Abstract
Hospital‐acquired pressure ulcers (HAPUs) affect patients during hospitalisation, putting patients at risk for further complications. HAPU is one of the hospital quality indicators that require quality initiatives or programmes to minimise its occurrence and consequences. The aim of this study was to assess the effectiveness of a developed quality improvement programme in preventing HAPUs. This is a retrospective comparative study, which tracked the outcomes of pressure ulcer prevention programme (PUPP) for 5 years from 2014 to 2018. Data from 50 441 patients were collected from different units in a tertiary hospital in the eastern region of Saudi Arabia. The programme focused on building a wound care team; providing education to hospital staff, patients, and their families; and continuous data monitoring, in addition to follow‐up visits after discharge. Implementation of the programme was successful showing a statistically significant reduction of HAPUs from 0.20% in 2014 to 0.06% in 2018 (P value <.001). The PUPP was effective in reducing the percentage of pressure ulcer cases. The programme can be extended and implemented in other hospitals.
Keywords: bed sores, pressure ulcer, prevention programme, prevention strategy, quality improvement, close monitoring for skin, staff, patient education
1. BACKGROUND
Pressure ulcers (PUs) are one of the iatrogenic sources of additional morbidity for hospitalised patients, with prevalence reported to range between 4% and 49% internationally.1 As such, they increase the cost of treatment and may increase the length of time spent in hospital. Furthermore, PUs are a major problem facing health care facilities. The devastating effect of PU goes beyond the physical complications on individuals to the huge financial burden on health care facilities.1
Pressure ulcer is “a localised injury to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure.”2 It is usually attributed to some factors such as limited mobility, poor nutrition, friction, shear, moisture, comorbidities, and ageing skin.2 The sacrum and heel are the two most common anatomical sites for hospital‐acquired pressure ulceration3 and as such represent the greatest clinical challenge to prevention. Sustained pressure perpendicular to the skin over a bony prominence at intensity sufficient to cause capillary occlusion and tissue necrosis is the major mechanism in PU formation.4 However, shear forces exerted in a parallel direction to the skin surface have also been identified as contributing PU formation5 and have the potential to cause ulceration and deep tissue damage at half the pressure required in the case of direct perpendicular pressure.
Beside the high cost of PUs management in hospitalised patients, it has also high impact on the medical condition.6 PU is considered preventable through the implementation of evidence‐based prevention programmes.6 Prevention of hospital‐acquired pressure ulcer (HAPU) has increasingly become the centre focus of healthcare facilities due to many reasons including the impact in reportable hospital performance metrics.7 Significant reduction of HAPU such as achieving 0% is very difficult though it is attainable through comprehensive and sustainable preventive measures.8 Key elements of such preventive programme measures should include the following: implementation of evidence‐based practices, evidence‐based product selection and healthcare providers' education and training.9
To assess the risk for pressure ulcer development, the study used the Braden scale, which was shown to be reliable and valid.10, 11 The Braden scale is composed of six subscales (perception, moisture, activity, mobility, nutrition, and friction/shear). Each subscale is scored from 1 to 4, where 1 indicates low functionality and 4 indicates no impairment. The risk assessment was performed from the time of patient arrival to hospital either through the emergency department (ED) or from other outpatient services, and then to follow the guided instruction and intervention accordingly. This study differs from previous research,12 in that it enrolled patients to the trial in the ED and followed them through to the intensive care unit (ICU) until their discharge. The reason for that was based on the fact that some patients often spend prolonged periods of time in the ED and/or the operating room (OR). This time may reach many hours, and it has been suggested that the pressure ulceration detected in ICU is actually the result of tissue damage developed prior to ICU admission in the ED.12
2. STUDY PURPOSE
This study aimed to assess the effectiveness of a developed programme in preventing HAPUs.
3. DESIGN
This is a retrospective comparative study of pressure ulcer prevention programme (PUPP) at single healthcare facility. The outcomes of PUPP were tracked for 5 years. The current project location was in Qatif Central Hospital, a tertiary hospital with 360 beds located in the eastern province of Saudi Arabia. The average annual census in 2018 was 5982 patients with 4.67 days average length of patient stay.
