ORIGINAL ARTICLE

Pressure ulcer prevention in Australia: the role of the nurse practitioner in changing practice and saving lives
Margo Asimus, Lorna MacLellan, Pui (Iris) Li
Asimus M, MacLellan L, Li P. Pressure ulcer prevention in Australia: the role of the nurse practitioner in changing practice and saving lives. Int Wound J 2011; 8:508513

ABSTRACT Key Points

pressure ulcer is an adverse
event causing detrimental impacts on individuals and health care system. a nurse practitioner-led pressure Ulcer Prevention Program (PUPP) in Australia has been proven a success: decease in pressure ulcer prevalence and cost saving. an inter-professional project team, led by a nurse practitioner in wound management, was established with members from nursing, allied health and senior management. The members were chosen for their clinical expertise and their ability to provide strong leadership. Medical staff contributed to subgroup activities as key stakeholders. strategies included annual surveillance study, appropriate use of equipment and staff education. the key to success is the strong support from the Executive sponsor from the health organisation and the leadership from the nurse practitioner, clinical leader of the program.

This paper reports on a successful nurse practitioner-led Pressure Ulcer Prevention Program (PUPP), established with members from nursing, allied health and senior management, within a regional area health service in Australia. The aims of PUPP were to quantify the prevalence of pressure ulcers within the health organisation, evaluate the policy compliances, identify cost effectiveness by implementing appropriate pressure redistributing surfaces and raise awareness of pressure ulcer prevention amongst all levels of clinical staff. The strategies include annual point prevalence study across 41 facilities, mattress replacement and online education program. The prevalence survey data were collected by skin inspection and chart audits by the trained surveyors. Since this quality improvement program commenced in 2008, it has demonstrated a reduction in pressure ulcer prevalence by 16.4%, increased pressure ulcer risk assessment by 7.9% and use of appropriate pressure-relieving devices by 46.5%, which led to cost saving of AUD 500 000. This paper highlights the patient and organisation benets that management and clinicians can accomplish through a systemic collaborative approach, in particular with strong support from the Area Executive Team of the health organisation.
Key words: Cost Management Pressure ulcers Prevalence Quality improvement

INTRODUCTION
Pressure ulcers are painful, socially unacceptable and costly, and are considered to be a

Authors: M Asimus, NP, STN, RM, RN, Cert IV of Assessment and Training. Greater Newcastle Cluster, Hunter New England Local Health District, NSW, Australia; L MacLellan, MN, MNP, RN, SCM, School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia; Pui (Iris) Li, MN, RN, Cert IV of Assessment and Training, Nursing and Midwifery Services, Hunter New England Local Health District, NSW, Australia and School of Nursing and Midwifery, Faculty of Health, University of Newcastle, NSW, Australia Address for correspondence: M Asimus, Hunter New England Local Health District, Wallsend Health Campus, Booth Building, Longworth Ave, Wallsend, NSW 2287, Australia E-mail: Margo.Asimus@hnehealth.nsw.gov.au

key indicator of the quality of nursing care (1). Despite pressure ulcers being recognised as a largely preventable adverse event, they remain a major problem for patients in all health care settings and can lead to increased morbidity particularly for the chronically ill and the elderly (2). In some instances, pressure ulcers are complicated by infection, patient deterioration and even death if strategies are not implemented early in patients identied at risk (3,4). Health economists worldwide are fully aware of the nancial burden of pressure ulcers on society. An Australian study reported a median of 95,695 cases of pressure ulcers incurs a median opportunity cost of AUD 285 million (5). The Institution for Healthcare

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Improvement (IHI) estimated pressure ulcer treatment to cost the US health care system US $11 billion per year (4) and a study conducted by the Society of Actuaries reported that pressure ulcer is the most expensive medical error in the USA (6). In 2007, the US Medicare and Medicaid Services announced they would no longer reimburse facilities for hospitalacquired Grades 3 and 4 pressure ulcers (4). Thus, there is a nancial incentive for health care facilities in the USA to take pressure ulcer prevention seriously and implement evidencebased therapies to eradicate this major health burden. This paper describes the steps taken by an area health service in Australia to change the culture and improve the outcomes of patients in its care.

The overall aims of this project were to decrease the prevalence of pressure ulcers by improving quality of care and subsequently reducing the overall health care cost caused by pressure ulcers.

