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Stop the Pressure Lincoln - 15 October 2013

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Presentations from the Stop the Pressure Lincoln event held for 500 student nurses and caremakers at The Engine Shed, Lincoln on 15 October 2013 …

Presentations from the Stop the Pressure Lincoln event held for 500 student nurses and caremakers at The Engine Shed, Lincoln on 15 October 2013

This event supports Stop the Pressure, a campaign to raise awareness of pressure ulcers

The hashtag used at this event was #stopthepressurelincoln


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  • Self explanatory – may be worth pointing out that if we were to redo the health economics analysis on 2011 figures we would expect much higher costs
  • They set a clear aim and exceeded their target for rescreening using ‘MUST’
  • Sal
  • BethNeed to be able to pass on our knowledge to our patients and explain ways to prevent damage either in an acute setting or when they are discharged.
  • Mel
  • Charlie
  • Siobhan + Ashleigh
  • Over the last couple of years the NHS has not only seen tremendous change, but has had to answer for the quality of care and culture within its organisations.These difficulties have been highlighted within the Francis report and most recently Don Berwick’s review of the NHS safety culture.Nursing care has never before been under the spotlight in such a way. We have heard some terrible stories relating to poor care from distressed relatives to other members of the nursing teams.
  • The Keogh Reviews have once again highlighted the need for a National robust nursing & midwifery strategy which of course as you know is compassion in practice
  • CNO Jane Cummings launched the nursing & midwifery 3 year strategy at last years CNO conference. The National lead is Juliet Beal and our Regional lead is Julie Firth.With the findings of the Keogh Reviews, and the Don Berwick review on the NHS, Compassion in Care has become even more relative in these changing times.
  • So let’s remind ourselves……CareDelivering high quality care is what we do. People receiving care expect it to be right for them consistently throughout every stage of their life.CompassionCompassion is how care is given, through relationships based on empathy, kindness, respect and dignity.CompetenceCompetence means we have the knowledge and skills to do the job and the capability to deliver the highest standards of care based on research and evidence. CommunicationGood communication involves better listening and shared decision making - ‘no decision about me without me’.CourageCourage enables us to do the right thing for the people we care for, be bold when we have good ideas, and to speak up when things are wrong. CommitmentCommitment will make our vision for the person receiving care, our professions and our teams happen. We commit to take action to achieve this.
  • Notes from left to rightDeliver evidence-based care & extend evidence through researchExplicitly demonstrate our impact on outcomes Make ‘every contact count’ to promote health and wellbeingSupport people to remain independentMaximise the contribution to specialist community public health nursingDesign our services so people, and their carers and family are active participants in their carePrioritise patients and the people who receive care in every decision we makeCollect, listen to and act on feedback and complaintsPromote personal responsibility for health and wellbeingFollow evidence-based best practice to deliver high quality outcomes to those that use health and care services Measure what we do and our contribution to qualityBe transparent and publish the outcomesPromote careers in research to strengthen the focus on evidence based practiceEnsure all registered nurses & midwives understand their leadership role with the wider care-giving teamFree our leaders to have time to lead e.g. supervisory status, better use of technologyEmpower nurses, midwives & registered managers to make local changes to improve care.Use evidence based staffing levelsCommit to and support life long learning for the whole care-giving teamRecruit staff with the right culture & valuesCreate worthwhile & rewarding jobsCreate equality of opportunitySupport each other & new entrants to the professionsBe professionally accountableEmbrace new technologyBe productive and efficient