4. IMPLEMENTATION OF PUPP
A quality improvement project was initiated by the hospital administration to improve patient wound management through education and documentation of risk assessment. During Fall of 2014, the nurse director, quality improvement nurse, clinical nurse educator, and wound care team including doctors, dietician, health educators, and infection control met to review the hospital pressure ulcer rates and the implemented practices. An initial assessment of the committee found that policy and procedure were incomplete and outdated, there was no protocol for general wound care and there was no complete wound care. Additionally, there was a shortage of proper beds and mattresses and heal protectors.
A decision was made to commence PUPP looking at three categories. The first category was creating a wound care team; second was hospital staff education about PUPP; and third was continuous data collection and monitoring through frequent reporting. The initial aim was to reduce the PU rates in the hospital by 50% within the first 6 months of the programme implementation.
The programme involves a comprehensive approach for managing the chronic non‐healing wounds. Therapeutic treatment plans are tailored according to each individual health condition. The programme also facilitates wound care promotion and enhances the response of non‐healing wounds such as chronic and multiple PUs, which might protect patients from being amputated such as cases with non‐response diabetic foot.
In September 2014, the hospital put into practice the wound care team and identified its members and responsibilities. The team included doctors, surgeons, nurses, dietician, and other healthcare providers. The team responsibility was to closely monitor and evaluate the patients' wounds and review the medical history and general health. The team conducts regular daily visits to review patients admitted in the hospital's wards. The team also meets one to two times per week to review the various cases and the PUPP progress. In addition to regular visits during treatment phase to patients admitted in the wards, wound care team provides additional clinical education to the nursing staff about wound care management. The team used different illustration methods such as using manikins, artificial body parts, posters, pictures, and different types of dressing during the demonstration to help other nurses understand the proper wound management. The team also provided workshops and bedside clinical educations to the staff. The PUPP was also included in the orientation programme to the newly hired staff in the hospital. Staff education was intended to provide knowledge about the best wound management practice including teaching the correct way of skin assessment and wound measurement; selection of the appropriate type of dressing based on the wound type, location, and stage; and monitoring the wound progress over time. It was also directed towards prevention of wound status deterioration or development of new wounds.
Family education was also an integral part of the prevention programme. Families' education is based on the bedridden patient's health status and level of knowledge. First, the team assesses the level of knowledge of patients and families, the presence of PUs, and their location and stage; and if no PU, the risk factors for developing them were assessed. Families' and patients' education is mainly about wound formation process, pathophysiology and healing progress, prevention of PUs, and the proper assessment and management of PUs. Then, if there are PUs, follow‐up visits in wards continue until the healing occurs. The team used videos and pictures and developed pamphlets in the Arabic language to educate families on various methods of preventing PUs. A post‐discharge home visit was also scheduled, within the first week after healing to evaluate the wound. Families were also provided the contact details of the PUPP team and were instructed to contact the team for any kind of queries. In some instances, families were asked to take photos of the wound and forward it to the team to provide the appropriate instructions and interventions.
The third part of the wound care programme was continuous data collection. In collaboration with nurse managers in all in‐patient units, the data were gathered from each unit in the hospital and then compiled together. The data included were as follows: the total number of inpatients, the total number of HAPUs, and the total number of wound care team assessments. The data also included the age of the patient, gender, diagnosis, date of PU development, stage, and location. The data were collected as weekly, monthly, every 6 months, and yearly totals. Averages of PUs are computed in a monthly, 6 months, and yearly basis, and also a report out of the data is completed and tracked.
5. DATA ANALYSIS
The collected data were entered into SPSS version 24, and both descriptive and inferential statistics were employed to analyse the gathered data. Chi‐square test was used for data analysis and a P value of <.05 was considered significant.
6. ETHICAL CONSIDERATION
Exempted IRB approval from the concerned hospital was granted prior to receiving data. All data were de‐identified prior to analysis and kept in a secured computer.
