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8 Wounds Middle East 2014 | Vol 1 Issue 2 | ©Wounds International 2014 | www.woundsinternational.com

Clinical practice

Background/aimsAt the SKMC, facility-acquired pressure ulcers (FAPUs) are being monitored as a key quality and safety performance indicator. Over the past few years, we have seen a major increase in FAPU prevalence, which has created a need for a taskforce to determine the root causes; these have been identified as being poor team communication, patient malnutrition and lack of preventative equipment. As a result, SKMC implemented the following PU-preventative strategies since 2008:

■ Performing the Braden Scale risk assessment (used to predict the risk of developing pressure ulcers; www.bradenscale.com) in all admissions

■ Consultation with dietician for nutritional management

■ Educating the staff about PUs ■ Developing the PUAP Pathway [Fig 1] ■ Incentivising by issuing awards to units with

zero FAPU incidents since 2009 [Fig 2] ■ Follow-up on PUs requiring wound care team

intervention. ■ Applying a non-adherent foam dressing

(Mepilex® Border Sacrum) over bony prominences in the ICU setting.

To assess the effectiveness of these strategies, the authors conduct annual surveys involving the collection of data on PU prevalence rates and identifying trends surrounding this, with the overall aim of improving quality of care and reducing healthcare costs. This is a continuous audit for quality improvement.

The European Pressure UIcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) defined pressure

ulcers (PUs) as ‘localised injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear or friction’[1]. PUs represent a significant health concern as they are associated with increased hospital stay duration, morbidity and mortality rates, and risk of comorbidities, and therefore have a considerable impact on patients' quality of life and healthcare costs[2].

The prevalence of PUs is often used as an indicator of quality care and/or the effectiveness of PU-prevention initiatives. Knowledge of PU has increased considerably over the past few decades, with the availability of numerous guidelines[1,3–5]. However, PU prevalence rates remain high. The EPUAP estimate PU prevalence rates to be approximately 15−20% among hospitalised patients in Europe [6,7].

PUs represent a major burden of sickness and reduced quality of life for patients and their carers [8,9]. They are a major problem for healthcare in the United Arab Emirates (UAE), although data on prevalence rates in this region are scarce. In light of this, at the Sheikh Khalifa Medical City (SKMC) in Abu Dhabi, PU prevalence surveys are performed once a year and the results are compared with international PU prevalence rates. Here, we report the findings of the 2013 audit and identify and discuss the achievements made at this hospital since 2008 as a result of implementing some PU-preventative initiatives.

Pressure ulcer prevalence and prevention in Sheikh Khalifa Medical City, Abu Dhabi

Pressure ulcers represent a major health challenge worldwide. Studies that examine pressure ulcer (PU) occurrence are of increasing interest in the drive to reduce the number of patients affected. In this article, Gulnaz Tariq and colleagues, report on the work at Sheikh Khalifa Medical City (SKMC) in Abu Dhabi where they have implemented PU prevention strategies to reduce prevalence. An annual survey allows collection of data on PU prevalence and effectiveness of these strategies, with the overall aim of improving quality of care and reducing healthcare costs. Here they present the findings from the 2013 audit to highlight the achievements made at the hospital since the implementation of the PU-prevention programme in 2008.

Gulnaz Tariq is a Wound Care Manager, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emitrates; Beji George is is a Wound Care Nurse, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emitrates

Author:Gulnaz Tariq

Practice development Practice development

✔ The only dressing supported by results of two randomised controlled trials1,2

✔ Significant reduction in pressure ulcer incidence3,4,5,*

✔ Substantial cost savings4,6,*

✔ Combats 4 extrinsic causes of pressure ulcers7,8,9,*

Can you afford the impact of not using our proven prevention?

