Taking the pain out of pressure injuries

13 December 2012
The cornerstone of pressure injury prevention is early recognition of those at risk and ensuring an effective management plan is in place. A key challenge is how we ensure that this is a routine part of practice and not missed in the hectic and busy clinical areas. With this in mind Auckland DHB has taken a systems approach to looking at implementing effective assessment strategies and being able to hardwire these in to routine practice.

Despite the best efforts of nursing teams, patients in our hospitals can still suffer pressure injuries during their stay. Harm from pressure injuries can be avoided when timely pressure injury risk assessments and intervention plans are instituted.

Teams at Auckland DHB have been using the Plan-Do-Study-Act (PDSA) approach to test a range of initiatives aimed at making it easier for nursing staff to carry out early assessments of a patient’s pressure injury risk. Following an assessment of the prevalence of pressure injuries occurring in the hospital, clinical staff were then engaged in a series of cause-and-effect sessions to develop an understanding of the issues surrounding pressure injuries.

“This approach identified two main barriers to full and proper assessment of pressure injury risk levels,” says Auckland DHB Improvement Specialist Sam Tobin. “These were both around the pressure injury risk management form in use.”

One barrier was around the time taken to fill out the form. In addition different departments had altered the form over the years, leading to multiple versions with subtle differences.

“Those departments that had altered the form to suit their own requirements were more likely to fill it in,” said Sam. “These two facts presented the perfect opportunity for us to take the best elements of existing resources and with clinical input using the PDSA approach develop a new pressure injuries risk assessment approach that staff would want to use.”

What they came up with is a two-pronged approach to pressure injuries risk assessment which incorporates a ‘Quick Risk Assessment’ built into the Hospital’s Early Warning Score form and a more detailed assessment form. The Quick Risk Assessment enables clinically sound, rapid assessment to be undertaken by all wards, leading to the longer more detailed assessments only when required.

The new detailed risk assessment form is A3 in size and has clear colour coded interventions that relate to patient risk, a built in grading tool (based on EPUAP) and a turns and intervention schedule.

“We consider this a big step forward as we will soon have all adult wards taking a uniform approach to pressure injury risk assessment,” says Sam. “We are also using the same PDSA approach to revise policy and guidelines around pressure injury prevention. Other initiatives include raising awareness of staff, patients and family members to risk factors, and improving our reporting interfaces and software.”

As a result of all this activity, Auckland City Hospital is beginning to see a drop in the number of severe hospital-acquired pressure injuries.

“There is always more we can be doing,” says Auckland DHB’s Nurse Advisor – Quality, Andrew Jull. “We have decided to make grade 3 and 4 pressure injuries serious and sentinel that will require deeper investigation if they occur.

“It is great to have First, Do No Harm helping us to learn and improve together. Many of the ideas we incorporated into our new pressure injury risk assessment form were inspired by work previously undertaken by Counties Manukau DHB, as well as the audit tool from Waitemata DHB. We have taken their learning and adapted it to suit our environment, which speeds up improvement processes.”