7. RESULTS
The data used in this study were patients' admission data that were collected since the beginning of PU programmes, that is, January 2014 until June 2018. The sample includes a total of 50 441 admitted patients in Qatif Central Hospital. The majority of the cases with PUs were males (67.4%), and the average age was 62 years. Patients with pus were from different inpatient units (such as medical, surgical, ICU, intermediate ICU, and PICU); however, the majority of the cases (41.3%) came from ICU, followed by medical wards (24.2%). Approximately 65% of the affected patients had stage 2 ulcer, and followed by stage 1 (17%) and unstageable (13%). Their ulcers affected different locations of their bodies with a majority (71.7%) in sacral areas, and 8.7% of the cases had more than one ulcer in multiple locations of their bodies. The average length of hospital stay prior to the development of the PU was approximately 36.6 days (range = 0‐108 days, SD = 27). Figure 1 showed that year 2014 recorded the highest admission cases (13 786 admissions), followed by year 2017 (11 502 admissions), year 2016 (10 048 admissions), and year 2015 (8892 admissions). It is important to state that the data for year 2018 were only available until June 2018, thus was omitted from interpretation.
Figure 1.
Number of admitted patients by year
This is a yearly tracking study, which aimed to assess the improvement in PU cases while the PU programme is implemented. Based on Table 1, X 2 (df = 4, P < .001) = 22.284 indicated that there is a significant difference between PU prevalence (%) and year at 0.05 significance levels. Scrutiny of Table 1 showed that PU prevalence (%) decreased over the years. In year 2014, PU prevalence was the highest at 0.20%, decreased to 0.17% during year 2015, and then further decreased to 0.05%, 0.06%, and 0.03% during years 2016, 2017, and 2018, respectively. Therefore, the study concluded that the PU prevalence decreased significantly as PU programme implementation becomes more structured.
Table 1.
Pearson chi‐square test for difference in prevalence
| PU | Total | ||||
|---|---|---|---|---|---|
| No | Yes | ||||
| Year | 2014 | Count | 13 758 | 28 | 13 786 |
| % | 99.80% | 0.20% | 100.0% | ||
| 2015 | Count | 8877 | 15 | 8892 | |
| % | 99.83% | 0.17% | 100.0% | ||
| 2016 | Count | 10 043 | 5 | 10 048 | |
| % | 99.95% | 0.05% | 100.0% | ||
| 2017 | Count | 11 495 | 7 | 11 502 | |
| % | 99.94% | 0.06% | 100.0% | ||
| 2018 | Count | 6211 | 2 | 6213 | |
| % | 99.97% | 0.03% | 100.0% | ||
Notes: Chi square = 22.284; df = 4; P < .001.
To further understand the prevalence of PUs, the study plotted monthly prevalence bar chart on a yearly basis as shown in Figure 2. Referring to the chart, it was observed that PU prevalence was relatively higher during year 2014 with the highest recorded prevalence of 0.54% in May 2014. It was also observed that PU cases were recorded every month (12 times) during year 2014. Looking into year 2015, there is a reduction in PU prevalence, in which the highest recorded prevalence was reduced to 0.33%, and 3 out of 12 months showed zero PU cases. For year 2016, the highest PU prevalence was 0.14% in April 2016, with only 5 months had PU cases recorded. In short, the implementation of PU programmes not only improves PU prevalence in the short run as proven by many studies8, 9 but also helps to eliminate PU prevalence in the long run as the PU programme implementation becomes more mature.
Figure 2.
Monthly pressure ulcer prevalence by year
8. DISCUSSION
PUs are a major clinical complication for patients and it poses a significant financial burden on healthcare facilities. Studies have shown that PUs are preventable by following proper prevention and management strategies.13, 14 This study reports the results of implementing a quality improvement project in a tertiary hospital over 5 years. The programme was built based on three elements: creating a wound care team; hospital staff, patients and family education; and data collection and monitoring. Developing this programme was based on the supporting literature and clinical research.10, 14, 15, 16 Overall, the results of this study show that the occurrence of PU was significantly minimised after implementing the PU programme.
As recommended by the American College of Physicians,15 clinicians must perform skin assessment to identify patients at risk for developing PUs. Skin assessment is the first step in any prevention programme16 because early detection of PU risk factors may prevent further complication.17Therefore, in addition to the initial skin assessment that was done upon admission, skin assessment using Braden scale, a reliable and valid tool, was done for all patients to predict the risk for developing PUs. Braden scale evaluates different predisposing factors that may lead to PU development such as sensory perception, mobility, activity, nutrition, friction/shear, and skin moisture in order to estimate the chance for developing PU.10 Those patients with high risk should receive a closer monitoring to evaluate any changes in their skin early. Our analysis shows that patients who had health conditions such as poor circulation, diabetes, or bed ridden were at a higher risk for developing PUs (71.5% of them developed stage 2 or 3 PUs, as compared to 40% of other patients who had no or low risk).