www.molnlycke.com/pupreventionFind out more

References: 1. Kalowes P. et al. Use of a soft silicone, self-adherent, bordered foam dressing to reduce pressure ulcer formation in high risk patients: a randomized clinical trial. Poster presentation at Symposium on Advanced Wound Care Fall, Baltimore, Maryland, United States of America. 2012. 2. Santamaria N. et al. A randomised controlled trial of the effectiveness of soft silicone foam multi-layer dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: The Border Trial. IWJ. 2013. 3. Brindle C.T. and Wegelin J.A. Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients. Journal of Wound Ostomy & Continence Nursing. 2012; 39(2):133-142. 4. Cherry C. and Midyette P. The Pressure Ulcer Prevention Care Bundle: a collaborative approach to preventing hospital-acquired pressure ulcers. Poster presentation at Magnet Research Day, Alabama, United States of America. 2010. 5. Chaiken N. Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing. Journal of Wound Ostomy & Continence Nursing 2012;39(2):143-145. 6. Padula W. et al. Improving the Quality of Pressure Ulcer Care With Prevention, A Cost-Effectiveness Analysis. Medical Care. 2011; 49(4). 7. Call, E. Pederson, J., Bill, B.Craig Oberg PhD, Martin Ferguson- Pell PhD, Wounds -2013, 25(4):94-103. 8. Call, E. Pederson, J., Bill, B. In vitro comparison of the prophylactic properties of two leading commercially available wound dressings. Poster presentation at Symposium on Advanced Wound Care Fall, Baltimore, Maryland, United States of America. 2012. 9. Call, E. Black J., Clark M. ,Alves P., Brindle T., Dealey C. Santa Maria, N International Panel Studies Creation of Guidance on Dressing Use in Prevention of Pressure Ulcers poster presentation SAWC spring 2012. * In addition to current prevention protocols.

Pro enPREVENTION

SHEAR MICRO-CLIMATEPRESSURE FRICTION

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Practice developmentPractice development

MethodSince 2006, SKMC has used the International Pressure Ulcer Prevalence (IPUP) Survey™ (Hill-Rom) for annual assessments of PU prevalence rates within the facility. The Hill-Rom IPUP Survey is an international audit conducted over a 3-day period involving over 900 facilities from across the globe. Each facility pre-selects a 24-hour period within the 3-day time frame for PU prevalence data capture. Following registration (at www.hill-rom.com/ipup), facilities receive online training, materials for patient questionnaire completion,

Admission

• Turnorrepositionatleastevery2hours,ormoreifneeded• Relievepressureoverbonyprominences• Keeppatientasflataspossibleduringrepositioningtoreducefriction/shear• Useappropriateequipmentduringrepositioning/turning• Usepressurereduction/reliefmattress/bed• Encouragepatienttoshiftweightevery15minuteswhensitting• Givedietandfluidsasprescribedandmonitorstatus/intake/output• Preventativeskincare;avoidhotbaths,massage• Keepheadofbedatlowestelevationasismedicallypossible• Manageincontinence,usediaperssparingly• Encouragethepatienttousebedrails/trapezebartoparticipateinrepositioning/turning• Usevigilancetoassesspatientswithcasts,hardsplints,backslabs,traction,oxygentubing, neckcollarandsupportstockings•Applyanon-adherentfoamdressing(Mepilex®BorderSacrum)forpatients<50kgor >80kgbodyweightifBradenscoreis<13

Thoroughskinassessment(includinghistory)

Developanindividualisedcareplanfortreatingandpreventing

furtherskinbreakdown.Consultwithwoundcareand

informthephysicianAssesspressureulcerriskeachshift:

lBradenScalel Completeholisticreviewforriskfactors

l Completedocumentation

Pressure ulcer assessment and prevention pathway

Yes

Yes

No

No

Bradenscore≤18ConsultwithwoundcareBradenscore>18

Reassesstheskinandpressureulcerriskeach

shift

IsthereskinbreakdownOrpressureulcer?

IsthereskinbreakdownOrpressureulcer

Figure 1. Pressure ulcer assessment and prevention pathway.

