Attempts to have pressure injury data regularly collected and reported as a nationwide quality indicator have been unsuccessful to date. But four district health boards decided not to wait for the rest of the country. FIONA CASSIE finds out about the Northern Region’s successful campaign to reduce harm from pressure injuries.
You can’t improve what you can’t measure’ is a maxim that Karen O’Keeffe fully supports.
To reduce patient harm from pressure injuries in the future, she believes, you first need to know how often they are causing harm now.
The experienced nurse manager has been clinical lead for the Northern Region’s First, Do No Harm patient safety campaign since before its launch in 2012. Reducing harm from pressure injuries is one of the six key focuses of the campaign, which set an initial goal of reducing pressure injuries to patients across the four DHBs (Northern, Waitemata, Auckland and Counties Manukau) by 20 per cent.
O’Keeffe says back in 2012 the four DHBs had been measuring pressure injuries (PIs) in a variety of ways, including annual prevalence audits. But Counties Manukau had already implemented a monthly audit process for measuring PIs so the other DHBs decided to follow their lead and use monthly audits to establish a baseline and then track the impact the quality improvement programme was making (go to www.nursingreview.co.nz for more details on the quality campaign elements and measures).
“When we first started out there was quite a difference in the median [incidence rate] between each DHB,” says O’Keeffe. Counties Manukau DHB had been focusing on reducing pressure injuries for some time so their rate for all pressure injuries (including low level grade 1) had already reduced from 12 per cent, when they first started monthly audits in February 2011, down to 3 per cent a year later. A low rate has been maintained by CMDHB ever since.
When the other three DHBs also began to focus on reducing pressure injuries the prevalence rate across the whole northern region reduced by 36.4 per cent – well exceeding the 20 per cent target. Two of the DHBs dropped their pressure injury rate by between 60 and 70 per cent.
“It’s a huge improvement in two and a half years,” says O’Keeffe. “Having a clear strategy and having agreed outcomes has made a big difference.”
The data is collected using the same means and with the same motivation – to learn and improve – so DHBs openly compare and discuss their results. Some DHBs have managed to reduce their grade 3 and grade 4 pressure injuries ‘significantly’, to the point where they are now quite rare events. “DHBs are looking at each other and asking ‘how did you do that?’ so there is a lot of sharing of resources and learning going on.”
Auditing for pressure injuries on a monthly basis is also part of the learning process.
O’Keeffe says when the auditors – usually wound care nurses – come across a grade 1 pressure injury during a ward audit, awareness is immediately raised and staff proactively ensure the injuries don’t get worse.
She says setting the audit threshold for reporting pressure injuries at grade 1 – a non-blanchable reddening of a bony prominence like a heel – is a tougher benchmark than that set by most harm reduction strategies, according to the research literature. The DHBs also adopted the policy of accepting any grade 1 PI found as hospital-acquired, rather than fighting over whether it happened before admission. If the DHBs left out reporting the grade 1 PIs, it would bring the overall rate across the Northern Region down to just one PI per 100 patients.
Consistent reporting standards means the region has baseline data from before and after its campaign so when it introduces new tools or systems it can see whether the changes are making pressure injury incidence better or worse.
O’Keeffe believes nursing plays a large role in reducing the risk of pressure injuries but using pressure injury incidence as a ‘nurse sensitive’ indicator has its challenges. She says the cause of pressure injuries are multifactorial and PIs could be better viewed as a systems-sensitive indicator of having the right resources, education and equipment available. “You have to have all your systems working well for people to have a good experience of care.”
The reduction in pressure injuries in general across the Northern Region means DHBs can now focus on pressure injuries that fall outside the traditional ‘bedsore’ variety; for instance, device-related PIs of noses and ears caused by oxygen therapy, babies in neonatal ICU or unwell people on bypass machines.
Aged care sector
The Northern Region’s pressure injury harm reduction strategy has gone beyond the four DHB’s hospital walls to include the residential aged care sector.
With the rest home sector having long-term residents, they needed a different reporting regime from that of acute care so are using an incident monitoring system to measure their pressure injury trends.
There is yet to be consolidated data for the sector across all four DHBs so there is also no report yet on trends. But 100 per cent of Northland’s residential aged care facilities are now reporting on pressure injuries and falls, and around a quarter of facilities in the other DHB areas.
“We are working towards the point that the facilities can see who is doing well and who can we learn from,” says O’Keeffe. The facilities are organised into clusters and just recently the campaign had more than 70 facilities from across the region at a learning event focused on pressure injuries and falls.
The First Do No Harm campaign has from the outset linked pressure injury and falls education. O’Keeffe says of the two indicators reducing falls is the more challenging as, while there is quite good evidence to build a pressure injuries campaign, there are many more factors involved in reducing falls.
Thinking nationally, acting regionally
Falls are one of the four quality and safety markers that were adopted by the Health Quality & Safety Commission in 2012 to evaluate the effectiveness of its national patient safety campaign Open for Better Care.