Education for frontline staff is another essential factor for any PU prevention and management programme.18 Part of our programme depends on providing education to nurses. The education covers the anatomy and physiology of the skin and PU formation and stages, risk factors for developing PUs, how to assess the wound, and how to perform good wound management by selecting the appropriate type of dressing and following the correct dressing technique. The wound management team was also responsible for educating staff about how to maintain the integrity of the skin by keeping it intact and hydrated, using suitable mattresses, and changing patient' position as needed.
The wound care team extends its educational activities to patients and family members (care givers). This involvement ensures compliance with the PU prevention programme14 and helps them share the responsibility of caring for patients. Family members were willing to help and learn the proper way of dressing to promote healing and minimise the complications of PUs. With the current shortage of nurses in many hospitals, sharing the responsibilities of patients and family members relieves some burden from nurses and minimises missing tasks. Sharing also encourages patients to take care of their skin during and after hospitalisation.
Staff nurses were instructed to document all risk assessment findings and any skin changes during hospitalisation. Documentation helped to improve the communication among heathcare staff, especially when patients were handed over to the next shift. The PU programme emphasises the documentation and tracking of all data during hospitalisation to detect any potential risk and manage it early. After discharge, there were follow‐up visits where the healthcare providers (physicians or nurses) can re‐assess the skin and provide education about wound management to patient and family members. In some cases, patients need to change the type of dressing due to either changes in the status of the wound or patient conditions. Hospitals provide the appropriate stocks to patients with teaching about how to use them.
It is evident when reviewing the results of the PUPP implementation that the existence of clear guidelines for nurses has improved the quality of patient care and patient outcomes due to the reduction in the number of PUs. Using Braden scale was effective to detect patients at risk for developing PUs. However, there are other scales and tools that can be used as well such as Norton scale and Cubbin and Jackson scale.15 Using a wound care team is essential to lead the programme and ensure follow up among nurses. The first step, however, before commencing the programme is to educate the team members and prepare them to lead and communicate with others. The availability of the appropriate types of dressing and devices in the hospital is a major element in the success of the programme. This requires sufficient financial allocation especially to inpatient units where patients are more prone to develop complications.
Other than the availability of resources, some key elements that have been identified for the success of the programme were as follows: the quality of learning material, the clinical qualification of wound care team, their ability to teach and interact with others, the available time to be spent with patient and their families to provide education, and the leadership and administrative support to the project. This programme did not focus on the devices such as using advanced types of mattresses due to limited resources. However, studies show that this strategy could be a strong contributing factor to minimise the occurrence and the complication of PUs.14
Hospital leaders should identify and then eliminate potential barriers in order to success in any prevention programme. Barriers could be the limited time for nurses to perform a comprehensive assessment, provide education, and complete documentation. The time is a crucial barrier because it is affected by the shortage of staff and the number of patients. Unwillingness to share the responsibility of care is another barrier.10 Implementing the prevention programme is the responsibility of multidisciplinary team including doctors, nurses, dieticians, and other healthcare providers. Additionally, ineffective handover between nurses may not focus on the priority for high risk patients to receive frequent assessment. Therefore, in the stage of planning for prevention programme, leaders should also ensure building a good strategy for handover among nurses and multidisciplinary team.
9. CONCLUSIONS AND RECOMMENDATIONS
This study reports the experience and results of implementing quality improvement project to reduce the occurrence of HAPUs. The programme was carried out over 5 years, and it has three major elements: first, creating a wound care team; second, providing education to hospital staff, patients and their families; and third, continuous data monitoring. The results show a significant reduction in the percentage of patients who developed PUs from 0.20% to 0.06%. The programme can be implemented in other hospitals inside and outside the region. Further studies are encouraged to add other factors such as using different types of beds or devices to reduce PUs, and planning for a feedback mechanism to monitor any changes in patients' skins and conditions.
