Pressure Injury Project Update - nra.health.nz · Various means have been used to achieve improvement/change One-off, and Monthly audits, with feedback to staff on audits Presentations

Pressure Injury Project Update6 November 2012

Collaborative Learning Session 2 @ Ko Awatea, CMDHB

Lift the Health of Aucklanders �� Improve Performance �� Live Within Our Means

Healthy CommunitiesQuality Healthcare

What we have been doing

� ADHB has been raising awareness (assessment, grading) and improving processes and tools

(policies, reporting, forms etc) relating to Pressure Injuries.

� Various means have been used to achieve improvement/change

� One-off, and Monthly audits, with feedback to staff on audits

� Presentations by topic experts

� Direct engagement with ward staff

� Expert groups focussed on specific issues, with steering group to remove barriers

Healthy Communities, Quality Healthcare 2

� Regional engagement and learning

� Roughly shaped by the DMAIC approach.

� Define

� Measure

� Analyse

� Improve

� Control

� We are now transitioning into the ‘control’ phase, though still have plenty of ‘improve’ yet to go...


Key messages - performance

We appear to;

� have reduced incidence of severe hospital acquired pressure injuries, but are causing and/or

finding more non-severe pressure injuries.

� be more aware of pressure injuries, with increased self-reporting.

� have an increased understanding that skin checks and other pressure injury cares (nutrition, turns,

continence management) matter. Many comments such as “…it’s nursing 101…”, and “…I expect

all my nurses to know this…” have been received during course of audits, yet indications are that in


all my nurses to know this…” have been received during course of audits, yet indications are that in

many pressure injury cases the basics may not be being done... Understanding + Capability +

Capacity

� still have some issues with false positives - cases where ‘grade 1’ is noted, but later determined not

to be (e.g. nappy rash, ECG tab marks etc)

� understand that nurses can and should lodge ACC forms as part of continuing care of their

patients.

Key messages - process

Think before acting

� Put effort into preparation before leaping to action

� Lots of resources available – appropriate/borrow/re-use

Clinical ownership essential

� Senior level for cut-through of barriers

� Ward-level for reality check


Set the right goal!

� ADHB will reduce incidence of PI by 20% by the end of 2012.

Example of system barrier

� Incident reporting allows organisational knowledge of issues for resource allocation and training,

other causative factors (e.g. equipment issues) and identification of whether injuries were

pre/post admission.

– ADHB uses Risk Monitor Pro (self reporting). Generally considered to run at about 30% of

reality.

� The project appears to have had some effect on self-reporting.

� It is still considered that RMPro reporting is running below reality.

� RMPro not user friendly


Issue Action

RMPro incident type classifications

unclear (leading to misreporting)

‘Pressure Injury’ will be given it’s own General

Incident Type classification

RMPro entry screens lengthy, and

not intuitive (so can take long time to

complete)

A ‘Quick Submission Form’ developed (at right),

and being trialled. This contains only fields

required by CEA’s to trigger follow-up and allow

proper DHB reporting

Limited feedback given to clinical

staff on any report (so perceived as

low value)

Means of increasing feedback has not yet been

identified – suggestions welcome

Ambiguity as to who, how and when

RMPro report should be completed

(so left to someone else…)

Increased focus on staff training, especially with

roll-out of QSF.

We are becoming better at preventing the more serious pressure injuries (because we’re

discovering more pressure injuries, and earlier),

or;

We are allowing more grade 1 pressure injuries to occur


Prevalence across ADHB

� To reduce the incidence of pressure injuries (of what ever grade), there are some key procedural aspects we can

affect;

– early risk assessment of all patients, on admission, on ward transfer, and if any significant change in status

– early and appropriate interventions to mitigate risk (especially turns, skin checks, washes, and continence

management)

– raising awareness of staff, patients and family members to risk factors.

� Where pressure injuries do occur, there are some key aspects we must improve on;

– grading of injuries

– completeness of documentation (Patient notes, ACC forms, RMPro)


– completeness of documentation (Patient notes, ACC forms, RMPro)

� In the case of at-risk patients, or patients with actual pressure injuries, we must improve on transfer and hand-over

procedures to and from other wards, residential care facilities, or other DHB’s;

– correct and complete notes, with details as to risk factors, interventions used and required e.g. equipment

requirements, turns register etc)

– minimise time taken between pressure area cares (e.g. waiting for ambulance, waiting for medication/xray,

transfer time, etc) and/or time on less-than-ideal support surfaces (e.g. on ambulance stretcher) and on number

of transfers between surfaces

Risk Assessments

� Risk assessments are an important aspect of preventing pressure injuries – they support nurses’ judgement and

knowledge, aid less experienced nurses in developing that judgement (if applied critically), and provide a

consistent format for patient notes (= faster and better review if needed).