Figure 2. Best compliance award

Assessskinandpressureulcerriskeachshift

Reviewoutcomesofplanandintervention

References1. European Pressure UIcer Advisory

Panel and National Pressure Ulcer Advisory Panel. Pressure Ulcers Prevention: Quick Reference Guide. (2009) Available at: http://www.epuap.org/guidelines/Final_Quick_Prevention.pdf (accessed June 2014)

2. Lenhe JM, Ayello EA, Zulkowski KM et al. Pressure ulcer knowledge in medical residents: an opportunity for improvement. Adv Skin Wound Care 2012; 25(3): 115−7

3. Medical Education Partnership. International Guidelines. Pressure Ulcer Prevention: Prevalence and Incidence in Context. A Concensus Document. 2009. Available at: http://www.woundsinternational.com/pdf/content_24.pdf (accessed June 2014)

4. Association for the Advancement of Wound Care. Association for the Advancement of Wound Care Guidelines of Pressure Ulcer Guidelines. 2010. Available at: http://www.guideline.gov/content.aspx?id=24361 (accessed June 2014)

5. Wound, Ostomy and Continence Nurses Society. Guidelines for Prevention and Management of Pressure Ulcers. 2010. Available at: http://www.guideline.gov/content.aspx?id=23868 (accessed June 2014)

6. Tannen A, Dassen T, Bours G, Halfens R A comparison of pressure ulcer prevalence: concerted data collection in the Netherlands and Germany. Int J Nurs Stud 2004; 41 (6): 607−12

7. Vanderwee K, Clark M, Dealey C et al. Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract: 2007; 13(2): 227−35

8. Franks PJ, Moffatt CJ. Focus on wound management. Quality of life issues in chronic wound management. Br J Community Nurs 1999; 4(6): 283–4.

9. Nixon J, Nelson EA, Cranny G, et al. Pressure relieving support surfaces: a randomised evaluation. Health Technol Assess 2006; 10(22): iii-iv, ix-x, 1-163

10. Home Health Agency (HHA) Medicare Cost Report Data. 2011. Available at: http://www.healthdata.gov/data/dataset/home-health-agency-hha-medicare-cost-report-data-fy-2011 (accessed June 2014)

11. Bales I, Padwojski A Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 2009; 18(4): 137−44

Clincial practice

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and literature on PU risk and survey guidelines and instructions. During the pre-selected 24-hour period, staff at the individual facilities collect and submit data as instructed. Once all data have been analyzed, Hill-Rom provides each facility with an electronic report that consists of the following information:

■ Organisation prevalence rate ■ System level analysis ■ Prevalence rates by unit ■ Comparisons and benchmarks of:• Patient characteristics• Body mass index• Wound risk• Census size/type• Prevalence by teaching status• Geographic location• Patient fall metrics

■ Independent National Database of Nursing Quality Indicators spreadsheet.

Agerange,years

%of

patie

nts

Agerange,years

%of

patie

nts

Figure 3. Proportion of patients with pressure ulcers (a) and facility-associated pressure ulcers (b) at the SKMC according to age range.

AssessmentsThe 2013 IPUP Survey was carried out on 22 February 2013. The survey report was reviewed for both PU prevalence data and trends at SKMC and the national benchmarks, and the following data were compared with the 2008 IPUP Survey results to assess whether improvements have been made with regard to PU prevention and financial implications:

■ SKMC PU prevalence ■ International prevalence ■ FAPU prevalence and associated treatment

costs (financial implications were assessed using a high estimate[10] and a low estimate [Bain Study 1997, unpublished] method)

■ Documentation patterns.

ResultsThe overall IPUP survey included 100,623 patients in 2013, an increase from the 85,161 total patients in 2008; the international portion of the total cohort also increased over the 6 years (from 2,352 patients [2.8%] to 9,542 patients [9.5%]). The total number of patients surveyed at SKMC also increased from 2008 to 2013 (n=360 and n=406, respectively). A detailed comparison of SKMC patient demographics is found in Table 1, Fig 3 and Fig 4, showing the two cohorts to be fairly similar.