Pressure injuries didn’t make the Commission’s short list because of concern there was still work to be done on finalising a quality indicator that could be used consistently across all DHBs.
O’Keeffe says the Commission has been looking at a pressure injury quality indicator once again and the Northern Region has been sharing its findings and suggestions on national reporting guidelines for both pressure injuries and falls.
She believes a national quality indicator for pressure injuries is definitely possibly, and desirable.
“It is much easier to learn when you are all measuring the same thing – then you can compare apples with apples as people are all reporting a grade 2 pressure injury the same way.”
She also believes the Northern Region monthly audit process has proven to be robust and helped results improve ‘dramatically’.
“I think one of our biggest successes has been that the DHBs have been very proactive, supportive and put the time and effort into [getting the data] and the patients are reaping the benefit of having a lot less harm related to pressure injury. Because we’ve been able to see what we’ve been doing is making a difference.”
Pressure Injury Classification System
- Grade 1: Non-blanchable erythema (redness) of an area usually over a bony prominence like a heel
- Grade 2: Partial thickness skin loss
- Grade 3: Full thickness skin loss
- Grade 4: Full thickness tissue loss (exposing bone, tendon or muscle)
- Ungradable pressure injury: Depth or grade (stage) of the PI can’t be determined because wound is covered by slough or dead tissue
Northern Region pressure injury harm reduction campaign
Harm reduction strategy
- Run a series of education events on assessing and reducing pressure injuries (and falls)
- Focus on pressure injury risk assessment and flagging people at risk of PIs
- Ensuring staff have better access to the right equipment i.e. appropriate mattress or pressure relieving device
- Ensuring appropriate 'bundles of care' are ready to match high, low and medium risk patients
- Ensuring key care plans highlighted for at risk patients (including bundle of care)
- The four DHBs share resources but currently do not have a standardised PI risk assessment tool.
- Sharing stories about the impact of pressure injuries on residents and patients to bring home its importance
- Number of pressure injuries: a monthly random audit of five patients per ward (or 15% of the ward or unit patients) to report the number of hospital-acquired pressure injuries from grade 1 to 4
- Compliance with how many patients have a pressure injury risk assessment/skin examination within six hours of admission or transfer
- Monthly random audit of 20 patients to see whether they are getting appropriate SSKIN care bundle. (SSKIN stands for surface, skin, keep moving, incontinence and nutrition)
- For residential aged care facilities the benchmark PI prevalence measure is how many grade 3-4 PIs developed per 1000 occupied bed days (reported on a monthly basis)
Latest ACC statistics for pressure injuries
- In the last decade* 2,001 (2.5 per cent) of the 80,777 treatment injury claims processed by ACC were related to pressure injuries.
- 1,320 (66 per cent) of the pressure injury claims were accepted by ACC.
- The annual claims for pressure injuries have steadily increased since the law changed a decade ago and have doubled in the past five years to nearly 400 a year.
- 14 claims in the past decade were lodged and accepted for deaths related to pressure injuries.
- In all, ACC has reported 172 adverse events related to pressure injuries to the Ministry of Health. The majority of these (140) were in the last five years. (Since late 2014, ACC has also been informing the Health Quality and Safety Commission.)
- The average age of people with ACC pressure injury claims was 71 years old and the vast majority were over 65 years old.
- Of the 1320 claims, the vast majority (1,212) related to public hospitals and only 41 related to residential aged care facilities.
- More than 950 claims (72 per cent) were regarded as being related to nursing care; claims were often accepted because there was no documented evidence of the provision of pressure area care.
*1 July 2005 to 30 June 2015. N.B. Treatment injury data dates from 1 July 2005 when ACC rules were changed to replace ‘medical misadventure’ with ‘treatment injury’. Treatment injuries need to prove a ‘direct causal link between the treatment and the injury’.
National under-reporting of pressure injuries: national moves still afoot
For some years there has been lobbying for national reporting of pressure injuries as a step to reduce the suffering caused by these preventable injuries.
In 2012 the Health Quality and Safety Commission left pressure injuries out of a list of 17 proposed quality indicators because "significant work" still needed to be done to develop a pressure injury indicator that could be used to collect consistent data.
There has also been calls for all DHBs to recognise high grade PIs as serious adverse events and to report them as such to the Commission.
The Commission noted in last year's serious adverse events report that the reporting of PIs was likely to be under-represented. This had been backed by a comparison of ACC and DHB reporting of serious adverse events in a six month snapshot that showed the 20 DHBs did not report 30 pressure ulcers captured in the ACC reports.
All DHBs had been advised that the Commission supported the Northern Region's voluntary policy of reporting all grade 3 or 4 pressure injuries developed in hospital as serious adverse events but the Commission says it was "notable" that the only DHBs to actually report pressure injuries were the Northern Region DHBs.
Meanwhile the Ministry of Health's Office of the Chief Nurse, ACC and the Commission are working together closely on plans to reduce PIs as a 'treatment-related injury' and a report, prepared by consultants KPMG, on a 'value proposition' for investing in pressure injury preventions is expected to be publicly released shortly.