Hospital‐acquired pressure ulcer incident rates among hospitals that implement an education program for staff, patients, and family caregivers inclusive of an after discharge follow‐up program in Saudi Arabia

Abstract

A tertiary public hospital in Saudi Arabia set out in 2015 to establish a team focused on reducing hospital‐acquired pressure ulcers (HAPUs). The pressure ulcer prevention program (PUPP) had a multifaceted approach and data were collected for a period of 5 years. The results showed a definite reduction in the incidences of HAPUs. Many such programs show similar positive results and echo many of the same considerations of risk, prevention strategies, and the need for early intervention. However, none of the other studies either replicate the hospital's PUPP nor the extent of the positive and lasting effect of the program. Eager to determine the contributing factor(s) in order that the project success could be continued and possibly replicated in other quality improvement projects, it was decided that an examination and comparison of other similar programs and their results would be necessary in order to uncover the answer. It was determined that the in‐person in‐home discharge follow‐up portion of the program most likely had the largest effect on the outcomes. Outcomes that were supported by the pre‐work completed during the hospital portion of the PUPP towards reducing HAPUs and readmissions.

1. BACKGROUND

Hospital‐acquired complications (HACs) are a major problem facing health care facilities, this an almost 4‐fold increase of in‐patients between 2016 and 2018. ¹ Therefore, arising from developing such complications as infections from medical devices like catheter‐associated urinary tract infection and/or central line associated blood stream infection, hospital‐acquired pressure ulcer (HAPU), pneumonia, or surgical site infection. ² Worldwide, hospitals strive towards positive patient outcomes and maintaining a positive professional reputation all while managing costs. ² Prevention of HACs has increasingly become the central focus of healthcare facilities due to several reasons. ³ Quality improvement projects targeted at reducing HACs can be strategies that provide a pathway to these goals. ⁴ Beyond the obvious pain and suffering inflicted upon those patients afflicted with HACs there are other costs to be considered. ⁵ Costs such as those that HCAs have upon reportable hospital performance metrics, which affects ones' professional reputation ⁶ as well as dollar costs of added care expenses ⁷ that are often not reimbursed. Significant reduction of HACs such as achieving a 0 % occurrence rate is very difficult. Hospital admission costs represented the greatest percentage of the total cost (62%). Sensitivity analysis showed that the total average monthly costs were most sensitive to variations in hospitalisation costs, ⁸ although it may be attainable through comprehensive and sustainable preventive measures. ⁹ , ¹⁰ Key elements of such preventive program measures should include: implementation of evidence‐based practices, evidence‐based product selection, provision of education to hospital staff by healthcare providers which can be performed through implementing evidence‐based prevention programs. ¹⁰ Despite best efforts, pressure ulcers (PUs) do still occur and patients are at risk for PU not only just in hospital but also once discharged home. ¹¹ In the hospital, 89% of PUs occur in the ICU population. ¹² While prevalence of category I–IV PUs was 8·0%, and the overall nosocomial PU prevalence was 4·5%. ¹³ All PUs can contribute to complications ultimately leading to readmissions (within 30 days of discharge). ¹⁴ There is a strong call in the literature for further research continuation in order to establish the circumstances that lead to the success or failure of a particular interventions. ⁸ The central pressure ulcer prevention program (PUPP) study offered for follow‐up deliberation is one that took place in a Saudi Arabian 360 bed tertiary hospital. This PUPP was multifaceted and took place over a 5‐year period. It created a wound care team and focused on providing education to hospital staff inclusive of patients and their families in hospital. The PUPP included planning care needs with each patient and their family in preparation for discharge. The program then followed patients and their caregivers at their homes providing follow‐up care, education, and support while tracking both PU healing progress as well as the development of potential new PUs. Throughout, the study carried out continuous data monitoring. This retrospective comparative study indicated a reduction of PUs from 0.20% to 0.06%. ¹ Of note is that the hospital PUPP initiated the use of Braden scale from the time of patient arrival to hospital, and implemented outlined guided instructions replete with applicable interventions for staff to follow^{. 1} The program differed from previous research ¹⁵ in that it directly enrolled qualified patients to the trial in the emergency department (ED) and followed those patients through to the intensive care unit (ICU) until their eventual discharge. The study took in account the fact that many patients often spend extended periods of time in the ED and/or in the operating theatre. PUs identified in the ICU but very likely resulting from damage to tissues prior to arrival in the ICU. ¹⁵ This paper will focus specifically on HAPUs and attempt to determine which underlying interventional factor(s) contributed to the exceptional success of Sulaiman Al Habib's PUPP.

