Judith Barker - ACT Health - Pressure Injury Prevention: Continuum of Care from Hospital to Community

Pressure Injury Prevention: Continuum of Care from Hospital to Community Judith Barker RN BHlthSc (Nurs) MNP Nurse Practitioner – Wound Management Community Care Program ACT Health

Overview

ACT environment

Community Wound Management Service

Nursing and Allied Health referrals

Minimum data set - Wound types

Cost and governance

Implement evidence based systems

Continuum of Care from hospital to community

Standardisation of resources - managing practice change

Prevalence results - community

ACT Health Environment - Community

Canberra - 101 years old

Government

360,000 people

2 public hospitals

Canberra Hospital

Tertiary teaching, catchment for trauma from surrounding NSW

699 beds - 1000 beds

3000 nurses ACT Health

Community Care Program 5 community health centres

Tuggeranong Health Centre Phillip Health Centre

City Health Centre

Gungahlin Health Centre Belconnen Health Centre

Community Wound Management

Service

Wound Management in the Community

• Link team – after hour community nursing service

• Walk in centres – nurse led

• General practice

• Podiatry – private/public

• High risk foot clinic

• Orthotics

• Seating clinics

• OPD clinics private/public

• Share care with palliative care/podiatry

Private nursing care agencies

Residential Aged Care Facilities

Alexander Maconochie Centre

Schools/child care centres

Providing an Evidence Based Wound Care Service for the ACT Community

Well-defined wound management pathway

• Community nursing referrals and OOS

• Community Wound Management Service referrals

• Allied Health

• Home or clinic base

• Three Tier Wound Management System - link with the acute setting

• Collaboration and multidisciplinary focus

Wound types – Referrals to Community Wound Management Service

Wound types – incidence new and review

pressure injuries

skin tears

dehisence wounds

burns

leg ulcers

170 – 220 active referrals

40 new referrals each month

100 – 150 patient contacts per month

Pressure injuries 12%

Skin tears 13%

Dehiscence 4%

Burns 1%

Leg ulcers 70%

Wound type referrals in aged care

Wound types – incidence new and review

pressure injuries

skin tears

venous

arterial

Wound types Canberra Hospital

Wound types – incidence new and review

pressure injuries

skin tears

dehisence wounds

burns

chronic wounds

Pressure injuries

Major challenge for healthcare professionals and systems

Collier, Moore 2006, Ousey 2005

Nursing specific clinical indicator & indicator for the quality of care

Baharestani et al 2009

Large percentage of pressure injuries are considered to be preventable

EPUAP & NPUAP 2009

Pressure injuries were the fifth most costly, commonly occurring

preventable condition

Jackson et al 2011

Cost and Governance

Cost of Pressure Injuries in ACT Health

$US 18,948,996

Establishment of the National Safety and Quality Health Service - Standard 8

Preventing and management pressure injuries International guideline

Strategic framework

Policy and Standard Operational Procedure Graves N Zheng H (2014) Modelling the direct health care costs of chronic wounds in Australia. Wound Practice

and Research .Vol 22 No1,

Understanding the depth of the problem through data collection

ACT Health

Annual prevalence

Incidence reporting :Riskman – alerts to NP

Score card

Clinical review

Community

Incidence auditing clinical file – minimum wound data set

ACT Health Patient Administration System

Canberra Hospital

Tissue Viability Unit – minimum wound data set

Incidence auditing at ward level for pressure injury – Audit angels

Extract from RiskMan – wound extension module (WEM)