  • Cambridgeshire children’s community nursing team provide life-lineThe children’s community nursing team at Cambridgeshire Community Services NHS Trust has been announced as the winner of NHS England’s 6Cs Live! September Story of the Month.Team photo, from left to right: Jenni Sherman, Children’s Community Nurse; Vicky Amiss-Smith, Continuing Care Nurse; MagsHirst, Play SpecialistThey have been chosen for the care they give to eight year old Ollie Duell and his family from Cambridge, helping them cope with the devastating impact of his illnesses.  Ollie’s mum Claire explains: "Since he was a baby Ollie has lived with a condition called Intestinal pseudo-obstruction where the intestines lose their ability to contract and push food and stools through his system." "Ultimately," she continues "this resulted in Ollie needing a multi-organ transplant (bowel, stomach, intestines and pancreas) and creation of a stoma at the Birmingham Children’s Hospital in October 2010 when he was just five years old. Since then he has had multiple problems with his stomach, bowel, intestines, duodenum and colon. "The nurses from the children’s community nursing team have been with us since Ollie was 3 months old, so know him inside out and provide the majority of his care at home, hugely reducing the amount of time he has had to spend in hospital."She says that the children’s nursing team have offered them a life-line, becoming part of their family and continues:"I cannot thank the children’s nursing team enough for all the care they give Ollie and the entire family. We consider them an integral part of our family life; without them it’s simple, we just wouldn’t cope."Ollie, like most boys is addicted to computer games and, as MagsHirst, Play Specialist with the children’s community nursing team explains, this can be used as a positive part of this care programme: "Ollie is a very special boy and copes with his conditions remarkably well but like all of us, every now and then he needs that extra bit of help. Through therapeutic play, we use computer games as one way to help him manage any concerns or fears he may have about his illness and treatment."The panel - which includes representatives from NHS England, Nursing Times, a 6Cs Live! patient champion and the RCNs Nurse of the Year – felt that the children’s community nursing team exemplified the values of the 6Cs. Sam Sherrington, Head of Nursing and Midwifery Strategy at NHS England, said:"When we read Ollie’s story it really struck all of the panel members how much of a difference the children’s community nursing team make to his and his family’s life. The team’s work shows that where the 6Cs of care, compassion, courage, commitment, communication and competence are used it is really felt by the patient and their families""The team not only provide vital care to Ollie but enable his family to spend precious time re-charging their batteries and doing the everyday simple things that most of us take for granted."As a result of the team’s fantastic care Ollie has been able to spend much more time at home and avoid stays in hospital as much as possible."Catherine Ray, a senior sister at Solihull Hospital, has been picked as the first ever winner of NHS England’s 6Cs Live! and Nursing Times’ story of the month competition.Catherine’s story was chosen from nearly forty other entries by the judging panel, which includes representatives from NHS England, Nursing Times, a 6Cs Live! patient champion and the RCNs Nurse of the Year.It was chosen because Catherine’s work showed exceptional nursing practice and embodied the 6Cs, showing care, compassion, competence, communication, courage and commitment towards her patient and his family.Catherine described how a patient with terminal lung cancer was made to feel as comfortable as possible and ensured his family was around him, with her going as far as to arrange for the gentleman’s pregnant daughter to have a 4D scan so he could see images of his unborn grandson.Catherine said:“The atmosphere on the ward was indescribable and the patient was so excited to meet his grandson, his spirits lifted and the staff were so happy to be a part of it.The patient went home soon after and died peacefully with his family around him.Catherine continued:“The family have been back on the ward a few times to visit and the last time they brought the new addition to the family, the healthy baby boy that we saw on that scan.”Sam Sherrington, Head of Nursing and Midwifery Strategy at NHS England, said:“Catherine went above and beyond to make her patient’s last few weeks as comfortable as possible, arranging a side room with an additional bed for his family to stay with him, arranging for him to go home the same day he decided – and the 4D scan showed such compassion.“It’s these individual stories that we want to hear about. There’s so much great nursing care going on right across the country and this is our chance to really shout about it.”Mandie Sunderland, chief nurse at Heart of England NHS Foundation Trust, said:“Good nursing requires many skills and attributes which have a positive impact on the patient experience and these are illustrated wonderfully in this short story.“Examples of where nurses have gone the extra mile to provide care and compassion like this should be celebrated. I am proud of Catherine’s achievement as winner of the first story of the month competition.”NHS England, in partnership with Nursing Times, is running the story of the month competition to find good examples of 6Cs practice and the winning story will be featured on the Nursing Times website and the 6Cs Live! Communications Hub.
  • Transcript