Meanwhile, Fig 5 shows the SKMC PU and FAPU prevalence trends between 2008 and 2013. The SKMC PU prevalence rate decreased from 9.2% in 2008 to 6.4% in 2013. The benchmark PU prevalence rates for long-term acute care facilities were 28.4% in 2008 and 25.0% in 2013. The SKMC FAPU prevalence rate also decreased, from 3.3% in 2008 to 2.0% in 2013. The benchmark FAPU prevalence rates for long-term acute facilities were 5.9% in 2008 and 3.8% in 2013.

In the 2013 cohort, the majority (94%) of patients with PU and all with FAPU were immobile [Fig 6]; note that data on the ambulancy status of patients in the 2008 cohort were unavailable.

Results showed high rates of PU documentation for both periods, with an increase in the rate of adequate documentation from 67% in 2008 to 95% in 2013 [Fig 7]. In the 2008 cohort, prior risk assessment had been carried out for all patients with PU and FAPU, with the last assessment being documented in the last 24 hours (except for one patient with a PU for whom it was documented within 72 hours to 1 week prior). Using the Braden score, 87% were deemed to be at risk of PU. Among the 2013 cohort, all eight patients with FAPU

a

b

NC=notcollected

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underwent PU risk assessment (all documented within the prior 24 hours); using the Braden score 87.5% were deemed at risk on admission, while all were judged to be at risk at last assessment.

Financial implications for FAPU prevalence at SKMC during 2013 were estimated in seven patients (one patient with deep tissue injury was excluded due to insufficient cost data) using a high estimate and a low estimate method [Table 2]. The total estimated treatment costs for these patients ranged $12,805.00−$44,975.05. When extrapolated to estimated annual costs, totals ranged $494,065.42−$1,624,543.39.

DiscussionThe results of the 2013 SKMC IPUP survey revealed a PU prevalence rate of 6.4% and FAPU rate of 2.0%, which are considerably lower than the national benchmarks of 25.0% and 3.8%, respectively, for long-term acute facilities. On comparison of the prevalence trends over the period 2008−2013, the pattern for the SKMC is very similar to that of the national benchmark, with an overall decrease over time. This finding of lower prevalence rates is encouraging, indicating that SKMC has good practices in place regarding the prevention of PUs. However, this drastically reduced prevalence rate is observed at all time points, which may suggest that the low prevalence rate is irrespective of the PU-preventive strategies implemented in recent years.

Risk assessment is an important strategy for the prevention and management of PUs. Risk factors for the development of PUs include older age (particularly >65 years), immobility, incontinence and increased length of hospital stay. The distribution of PU and FAPU prevalence rates according to age range shown in this audit [Fig 3] confirm the aforementioned age group to be a risk factor as the majority of patients with PUs and FAPUs were found among the 60−69 and 70−79 age groups. Immobility was also confirmed as a risk factor among the 2013 cohort (data not available for the 2008 cohort; [Fig 6]), as was incontinency [Table 1). Comparing the length of hospital stay among patients with PU or FAPU with that among all surveyed patients, a pattern of increased hospital stay is seen in the PU and FAPU groups, with nearly double the number of patients staying >30 days compared with the full population [Fig 4].

Risk assessment is one strategy that has been employed by SKMC, among a few others,

with the purpose of reducing PU prevalence. Standards of care for most hospitals require that an admissions assessment be completed and documented within 24 hours of admission. Another strategy is based on guidelines recommending that an admissions assessment be completed and

Figure 4. Length of hospital stay among patients with pressure ulcers (a), facility-associated pressure ulcers (b) and all surveyed patients (c) at the SKMC.