OBJECTIVES OF THE PROJECT

1. To quantify the prevalence of pressure ulcers within HNEH and provide tending data for future 2. To evaluate the effectiveness of policy implementation 3. To identify cost-effective strategies such as implementing appropriate pressure redistributing surfaces and reduction in prevalence rate 4. To raise awareness of pressure ulcer prevention and treatment among all levels of nursing, medical and allied health staff through compulsory online educational modules.

BACKGROUND OF THIS PROJECT

Hunter New England Health (HNEH) is one of the largest area health services in New South Wales, Australia providing services to 840 000 people living in metropolitan and regional areas as well as in rural and remote communities. Despite the organisation having established a pressure ulcer prevention and management policy in 2001, the nurse practitioner in wound management (NPWM) noted a signicant number of clients were being discharged from acute care facilities to community nursing service in HNEH with serious pressure ulcers. It was evident that the standard policy was having little or no effect in reducing the incidence of pressure ulcers. The policy was not embedded into routine clinical practice and a systemic approach to ensuring appropriate pressure ulcer prevention was required. Therefore, the proposal to establish a Pressure Ulcer Prevention Program (PUPP) was supported by the Area Executive Team (AET) and the quality improvement project commenced.

STRATEGIES Surveillance study

Annual pressure ulcer point prevalence study was one of the important strategies in PUPP to monitor the prevalence of pressure ulcers and evaluate the policy compliances. The methodology of the prevalence study was developed from Prentices study (7) conducted in hospital settings in Victoria, Australia. All consenting adult in-patients on acute and subacute wards, including patients agged for admission in Emergency Department, on the 41 facilities on the days of the study conducted were surveyed, except paediatrics, psychiatrics, community, operating theatres and day surgery. Prior to the survey, all surveyors were provided with education and were required to achieve competency in the training. An independent, who was not employed by the ward being surveyed, was allocated to each team. There were two to three surveyors in a team, which depended on numbers of patients being surveyed. The survey team assessed each consenting patients with the Waterlow risk assessment tool (8) for analysis of risk factors and the appropriateness of the equipment in place. The survey tool captured the following data points by skin inspection and medical chart audit: Patient demographics and primary medical specialty
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An inter-professional project team, led by an NPWM, was established with members from nursing, allied health and senior management. The members were chosen for their clinical expertise and their ability to provide strong leadership. Medical staff contributed to subgroup activities as key stakeholders.
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Use of pressure ulcer risk assessment tool and timing of risk assessment Use of appropriate pressure-relieving devices Number of pressure ulcers including anatomical location, stage and causes such as device-related Documentation of sources of pressure ulcer: hospital-acquired or pre-existing Risk prole Ethics approval was granted by the Hunter New England Human Research Ethics Committee. All participants were fully informed of the survey requirements before verbal consent was requested and were also aware that each data set would be anonymous. The rst HNEH point prevalence survey of 1407 in-patients, (excluding mental health inpatients) was undertaken in 2008 across the 41 facilities in HNEH. The prevalence rate was 29.4% in 2008. The survey was repeated in 2009 and 2010 with 1279 patients and 1331 patients being included in the 2009 and 2010 survey, respectively. The results were compared and shown a substantial improvement. Senior management engagement was vital to support the study. On average, 200 staff participated as surveyors in each of the studies. Survey teams included all levels of nursing staff from nursing students, local university academic staff to the most senior nursing clinicians.

to enable a scheduled systematic mattress replacement.

Rental equipment
The team investigated the frequency of use and the costs associated with renting dynamic bed surfaces for high-risk patients in the same three general ward areas. Of the 96 patients reviewed, 26 patients were found to have been prescribed rented powered mattresses, at a cost of AUD 22.83 per day. These patients were then assessed for risk of pressure ulcers using the Waterlow risk assessment tool (8). It was identied accordingly that only ten of these patients actually required the powered air mattresses. By implementing an algorithm to guide clinicians in the appropriate selection of equipment and replacing existing hospital mattresses in these 26 patients, a potential cost saving of $131 247 was made over 12 months.

Staff education
The initial pressure ulcer prevention and management educational online program consisted of four modules: Understanding pressure ulcers Staging of pressure ulcers Risk assessment and reassessment Developing a prevention plan

Appropriate equipment Mattresses

An audit of three general ward areas was undertaken to examine the condition of the standard ward mattresses. It was found that the quality of mattresses varied considerably, with few of them being in a perfect condition and some in a poor state of repair. It was concerning that many of these mattresses could be contributing to the incidence of pressure ulcers as there was no system in place to document the life of ward mattresses. This information was collated and then reported to the AET, who decided to replace all vinyl-covered mattresses with superior highdensity foam mattresses with a two-way stretch dartex cover. Approximately 600 old mattresses in the Newcastle metropolitan area have been replaced with these new highquality mattresses which are now coded
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This program was developed to guide clinicians in the best practice measures to reduce pressure ulcer occurrence. It is aligned with the HNE Health pressure ulcer prevention and management policy. Clinicians were educated and encouraged to take responsibility for pressure ulcer risk assessment of all admitted patients and provide appropriate preventative measures for at risk patients according to evidence-based protocols. Successful completion is recorded on the staffs learning record.

