Stop the Pressure Lincoln - 15 October 2013

#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

[email protected]

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


• 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.


• Full thickness skin loss involving damage to or necrosis of subcutaneous tissue.

• This may extend down to but not through the underlying fascia.


• 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

mailto:[email protected]

http://www.pursun.org.uk/

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

[email protected]

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


#stopthepressurelincoln#stopthepressure

SSKIN: For Students, BY Students.


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

http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=JqCwd2RlV9qkaM&tbnid=whjBnJSePGiqcM:&ved=0CAUQjRw&url=http://stackoverflow.com/questions/2872431/how-to-create-css-based-big-quotation-marks&ei=frJSUv_oH-ev0wWQloDIBw&bvm=bv.53537100,d.d2k&psig=AFQjCNHP5WXjo76EbWNFdPXTvUp1g74hKw&ust=1381237748589066


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.





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.





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.





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.





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


• 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


• Team answers question (use timer)

• Correct answer MOVE 2 squares

• Opposing team roll dice and move

• Repeat as before


• Team LAND on an SSKIN square

• Opposite TEAM picks up a SSKIN question card and reads out the question


• Correctly answer WIN an SSKIN token

• TEAM places SSKIN token on board



• TEAM places SSKIN token on board

• Place SSKIN token on board



• 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


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


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


5. Perfusion

6. Diabetes

7. Nutrition


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


5. Perfusion

6. Diabetes

7. Nutrition


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).

http://www.biomedcentral.com/1472-6955/12/19

http://www.biomedcentral.com/1472-6955/12/19

http://dx.doi.org/10.1016/j.ijnurstu.2013.04.001

http://www.sciencedirect.com/science/article/pii/S002074891200421X

http://www.sciencedirect.com/science/article/pii/S002074891200421X

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


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

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• 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


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


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

http://www.nhsemployers.org/caremakers/Pages/How-do-I-become-a-caremaker.aspx

mailto:[email protected]

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


Dr Ruth May and Lyn McIntyre

NHS England Midlands and East

Health & Medicine

Stop the Pressure Lincoln - 15 October 2013