Lengthofhospitalstay,days

%of

patie

nts

Lengthofhospitalstay,days

%of

patie

nts

%of

patie

nts

Lengthofhospitalstay,days

NC,notcollected

a

b

c

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documented within 24 hours of admission[10] . This audit showed a 42% increase in adequate documentation submission from 2008 to 2013 [Fig 7]; the rate of risk assessment was 100% in both surveys.

In the 2013 survey, financial implications of FAPUs were assessed and estimated. It has been estimated that $11 billion is spent on PU treatment each year in the US11. This survey estimated a maximum of ~$1.6 million to be spent on the treatment of FAPUs [Table 2].

The PU prevalence rate was reduced by 30% from 2008 to 2013; similarly, a 39% reduction was seen with the FAPU prevalence rate. However, it does remain encouraging that comparisons with 2008 data from the same facility confirm these PU-preventive initiatives have been effective. Wme

Figure 6. Rates of self ambulancy among patients with pressure ulcers at SKMC in 2013 (data not available for 2008).

This audit showed a 42% increase in adequate documentation submission from 2008 to 2013 [Fig 7]; the rate of risk assessment was 100% in both surveys.

Clinical practice

a

b

Figure 7. Pressure ulcer documentation patterns for SKMC in 2008 (a) and 2013 (b).

a

b

Year

Prev

alenc

erate

,%

Year

Prev

alenc

erate

,%

Figure 5. Pressure ulcer prevalence trending for (a) SKMC and (b) national benchmarks.

%of

patie

nts

Selfambulantstatus

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Table 2. Estimated FAPU treatment costs

FAPU stage No. of pts with FAPU

High estimate Low estimate

Treatment cost per pt

Estimated variable cost (35%)

Estimated treatment cost

Treatment cost per pt

Estimated variable cost (35%)

Estimated treatment cost

I 2 $15,592.85(AED57,272)

$5457.50(AED20,045)

$10,915.00(AED40,090)

$93.00(AED342) $33.00(AED121) $66.00(AED242)

II I $17,553.86(AED64,475)

$6143.85(AED22,566)

$6143.85(AED22,563)

$2100.00(AED7,713)

$735.00(AED2,699) $735.00(AED2,699)

III 0 $23,042.85(AED84,636)

$8065.00(AED29,623)

$0.00 $8575.00(AED31,496)

$3001.00(AED11,023)

$0.00

IV 0 $26,953.67(AED99,001)

$9433.78(AED34,650)

$0.00 $9545.00(AED35,059)

$3341.00(AED12,272)

$0.00

Unstageable 4 $19,940.14(AED73,240)

$6979.05(AED25,634)

$27,916.20(AED102,536)

$8575.00(AED31,496)

$3001.00(AED11,022)

$12,004.00(AED44,091)

Total 7 Weightedavgcost(percase):$6425.01(AED23,599)

$44,975.05(AED165,193)

Weightedavgcost(percase):$1829.29(AED6,719)

$12,004.00(AED44,091)

Avg=average;FAPU=facility-associatedpressureulcer;pt=patient.

Table 1. Patient demographics for SKMC.

Characteristic 2008 survey 2013 survey

Totalpatientssurveyed,n 360 406

PressureulcerprevalenceincludingStage1,n(%)

31(9) 26(6)

Facility-associatedpressureulcer(FAPU)prevalence,n(%)

12(3) 8(2)

Dataforpatientswithadmittedpressureulcers/FAPU

Gender,%MaleFemaleNotcollected

55/5039/336/17

88/8612/140/0

Bodymassindex,%UnderweightNormalOverweightObeseSeverelyobese

21/2748/450/010/921/18

12/050/6327/130/012/25

Pressureulcerstage,%StageIStageIIStageIIIStageIVUnstageableDeeptissueinjury

42/5033/3619/02/04/140/0

18/2526/178/85/018/423/8

Albuminlevel(g/dL),%0−2.52.6−3.53.6−7.0Notcollected

57/4233/330/810/17

42/3850/638/00/0

Incontinency,%YesNoNotcollected

90/1005/05/0

95/1005/00/0

Clinical practice