� Completion of risk assessments is an aspect of process – something ADHB has full control over. This is different

from the outcome of prevalence.


Risk Assessments

� Conducting an assessment of every patients’ pressure injury risk is considered best practise nursing at ADHB.

� A number of barriers to full and proper assessment of patients’ Pressure Injury Risk levels have been

identified, and are being worked on;

Issue Action

Multiple versions of Waterlow across ADHB

adult wards

New form developed and being trialled. All adult wards will

move to using new form. Review of Children’s Health

assessment on hold.

Waterlow, interventions, turn schedules on

different forms

New form incorporates best of all previous items.


Time taken to complete Waterlow for

(assumed) low risk patients = reason for not

doing assessment

“Quick Risk Assessment” built into EWS form = easy

documentation of clinically sound, rapid assessment,

?leading to detailed assessments /interventions only when

justified. APU (100+ pt/day) has agreed to do this.

Prompts for interventions, equipment

selection, ACC lodgement, RMPro entry not

sufficient.

Prompts included in new form. Need to ensure staff

understand importance of RMPro (ADHB can learn from

incidents) and ACC forms (optimal post-discharge patient

care, patients don’t have to chase GP’s).

Risk Assessments - PDCA


Awareness/Grading

� Proper identification of pressure injuries allows early intervention and treatment.

� Grade 1 pressure injuries are reversible, and should be considered the ‘tip of the iceberg’

whereby the patient’s body is declaring ‘I’m at high risk’.

� A number of barriers to awareness and grading have been identified, and are being worked on;

Issue Action

Difficulties in

grading

Nurse Educators + Nurse Specialists

overseeing audits.


Grading tool developed and distributed to NE’s

and CN’s.

Patient/family

members not

aware of

risks

Patient information brochure developed and

distributed for trial in high-prevalence wards.

Children’s Health brochure on hold.

Formal

education

Wound care group updating intranet

information (+ policy/guidelines)

Moodle module under development.

‘Hands-on’ equipment sessions being

established

Currently…

� Ongoing monthly PI audits

� World Pressure Injury Day

� considering whether to set policy of Grade 3

or 4 PI as ‘never events’. Big step, with

multiple pros and cons. If done will need to

be done correctly to really improve patient

safety.

What’s next?


safety.

� Looking for a home... workplan ‘to do’ list

used to capture thoughts and follow-up

actions

World pressure injury day


Other stakeholders


Pre-admit / transit / post-discharge


� Working on ways to improve pre-admit and post-discharge issues (e.g. DN, community

factors, transport delays, communications - GP - family) which may affect patient

outcomes. MUST BE REGIONAL

� Normalise admission/discharge forms and notes

The various steps have been (in approximate order);

� Establishment of Steering Group (expert knowledge + organisation leadership + small budget = group that can properly

consider issues that crop up AND has the power to do something about them)

� Communications with staff about program (‘upcoming audits and improvement work aimed at increasing patient safety’)

� Whole-of-DHB audit conducted Dec 2011 (all patients at ADHB audited on one day)

� Review of first audit to extract areas of interest

� Cause + Effect sessions with clinical staff to test those areas of interest, raise new ones, and prioritise activities

– Policies and procedures (tools for clinical staff)

– Awareness of PI, prevention/grading

– Equipment issues (awareness of selection, access – right patient/right equipment/right time

Summary of activities


– Equipment issues (awareness of selection, access – right patient/right equipment/right time

� Engagement with other DHB’s and ARRC via FDNH

� Monthly audits developed and begun, reporting to steering group, board, FDNH. Audits used as vehicle to convey information

each month (pre = “this month focus is on…”, post = “this month we found that…”). The audits are (at the moment) intended

to continue indefinitely.

� Policy and forms reviewed and improved (PDCA cycles)

– Issue identified, expert group formed, task determined

– Improvement team activities, and then refers back to EG

– Trialled/tested in real world, feedback gathered

– Alterations made, reviewed by EG, confirmed with testers, Rolled out

– ^ ideal… reality = messier – e.g. forms process. Use stakeholder engagement and steering group to remove barriers.

� Educational material developed (classroom and hands on)

� Awareness campaign around World PI day.

� … ongoing ownership (quality and clinical, not improvement)

Challenge to the room #1


Can NZ contribute to global body of knowledge on pressure injuries?

• Means

• Lots of good data

• Good communication channels

Challenge to the room #2


• Motive

• demographics and health trends

• Opportunity

• Nimble, can implement quickly and learn

• Willingness to move

Documents

Pressure Injury Project Update - nra.health.nz · Various means have been used to achieve improvement/change One-off, and Monthly audits, with feedback to staff on audits Presentations