Al Mutair A, Ambani Z, Al Obaidan F, Al Salman K, Alhassan H, Al Mutairi A. The effectiveness of pressure ulcer prevention programme: A comparative study. Int Wound J. 2020;17:214–219. 10.1111/iwj.13259
REFERENCE
- 1. Shahin E, Dassen T, Halfens R. Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study. Int J Nurs Stud. 2009;46:413‐421. [DOI] [PubMed] [Google Scholar]
- 2. Bluestein D, Javaheri A. Pressure ulcers: prevention, evaluation, and management. Am Fam Physician. 2008;78(10):1186‐1194. [PubMed] [Google Scholar]
- 3. Santamaria N, Carville K, Prentice J, et al. Reducing pressure ulcer prevalence in residential aged care: results from phase II of the PRIME trial. Wound Practice Res J. 2009;17(1):12‐22. [Google Scholar]
- 4. Hagisawa S, Shimada T, Arao H, Asada Y. Morphological architecture and distribution of blood capillaries and elastic fibres in the human skin. In: Clarke M, ed. Pressure ulcers: Recent advances in tissue viability. London: Quay books Division, MA Healthcare Ltd; 2004:31‐38. [DOI] [PubMed] [Google Scholar]
- 5. Sharp CA, McLaws ML. A discourse on pressure ulcer physiology: the implications of repositioning and staging. World Wide Wounds. 2005:1‐14. www.worldwidewounds.com/2005/october/sharp/discourse-on-pressure-ulcer-physiology.htm. [Google Scholar]
- 6. Cano A, Anglade D, Stamp H, Joaquin F, Lopez J, Lupe L, Schmidt S, Young D. Improving outcomes by implementing a pressure ulcer prevention program (PUPP): going beyond the basics. Healthcare. 2015. 3, 3, 574‐585). Multidisciplinary Digital Publishing Institute [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. US Department of Health and Human Services . Hospital Compare. Available online: http://www.medicare.gov/hospitalcompare/search.html (accessed on June 11, 2018).
- 8. Duncan KD. Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf. 2007. Oct 1;33(10):605‐610. [DOI] [PubMed] [Google Scholar]
- 9. Roe E, Williams DL. Using evidence‐based practice to prevent hospital‐acquired pressure ulcers and promote wound healing. Am J Nurs. 2014;61–65(33):114. [DOI] [PubMed] [Google Scholar]
- 10. Agency for Healthcare Research and Quality . Preventing Pressure Ulcers in Hospitals. AHRQ: Rockville, MD, USA. 2014. Available at: https://bit.ly/2zmMfD7
- 11. National Pressure Ulcer Advisory Panel , European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Ulcer Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. NPUAP: Washington DC, USA. 2014. Available at: https://bit.ly/1r98AGV (accessed June 16, 2019)
- 12. Brindle CT. Outliers to the Braden scale: identifying high‐risk ICU patients and the results of prophylactic dressing use. WCET J. 2010;30(1):11‐17. [Google Scholar]
- 13. Fremmelevholm A, Soegaard K. Pressure ulcer prevention in hospitals: a successful nurse‐led clinical quality improvement intervention. Br J Nurs. 2019;28(6):S6‐S11. [DOI] [PubMed] [Google Scholar]
- 14. Guzman J, McClanahan R, Vaughn S. Development of guidelines for pressure ulcer prevention. Wounds Int. 2018;9(4):34‐38. [Google Scholar]
- 15. Qaseem A, Mir TP, Starkey M, Denberg TD. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):359‐369. [DOI] [PubMed] [Google Scholar]
- 16. Zakaria AY, Taema KM, Ismael MS, Elhabashy S. Impact of a suggested nursing protocol on the occurrence of medical device‐related pressure ulcers in critically ill patients. Cent Eur J Nurs Midwifery. 2018;9(4):924‐931. [Google Scholar]
- 17. Fazel FS, Derakhshanrad N, Yekaninejad MS, Vosoughi F, Derakhshanrad A, Saberi H. Predictive value of Braden risk factors in pressure ulcers of outpatients with spinal cord injury. Acta Med Iran. 2018; 56(1):56‐61. [PubMed] [Google Scholar]
- 18. Cameron R, Rodgers A, Welsh L, McGown K. Developing eLearning for pressure ulcer prevention and management. Br J Nurs. 2014;23(15):S16‐S23. [DOI] [PubMed] [Google Scholar]