PROJECT OUTCOMES Reduction in the prevalence and severity of pressure ulcers

Area-wide prevalence of all pressure ulcers was reduced from 29.4% in 2008, to 23.8% in 2009 and 13.0% in 2010 (Figure 1). There was a decrease in the prevalence of hospital-acquired pressure ulcers, from 23.4% in 2008 to 17.2% in 2009 and 8.0% in 2010. The total number of pressure ulcers decreased from 884 (2008) to
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35.00% Prevalence 30.00% Hospitalacquired PU Prevalence

25.00%

20.00%

15.00%

10.00%

5.00%

0.00% 2008 2009 2010

Figure 1. Changes in pressure ulcer prevalence and hospital-acquired pressure ulcer prevalence in the health organisation. Table 1 Change in pressure ulcer prevalence in major hospitals with mattresses replacement Year Institute Number of consenting patients Number of patients with pressure ulcers Prevalence of pressure ulcers Prevalence of hospital-acquired pressure ulcers 2009 Number of consenting patients Number of patients with pressure ulcers Prevalence of pressure ulcers Prevalence of hospital-acquired pressure ulcers 2010 Number of consenting patients Number of patients with pressure ulcers Prevalence of pressure ulcers Prevalence of hospital-acquired pressure ulcers Change in hospital-acquired pressure ulcer prevalence from 2008 to 2010 2008 John Hunter Hospital 312 98 314% 282% 293 77 263% 215% 266 36 135% 71% 21.1% Belmont Hospital 68 28 406% 279% 45 17 378% 178% 58 11 190% 86% 19.3% Royal Newcastle Centre 54 22 407% 389% 77 22 286% 156% 63 6 95% 79% 31.0%

611 (2009) and had a further reduction to 344 in 2010. The severity of pressure ulcers was also reduced. The total number of the more serious Stage 3 and 4 pressure ulcers decreased from 14.9% in 2008 to 13.9% in 2010. In 2008, 52.7% of the patients were classied as very high risk developed pressure ulcers, whereas there were only 44.3% and 23.3% of the patients in this category in 2009 and 2010, respectively. There was a signicant reduction in hospitalacquired pressure ulcer prevalence in the hospitals where the standard mattresses had been replaced by high-density foam mattresses. Table 1 indicates the reduction of
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hospital-acquired pressure ulcer prevalence rate of those three major hospitals with mattresses replaced.

Risk assessment and pressure-relieving devices

There was an increase in compliance by clinical staff to risk assessment from 78.9% of the surveyed patients in 2008 to 79.2% in 2009 and 86.8% in 2010. Also, there was a substantial increase in the prescribing of appropriate pressure-relieving devices. In 2008, only 44.4% of high-risk patients had been provided with the correct devices, whereas this was increased
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to 71.5% of high-risk patients being provided with appropriate devices in 2009 and there was a further increase to 90.9% in 2010. This change in practice was undoubtedly responsible for the overall reduction in pressure ulcers in 2009 and 2010.

Cost saving from power air mattress rental

Because of the mattress replacement and the implementation of the equipment algorithm, more appropriate equipment has been prescribed by clinical staff. There has been a signicant reduction in hiring of powered mattress systems, which has resulted in a cost saving of over AUD 500 000 in the rst year of the program. This has been a positive outcome for both the patients and for management who continually struggle to balance the delivery of quality patient care with budgetary constraints.

CHALLENGES
The key challenge we identied during the implementation of the PUPP was the geographical size of our health organisation, which is as big as England. It was a huge challenge to ensure messages have penetrated to every level across 41 facilities. Therefore, our program sponsor from AET became the key person to disseminate information. Key stakeholders were also identied during monthly senior nursing manager meetings to facilitate communication. During the period of the rst prevalence study in 2008, the PUPP team visited all the survey facilities supervising the surveyors and ensured the methodology was followed at every site. The PUPP team prepared survey reports together with recommendations for each ward and facility, which helped facility managers and Nurse Unit Managers understand how well their ward performed. All reports were uploaded on HNEH intranet. Over these 3 years, each facility has taken the ownership in pressure ulcer prevention.