1.1. Study purpose

This study has been designed and aimed towards narrowing down the best strategies to decreasing HAC incident rates, specifically the HAPUs rates. Through determining which factor(s) contributed to the successes made with the Saudi Arabian PUPP. This was undertaken with the purpose that if those elements from the original study are in fact identifiable, they could then be capitalised upon for use in future quality improvement program efforts. Furthermore, to contribute to the further study in regards to the importance of discharge follow‐up care as it relates to PU healing and better overall patient care outcomes, potentially evidenced by wound healing and decreased re‐admissions related to PU complications.

2. MATERIALS AND METHODS

Given the aims of this study, a systematic review of studies published between 1 January 1998 and 31 January 2020 have been conducted in accordance with published guidelines. We have used the PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Register of Controlled trials databases. The literature will be cross‐referenced and compared for similarities and differences in order to establish what stands out in the Saudi program. Search terms included Hospital‐acquired complications, hospital acquired PUs, providing education to hospital staff, bedsores, PU, decubiti, and discharge.

2.1. Participants

A PUPP was introduced to public hospital staff in Saudi Arabia at the beginning of year 2015. It included follow‐up home support after discharge. The yearly data of inpatient counts and recorded HAPU complication count was obtained from the hospital's record system for the years 2015, 2016, 2017, and 2018. In addition, the HAPU incidents rates were calculated by dividing the total number of inpatients with HAPU complications by the total number of inpatients.

2.2. Instrument

R version 3.6.1 was used to conduct the analysis. Line plot was generated for total number of inpatients by each year, as shown in Figure 1. The chart demonstrates that the Al Habib hospitals participated in this study.

FIGURE 1.

Total number of inpatients from year 2016 to 2018

2.3. Procedure

A systematic review of studies as well as a meta‐regression of the data will be undertaken. This is to be performed, in order to establish the effectiveness of PUPPs on the reported status of the HAPU incident rates. Particularly, among hospitals that have conducted an education program for staff, patients, and their families with home‐based follow‐up after being discharged. In order to identify any particular or outstanding factors contributing to improved outcomes. This study experienced an up‐trend for number of inpatients from year 2016 to 2018. In year 2018 particularly, the hospitals experienced more than a 3‐fold inpatient growth in comparison to year 2017. This is most likely due to an increase in admissions to the hospitals, and also changing policies of hospitals to accept insurance claims from inpatients.

2.4. Analysis of data

Cross tabulation between Year and HAPUs was conducted and the R outputs were presented above, In 2016, there are 5 cases of HAPU, followed by 7 cases of HAPU in 2017, and 6 cases of HAPU in 2018. Surprisingly, the number of inpatients tripled from 2017 to 2018, however, the number of HAPU cases remained low. Pearson's chi‐square test with χ ² = 7.3672, and P value = .02513 clearly shows that there is a significant difference in proportion of HAPU (in this case, the incident rate of HAPU) in different years. To better understand these differences, the study plots a line chart using the incident rates of HAPU in 10 000 inpatients, as depicted in Figure 2.

FIGURE 2.

Hospital‐acquired pressure ulcer incidents per 10 000 inpatients

3. RESULTS

Based on the chart, hospitals that underwent an education program for staff, patients, and their respective families in year 2016 were experiencing about 5 inpatients with HAPU per 10 000 inpatients recorded. The HAPU rate per 10 000 inpatients went slightly higher in year 2017 at 6 HAPUs per 10 000 inpatients and then dropped to about 2 HAPUs per 10 000 inpatients in year 2018. Notice that while the total number of inpatients tripled in year 2018, the HAPU rate per 10 000 inpatients dropped even lower. This situation may be due to the maturation of prevention actions among hospital staff pertaining to HAPU complications. From the findings, the HAPU rate per 10 000 inpatients is expected to achieve 5 HAPU in the first year of education program implementation, and is expected to drop even further to approximately 2 HAPUs at the third year.

