1. 30th September 2009
Presenters: Hamish Laing & Annette Bartley

2. 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

3. Fundamental safety principles
Prevention
Detection
Mitigation

4. 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!

5. 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

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

7. 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:

8. 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 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.

9. An International concern
EPUAP hospital prevalence survey pilot 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

10. 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:

11. 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

12. Spread the Learning and celebrate the successes

14. 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

15. 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.

16. 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

17. 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

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

19. Tools
Atmos Air 9000

20. 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, information distribution list, monthly conference calls with experts
70% reduction in pressure ulcer incidence and 30% reduction in prevalence

21. 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

22. Adapt Adopt
Abandon
Spread the Learning and celebrate the successes

23. ALL OR NONE-COMPOSITE MEASURE
Compliance ( 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

24. 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

25. 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….?

26. 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

27. 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

28. 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

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

30. Destination?
Zero

31. 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

32. Hywel Dda

33. Spread units

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

35. 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)

36. Hamish will now describe the ABM story