DISCUSSION
Pressure ulcer prevention and management were redesigned using small teams and an inter-professional collaborative approach.
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The annual surveillance study, with the sample sizes ranging from 1279 to 1407 and the consenting rate between 82% and 87% over these 3 years, has shown a huge reduction in pressure ulcer prevalence rate of 16.4% over the past 3 years. The severity of pressure ulcers was also reduced. The validity of the studies was strengthened by direct skin inspection, allocating an independent to each survey team and competence of the online training program. Replacing vinyl mattress with high-density foam mattress was one of the key factors in to the reduction of the hospital-acquired pressure ulcers, although mattresses were only replaced in all the tertiary hospitals because of the nancial constraint. The medical chart audits during the three prevalence studies have identied an increase in staffs compliances in pressure ulcer risk assessment; approximately 46% increase in risk assessment was evidenced. The surveillance study itself was also an exercise facilitating clinicians to gain better understanding of policy requirements, evidence-based practice and knowledge on pressure ulcer prevention and management. With the support and leadership from the local stakeholder, staffs are encouraged to complete pressure ulcer online education program. The increase in the appropriate use of pressure-relieving equipment was evidence of better knowledge in pressure ulcer prevention. Monthly hiring cost of pressure-relieving devices was evaluated for those hospitals with high-density foam mattresses purchased. There was AUD 500 000 of cost saving over the rst year after the implementation of the equipment algorithm and staff education program; more appropriate equipments have been prescribed by clinical staff. The strategies of PUPP have reduced the number of pressure ulcers identied in a repeat study and subsequently saved signicant amounts of the health budget over the period of the study. The overall outcomes would not have been achieved had it not been for the combined efforts of all teams and so their involvement is valued and acknowledged. The data reveal evidencebased, cost-efcient and sustainable strategies were implemented. This is because of the clinical staff having an increased knowledge of pressure ulcer prevention and management strategies. These gures also demonstrate the
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staffs commitment to improve clinical practice and their adherence to policies in an effort to reduce pressure ulcer prevalence in their area.

CONCLUSION
Clinicians trained in pressure ulcer risk assessment, prevention and treatment have the ability to contribute signicantly to improving the appropriate pressure ulcer prophylaxis and reduce subsequent pressure ulcer complications. Pivotal in achieving positive outcomes was the collaborative approach between clinical staff and senior management. The data demonstrate that there has been a substantial improvement in the quality of care to patients in HNEH over the last 3 years. This change in culture has occurred because of the provision of educational modules and an increased awareness of pressure ulcers and prevention strategies. There has also been willingness by each individual member of staff to make a contribution to a positive outcome for the patients in their care.

Health District. Also, all clinicians participated as a surveyor. This project was supported by Nursing and Midwifery Services, Hunter New England Area Health Service. This project won the Quality and Safety Award at the HNE Health Awards and the Clinical Excellence Commission Award for Improvement in Patient Safety at NSW Health Awards, both in 2009.

REFERENCES
1 Angel D, Sieunarine K, Hunduma N, Clayton M, Abbas M, Ponosh S. Postoperative pressure ulcers in vascular patients after epidural analgesia: case reports. Primary Intent 2004;12:348. 2 Lyder C. Pressure ulcer prevention and management. JAMA 2003;289:2236. 3 Duncan K. Preventing pressure ulcers: the goal is zero. Jnt Comm J Qual Patient Saf 2007;33:60510. 4 Bales I, Padwojski A. Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 2009;18:137144. 5 Graves N, Birrell F, Whitby M. Effect of pressure ulcers on length of hospital stay. Infect Control Hosp Epidemiol 2005;26:2937. 6 Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziekiewicz E. The economic measurement of medical errors. URL http://www.soa.org/les/pdf/ research-econ-measurement.pdf [accessed on 20 September 2010]. 7 Prentice J, Stacey M, Lewin G. An Australian model for conducting pressure ulcer prevalence surveys. Primary Intent 2003;11:87109. 8 Waterlow JA. The use of the Waterlow pressure sore prevention/treatment policy card. Primary Intent 1995;3:1421.

ACKNOWLEDGEMENTS
We acknowledge the support from the Executive sponsor of the program, Director of Nursing and Midwifery Services, Mr Chris Kewley, and Ms Felicity Williams, Nursing and Midwifery Services and Pressure Ulcer Prevention and Management Committees and senior managers in Hunter New England Local

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