4. DISCUSSION

HAPUs are a key performance indicators concern around the globe and guidelines have notably been established by the European Pressure Ulcer Advisory Panel (EPUAP). Originally published in 2009 with a 2nd edition published in 2014, the guidelines provide evidence‐based support that covers prevention, intervention, and treatment. ¹⁶ A range of patient populations are considered, inclusive of those in adult ICUs. ¹⁶ Individual health organisations have been left to develop customised PUPP of their own determinations based on population demographics, specific requirements, and care culture. This has led to wide variety of strategies and minimal standardisation, making cross‐referencing somewhat of a challenge. The sacrum/coccyx was the most common site of hospital‐acquired pressure injury in all patients. ¹⁷ Specialised equipment like pressure off‐loading devices such as pillows, wedges, gel pads, specialised mattresses, and products in the form of commercial creams and dressings can all have a place in strategies to prevent and treat PUs. ¹⁷ , ¹⁸ However, they are costly and perhaps the most cost effective and best prevention comes in the form of simple all be it—time‐consuming care interventions. Care that can be provided in a professional setting but also be transferred to the duties of caregiver family members once patients are ready for discharge home. Upon review of 21 individual studies, it was noted that the number one risk factor identified throughout this literature review cited immobility as the leading probable cause for developing a PU. ¹⁸ Advanced age was the next prevalent risk factor ¹⁹ then followed by an equal mention of being in ICU, ¹⁹ and having multiple co‐morbidities ¹⁸ trailed by having continence issues. ¹⁹ And although many studies focus on ICU settings, PUs can develop in any setting where an individual is rendered immobile. Acute circumstances pose a risk however chronic situations have longer effects and require larger recovery efforts while lengthening said recovery times. To the individual and their family—devastating. To health care institutions—costly in dollars ²⁰ and in professional reputation. In that immobility is considered the number one risk factor for developing a PU, then it stands to reason that mobilisation and repositioning is the number one preventative intervention against PUs. ¹⁹ Position change for immobile patients is recommended after 2–3 hours ²⁰ In fact, the protracted pressure on an area for more than 2–3 hours causes disruptions nerve impulses as well as diminishes blood supply. Decreased circulation then reduces nutrition which can then lead developing PUs. ²⁰ Helping patients and family understand the how and why of mobilisation can be a powerful thing. One Indian study involving home care settings of bedridden patients set out to do exactly that. ¹³ Two trainings were developed to educate family caregivers how to care in such a way as to avoid PU. Both groups were given a self‐instruction manual and the first group was additionally given a prevention package. This package included home visit follow‐ups with one‐on‐one in‐person instruction as well as assessing for PU with the highly predictive value Braden scale. ²¹ It was shown that the group with the additional follow‐up visits and training had a PU occurrence rate reduction from 7% to 5%. The study concluded that education about PU reduction strategies with non‐professional caregivers, in a home care setting, can reduce incidences of PU. ¹³ Another similar study in Iran, directed at Stroke patients, provided two groups standard education with one group having the added benefit of additional home visits to reinforce teaching to family‐based caregivers. The group with the extra weeks of education reinforcement visits had half the PU incidence rate of that of the group that had only received the standard education at time of discharge. The study concluded that home‐based training of family members is cost effective and is practical in reducing PU incidence. ²² Many parts of the Saudi multi‐faceted program were seen representationally throughout the PUPPs that were reviewed. These included the importance of early identification of high PU risk patients, ²² the use of Braden Scale, ¹⁴ the inclusion of a Wound Care Nurse, ¹⁹ discharge instructions, ²³ as well as the importance of Patient/Family Centered Care. ¹⁹ All this, in addition to the education provided and interventions (repositioning, assessment, nutrition, skin care) implemented. Family caregiver skills that also require education and support include assessment, nutrition, ²³ and basic skin care. These skills are noted to be included in most of the reviewed PUPP programs directed at the reduction of PU occurrence. There is plenty of literature available for review about PUs and HAPUs. Although when filtered, a gap appears to exist, in regard to effectiveness of post discharge programs aimed to help support family caregivers to care for patients at risk of PU development. Acknowledgement of the importance of discharge instructions ²³ and involvement importance of family as caregivers ¹⁸ is found; however, only two studies in addition to the Saudi study specifically targeted outcomes of actual in‐home, in‐person education and support reinforcement programs, and their effect on decreasing incidences of PUs. ¹³ The Indian study and the other Iranian study, as previously discussed, both having used similar methodologies. The importance of in‐person interaction was highlighted in both of these studies. Both the Indian and the Iranian studies included basic education and then offered additional in‐person support to one of two groups in each study. The results confirmed the importance of in‐person exchanges as groups with in‐person follow‐ups had significantly better outcomes. ¹³ Supporting this idea of offering post discharge follow‐up support, is another study performed with the intent to track what the technological effect of a telehealth follow‐up program would have in decreasing PUs post discharge home. ²³ Unlike the in‐person exchanges of the Indian and Iranian studies, this study concluded that telenursing had no statistically significant impact on either prevention of PUs or readmission of those patients having head trauma. Despite noting that similar telehealth programs report having had positive effects. ²³ An innovation in technology that was shown to make a positive contribution towards reducing PUs is that of instructional videos. One Turkish study designed and implemented a website that offered “how‐to” videos available to family members who lacked professional training and found themselves in caregiver roles to those at high risk of developing PUs. Mainly intended for Stroke patients, the most accessed videos were those that pertained to preventing PUs, pressure points, as well as arm and leg exercises (mobilisation). ¹⁹ An interesting point to note is that the site was not password protected and although aimed at Turks inside of Turkey—it was accessed by Turkish speaking caregivers residing in places like United States, Russia, and Germany. This speaks to the needs of these caregivers on a global level. ¹⁹

