views expressed in this presentation are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Student Competition to be launchedStudent Rate £35.00 per day
On the couch:an interview
Video: Dr Helen Bevan
Introduced by
Charlotte Johnston
Student nurse
University of Lincoln
6 c’s – aims, website and Care Makers
Dr Ruth May
Chief Nurse NHS England
Midlands and East
and
Care Makers
Compassion in PracticeProgress and DevelopmentsPresented by Ruth May
Regional Chief Nurse
NHS England (Midlands & East)
October 2013
156
The Nursing Narrative
NHS England | Ruth May | Twitter: RMayNurseDir
The Keogh Review
157
• A limited understanding of and failure to genuinely listen to patients and staff
• The lack of value and support being given to frontline clinicians, particularly junior nurses and doctors
• More work needed at some trusts on issues such as reducing incidents of pressure ulcers
• Essential standards for staffing
NHS England | Ruth May | Twitter: RMayNurseDir
Developing the culture of compassionate care
158 NHS England | Ruth May | RMayNurseDir
159
Our values and behaviours are at the heart of the vision and all we do
Care Compassion
Competence Communication
Courage Commitment
NHS England | Ruth May | Tw itter:RMayNurseDir
160
Six Areas for Action
Helping people to stay independent, maximising well-being and improving health outcomes
Working with people to provide a positive experience of care
Delivering high quality care and measuring impact
Building and strengthening leadership
Ensuring we have the right staff, with the right skills in the right place
Supporting positive staff experience
NHS England | Ruth May | RMayNurseDir
NHS England | Ruth May | RMayNurseDir161
The children’s community nursing team at Cambridgeshire Community Services NHS Trust has been announced as the winner of NHS England’s 6C’s Live! September Story of the Month
Catherine Ray, a senior sister at Solihull Hospital, has been picked as the first ever winner of NHS England’s 6C’s Live! And Nursing Times’ story of the month competition
162
Click icon to add pictureClick icon to add picture Click icon to add picture
NHS England | Ruth May | Twitter: RMayNurseDir
What are Care Makers?• We are looking for individuals who can be ambassadors for compassion in practice
and who can demonstrate and advocate the 6C’s in their practice
• Care makers are ambassadors for the 6C’s
• The first cohort of 55 Care Makers were recruited prior to the CNO Conference in
2012 of newly qualified nurses, student nurses, midwives, and healthcare assistants
• Principles for creating this network include
To inspire young people
A shared purpose to transform the NHS Culture in Nursing,
midwifery and care staff
To be advocates for compassion in practiceNHS England | Ruth May | RMayNurseDir163
How to become a Care Maker• From mid-October applications can be downloaded from
http://www.nhsemployers.org/caremakers/Pages/How-do-I-become-a-caremaker.aspx
• Applications should be submitted, including a reference from an appropriate senior
representative, to [email protected]
• NHS Employers sift through applications into yes – queries to go to Region
• On a set day every month NHS Employers will send applications to regional nurses
for review with partner organisations if agreed
• Applications will be assessed against the definitions of the 6C’s
• We need to recruit 350 in the next round; the national target is 1000 by the end of
March 2014
NHS England | Ruth May | Twit ter:RMayNurseDir164
Tweets and Pledges:how have we done?
Lynnette Leman
Digital Communications Officer
NHS Improving Quality
Joe McCrea
Film maker and Strategic Adviser
NHS Change Day
Wrap up, thanks, reflections on the day
and looking to the future
Professor Sara Owen and Charlotte Johnston
University of Lincoln
Dr Ruth May and Lyn McIntyre
NHS England Midlands and East