30th September 2009 Presenters: Hamish Laing & Annette Bartley

The Campaign The aim is to save 1000 lives and to avoid up to 50,000 episodes of harm in Welsh healthcare by April 2010

Fundamental safety principles Prevention Detection Mitigation

Transforming Care at the Bedside Commenced in 2003 in the USA Sponsored by Robert Wood Johnson Foundation in collaboration with IHI Empowers frontline teams to seek out ways of continuously improving the care they provide Provides a framework & the HOW!

Transforming Care at the Bedside Part of 1000 lives campaign Three pilot sites (Hywel Dda & NWT) ABM focused on Pressure Ulcers TCAB CORE THEMES Transformational Leadership Safety & Reliability Value added care Patient Centred Care Teamwork and Vitality

! Transforming Care at the Bedside framework Spread the Learning and celebrate the successes 4 4 4

Why this work is so important Pressure Ulcers are avoidable!!! Without a concerted effort by family/caregivers and health professionals alike, the problem will continue to spiral out of control.” Source: www.la4seniors.com/bedsores

Facts Pressure sores are an increasing problem that affect thousands of people unnecessarily every year The cost of treating a pressure ulcer varies from £1,064 -£10,551 with the estimated total cost in the UK of between £1.4–£2.1 billion annually (4% of total NHS expenditure)* Pressure sores are associated with a 2 - 4 fold increase in the risk of death in older people in intensive care units They are painful, debilitating and can be life threatening ( Bennett et al 2004) Costs increase with ulcer grade because the time to heal is longer and because the incidence of complications is higher in more severe cases Pressure ulcers represent a very significant cost burden in the UK. Without concerted effort this cost is likely to increase in the future as the population ages.

An International concern EPUAP hospital prevalence survey pilot 2002 - 5947 patients Belgium 21.1%, Portugal 12.5%, Italy8.3% Sweden 22.9%, UK 21.9% Overall prevalence 18.1% Influenced by patient population and their vulnerability to develop pressure ulcers

The evidence tells us that… Skin Integrity can deteriorate in hours Frequent assessment prevents minor problems from becoming major ulcers Risk is predictable age immobility, incontinence, poor nutrition, sensory problems, circulation problems , dehydration and poor nutrition Wet skin is more vulnerable to skin disruption and ulceration But dry skin is a factor as well Continual pressure, especially over bony prominences, increases risk Pressure relieving surfaces work Reddy et al JAMA 2006;296: 974-84

What was different about our approach? Transforming Care at the bedside (TCAB) Applied all core themes Sole focus on prevention Frontline engagement Quality Improvement methodology Testing of interventions used elsewhere Understanding the science of reliability

Spread the Learning and celebrate the successes

Learning and improvement Sequential Building of Knowledge: Include a Wide Range of Conditions in the Sequence of Tests Breakthrough Results Theories, hunches, & best practices Learning and improvement A P S D Evidence & Data

What are we trying to accomplish? Reduce Pressure Ulcers by 50% Increase the number of days between a hospital acquired pressure ulcer Preventing pressure ulcers isn't difficult! It just requires attention to the details and re-establishing good habits. Our Premise- Use rounding/bundles to implement new habits and ways of thinking can and will ultimately impact outcomes.

Whose job is it? This is a story about 4 people named everybody, somebody, anybody and nobody. There was an important job to be done and Everybody was asked to do it. Everybody was sure somebody would do it. Anybody could have done it but nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought anybody could do it, but nobody realized that everybody wouldn't do it. It ends up that everybody blames somebody when nobody did what anybody could have done

Process Eyes Make the process for preventing Pressure Ulcers visible to ALL Measure it -so we can ‘see’ if it is adhered to and whether it is effective Make it easy for others to do the right thing (simple checklists, reminders) The right process with high percentage compliance WILL influence outcomes

Visual cues & measurement 2 Hourly round sheets 6 8 10 6 8 10 12 2 4

Tools Atmos Air 9000

New Jersey Hospital Association Exemplars of success “No ulcers” Nutrition and fluid status Observation of skin Up and walking or turn and position Lift (don’t drag) skin Clean skin and continence care Elevate heels Risk assessment Support surfaces for pressure redistribution New Jersey Hospital Association Educational programs, e-mail information distribution list, monthly conference calls with experts 70% reduction in pressure ulcer incidence and 30% reduction in prevalence

Exemplars of success Six hospitals had no pressure ulcers for 1 year Ascension Health Nurses throughout the organization created and implemented care methods under the SKIN bundle Reduced pressure ulcer incidence to about 1.4 per 1,000 patient days system-wide Six hospitals had no pressure ulcers for 1 year Almost all that did occur were Stage I or II SKIN bundle Surface selection Keep turning Incontinence management Nutrition

Adapt Adopt Abandon Spread the Learning and celebrate the successes

ALL OR NONE-COMPOSITE MEASURE Compliance (6 or non-compliant) Y/N 1. Risk assessment on admission 2. Communication of risk status-Verbal & Visual Cue 3. Surface- x 4. Keep patients turning- care round 5. Inspection-care round 6. Nutritional assessment- care round ALL OR NONE-COMPOSITE MEASURE

Intentional Rounding Created more time-less bell calls Pressure areas checked Position changed Pain assessment Nutrition-check (fluids encouraged where appropriate) Obstacles & Call bells –Call don’t fall Personal Hygiene Emotional support

Measures Safety Cross Time between events- Outcome measures Raises awareness at the frontline & is easy to use Time between events- Time between chart & safety cross Aim to increase the number of days between events Outcome measures Pressure Ulcer rate (per 1000 days) Enables comparison between sites Pressure Ulcer count More meaningful as It relates to people! Aim to reduce the incidence by….?

Safety Cross Aim- To acquire a green cross or decrease the number of red squares (time between) No new case identified New case identified Admitted with or transferred from another unit with pressure ulcer

Process Measures Percentage compliance with risk assessment (aim>95%) Percentage compliance with ALL elements of the Pressure Ulcers bundle components (ALL or None Composite measure) Percentage compliance with 2hourly care rounds

Tips for getting started Form a multi-disciplinary improvement team- include nurse, doctor, educator, QI rep, dietician, materials management staff, patient Start on a ward with high-risk patients and a clinical champion Segment-Achieve high reliability with patients who share risk factors Standardize-Assessment tools, checklists, cues, alerts, and reminders Build reminders and monitors into routine documentation

The big picture and the detail…. From M. Bisognano

Destination? Zero

Results Local engagement of all team members Data collection at ward level Partnership with patients and families Increased compliance with key processes At least 50% reduction on pilots ward Days between events range from 180 to 515 days

Hywel Dda

Spread units

Number of days since a Pressure Ulcer developed on Anglesey ward Winners of “Improving Quality through better use of resources” NHS awards 2009 520

Heart & Minds ‘If you want to build a ship do not gather men together and assign tasks. Instead teach them the longing for the wide endless sea’ (Saint Exupery, Little Prince)

Hamish will now describe the ABM story