5. CONCLUSION

A Saudi Arabian hospital system, introduced a PUPP in 2014 and outcome data were tracked for 5 years. The data were thoroughly reviewed again, focusing on the education retention effect in staff and staff culture as a partial answer to the positive results that were noted to carry through several years and also through a large inpatient growth period. ¹ A further scrutiny of these exceptional results, was intended to unearth the key intervention factors to the success of this PUPP. Performed in order to capitalise, sustain, and build upon for future quality improvement projects, it has had the authors focused on the education and discharge follow‐up efforts of similar PUPPs. Particularly concentrating on parts of the PUPP that were directed at discharge including family caregiver involvement and the then in‐person, in‐home follow‐up support. Although almost all of the studies reviewed demonstrated positive effects—none so much as the current study results. The factor that the current program has, that is perhaps missing or not having as strong a presence in the other programs, was determined to be a multi‐faceted program that laid a solid foundation together with in‐person follow‐up visits to support discharged patients in their homes. It was observed that the in‐person in‐home discharge follow‐up portion of the program had the largest positive effect on the outcomes. Outcomes that were supported by the pre‐work achieved during the hospital role of the PUPP towards reducing HAPUs and readmissions. Furthermore, there is reason to believe that the in‐person support visits may well be one of the most important considerations moving forward. As Covid‐19 times takes us into a new chapter of social distancing, one has to wonder how this will affect follow‐up home programs. Just as we are discovering the immeasurable contributions that in‐person education follow‐ups can have on patient outcomes, cautionary social distancing threatens to usurp its' potential benefits. This calls for innovative approaches to either replace in‐person visits with an equivalent viable option and/or come up with protective measure protocols to ensure the safety of patients, families, and visiting caregivers. As hospitals move towards improving discharge support services, infection control will have to be an even more critical consideration.

Al Mutairi A, Schwebius D, Al Mutair A. Hospital‐acquired pressure ulcer incident rates among hospitals that implement an education program for staff, patients, and family caregivers inclusive of an after discharge follow‐up program in Saudi Arabia. Int Wound J. 2020;17:1135–1141. 10.1111/iwj.13459