2014 International guidelines

EPUAP, NPUAP, PPPIA

Launched in August 2014

Special populations

- bariatric

- operating rooms

- SCI

- critically ill

- older adults

Evidence based systems: continuum of care

Risk assessment

Equipment – support services and surfaces – improve timely access

Experts and Education Acute and community focus

Resources for pressure injury prevention and management

Assessment

Waterlow - on discharge

Waterlow risk assessment – 1st visit

Wound assessment/digital photography/tracing

Care plan – trial PI

Resources in car

Waterlow - high risk - referral to OT

Stage 2 pressure injury and above – referral to OT and Nutrition

Communication/hand over

- Community to hospital

- GP

Equipment -Support surfaces

Community Equipment Scheme/service

Hiring of support surfaces – ACT Equipment Scheme

Rapid response service

2010 hospital wide mattress replacement

constant low pressure mattresses

2012 Establishment Central Equipment Store

Alternating air mattress / cushions -30mins – 1 hr

Heel tofts

Skin IQ microclimate

Rapid Response

Occupational therapy referral service

40 new referrals each month

Monday – Friday service

Respond and action within 48hrs

Pressure relieving equipment

Hospital bed

Palliative care

Bariatric

Wound clinicians across the health service

2012 Growth in networking within our acute and community and

residential aged care

2008 Nurse Practitioner Wound Management – community

2010 CNC Wound Management – Canberra Hospital

2010 OT Rapid Response Service

2012 Establishment Tissue Viability Unit

4th rotation of 2 RNs for 6 months

2013 Diabetic High Risk Foot Clinic ( Multidisciplinary)

2014 CNC Wound Management - Community

Regular review multidisciplinary referrals

Nutrition, occupational therapist, physiotherapist

Numerous medical teams

2014 Expert Resources

Patient Centred Wound Services

Nurse Practitioner –

Wound Management Community ACT Health

Staff Development

Unit

Education

Clinical Nurse Consultant-

Wound Management

Community

Central Equipment

Store Canberra Hospital

5 Community Health Centres

2 Registered Nurse - months

rotation in TVU - CH

Allied Health rapid response

High Risk Diabetic Foot

Clinic

ACT Equipment Hiring Service

Clinical Nurse Consultant

Tissue Viability Unit

Education

Staff Development Unit – ACT Health

Focus on pressure injury prevention

4 e-learning modules

6 wound days/annually

11 wound afternoon sessions/annually

80 community nurses complete WoundsWest PIP module prior to annual prevalence

Practice development program - community/nurses/AH

Include AWMA (ACT) – Twilight Educational Evenings, Symposium and Conferences

Resources

Standardisation of product range from hospital to community

Foam dressings - meplix boarder sacral & heel dressings

Conveen skin care range - cleanser and creams

Removal of kylies - Touch Dry disposal

Review of Incontinence management and products - pads range for areas and education

Nutritional supplements

Pressure Injury Prevalence in the Community

Wound awareness week

2014 - 361 patients surveyed

80 community nurses

Prevalence over 1 week

All patients seen during this week – home and clinic visits

Manual data collection

Prevalence by year

Documenting patient education

56

92

43

66

38

85

0

10

20

30

40

50

60

70

80

90

100

Canberra Hospital Community

Compliance to Documenting Patient Education by Year

2012

2013

2014

%

Hospital acquired pressure injuries

4

0

5

10

15

20

25

30

35

40

CHCACT

Patients with Hospital Acquired Pressure Injuries by Year

2010

2011

2012

2013

2014

Age of patients

Referral to Multidisciplinary Team

HA Pressure injuries

Canberra Hospital Community Care

Stage 1 52% 80%

Stage 2 24% 20%

Stage 3 0% 0%

Stage 4 0% 0%

Unstageable 4% 0%

DTI 20% 0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Perc

ent

Classification of Hospital Acquired Pressure Injuries by Facility 2014

Challenges

High risk patients

Educating/supporting paid carers

Long term pressure injuries

Bariatric patients

Aged population

Co morbidities

Turning regime for the high risk patient

Equipment – maintenance

Purchasing/funding for new equipment

Future direction

Risk assessment in out patient settings

e – records – ongoing collation of data

Coding of pressure injuries

Increased bariatric equipment and services

Improve timely access to equipment for high risk patients

Summary

Targeting pressure injury prevention in the community

Targeted resources for our health environment

Practice changes – implemented evidence based practice

Standardised products and resources from hospital to community

Continuum of care from hospital to community

Reduced the prevalence of pressure injury

Data - earlier identification of stage 1 and strategies implemented

THANK YOU

Judith Barker

[email protected]

Collier M & Moore Z (2006) Etiology and risk factors. In M. Romanelli (Ed), Science and practice of pressure Ulcer Management (pp. 27-36). London Springer

Ousey K (2010) Pressure area care. Oxford: Blackwell Publishing

Baharestani MM, Black JM, Carville K, Clark M ,Cuddigan JE ,Dealey C et al (2009) Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus. International Wound Journal,6(2), 97-104

European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel. Prevention and Treatment of pressure ulcers. Washington DC: national Pressure Ulcer Advisory Panel: 2009

Jackson T, et al. (2011) Marginal costs of hospital-acquired conditions: information for priority-setting for patient safety programmes and research. Journal of Health Services Research and Policy. Vol 16 No 3 July

Graves N Zheng H (2014) Modelling the direct health care costs of chronic wounds in Australia. Wound Practice and Research .Vol 22 No1,

References