    • 1. #stopthepressure Lincoln 15th October 2013
    • 2. Welcome Professor Sara Owen Pro-Vice Chancellor University of Lincoln
    • 3. Introduction Lyn McIntyre Deputy Nurse Director, Midlands and East Charlotte Johnston Student Nurse, University of Lincoln
    • 4. NHS Midlands & East 4
    • 5. 5 • New numbers trend • Midlands and East New grade 2, 3 and 4 pressure ulcers
    • 6. Resources 6 NHS | Presentation to [XXXX Company] | [Type Date]
    • 7. 7 NHS | Presentation to [XXXX Company] | [Type Date]
    • 8. The Swan’s Story http://www.youtube.com/watch?v=IJ 8FEhE561Y&sns=em
    • 9. Pressure ulcer recognition and prevention Mark Collier Tissue Viability Nurse Consultant United Lincoln Hospitals NHS Trust
    • 10. PRESSURE ULCER RECOGNITION AND PREVENTION.. United Lincolnshire Hospitals NHS Trust Mark Collier, Lead Nurse/Consultant - Tissue Viability, United Lincolnshire Hospitals NHS Trust mark.collier@ulh.nhs.uk
    • 11. Pressure Ulcers:
    • 12. Current terminology? • Bedsore • Pressure Sore • Decubitus Ulcer • Pressure Ulcer What term do you use/prefer?
    • 13. What is a Pressure Ulcer? ‘A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. (EPUAP 2009)
    • 14. What is a Pressure Ulcer? ‘Ulceration of the skin due to the effects of prolonged pressure, in association with a number of other variables’ (Collier 1995) ‘an area of localised damage to the skin which can extend to underlying structures such as muscle and bone. The damage is caused by a combination of pressure, shearing and friction forces and moisture’ (NICE, 2005)
    • 15. Pressure External pressure will be transmitted from the skin to the underlying bone, compressing the tissues, including the smaller blood vessels, between these two structures. When prolonged this pressure can lead to inadequate blood supply and cause tissue death.
    • 16. Shear A parallel force, shear damage occurs when deeper skin layers and skeleton move away from the upper skin layers. This causes stretching of the small blood vessels which, if unrelieved, will lead to inadequate blood supply leading to tissue death. For example when a patient slides down the bed the skin over the sacral area adheres to the bed sheets and remains in the sitting position as gravity forces the deeper underlying tissues and bone to slip down the bed.
    • 17. Friction Friction results form is the skin rubbing against another surface. Friction forces can contribute to the development of pressure ulcers by causing the skin layers to separate forming a blister, or by compromising the intact nature of the skin. For example ill-fitting shoes or during poor moving and handling techniques, such as moving patients up the bed on a sheet .
    • 18. Can you measure Pressure?.. ‘a perpendicular load or force exerted on a unit of area’ Bennett and Lee (1985) Force Pressure = --------------Surface Area
    • 19. Potential Sites for Pressure Ulcers • Bony prominences • Consider – – – – Oxygen masks Catheters and tubing Surgical appliances Prosthesis
    • 20. Factors that increase the risk of developing a pressure ulcer
    • 21. Variables - ‘evidence based’ • Age • Nutrition • Medical Condition • Medical Interventions • Peripheral Vascular Disease (PVD) • Patient Support Surfaces • Drug Therapy • Care being Given
    • 22. Age • Extremes of age • The skin of elderly patients is thinner, drier and less elastic increasing the risk of damage. • Neonates and young children are also at increased risk of skin damage because their skin is still maturing.
    • 23. Nutritional Status • Dehydration and malnutrition lead to poorly nourished, inelastic tissues that are more prone to damage. • Consider – Likes and dislikes – Appetite – Chewing and swallowing difficulties – dentures, sore throat/mouth – Physical ability to feed themselves?
    • 24. BMI • Very thin patients have less fatty tissue over the bony prominences to protect from pressure. • Obese patients may have difficulty moving and therefore repositioning to relieve pressure.
    • 25. Medical History • Conditions causing reduced mobility & sensation. • Terminal illness due to multi-organ failure, poor nutritional status & immobility. • Conditions affecting the circulation and oxygenation of the blood. • Consider – – – – – Heart disease COPD and lung diseases Peripheral vascular disease Diabetes Anaemia
    • 26. Medication • Anti-inflammatory drugs (including aspirin) and steroids may prevent healing. • Chemotherapy drugs may damage healthy tissues. • Sedative drugs may affect mobility and sensation.
    • 27. Reduced Mobility • Inability to move self in order to relieve the pressure. • Consider immobility/reduced mobility due to: – – – – – – – – – – #’s Surgery Epidurals Traction Pain Paralysis CVA MS Arthritis Drains & tubing
    • 28. Sensory Impairment/ Reduced Consciousness • Unaware of the need to relieve pressure. • Consider – – – – – Unconsciousness Sedation Spinal Cord Injury Diabetic neuropathy Neurological Conditions egg MS, CVA
    • 29. Moisture Lesions • A combination of moisture and friction may cause moisture lesions in skin folds. • A lesion that is limited to the natal cleft only and has a linear shape is likely to be a moisture lesion. • Peri-anal discolouration / skin irritation is most likely to be a moisture lesion due to faeces.
    • 30. Incontinence • Urinary and faecal incontinence cause excoriation of the skin. • Moisture causes maceration of the skin. • Consider – Barrier creams/films
    • 31. Skin Hygiene • Excessive use of soaps will remove the skin’s natural protective oils and dehydrate it. • Consider – Skin cleansers
    • 32. Cost of Pressure Ulcers? Additional treatment / management costs associated with an Orthopaedic patient with one Grade 4 Pressure Ulcer equals…. £40,000 Sterling Collier M (1993) Quality Report, Addenbrookes NHS Trust from £1,214 (cat 1) to £14,108 (cat IV) Dealey C, Posnett J et al (2012)
    • 33. © Mark Collier
    • 34. SSKIN - what does it stand for? • • • • • S = Surface S = Skin Inspection K = Keep moving I = Incontinence N = Nutrition
    • 35. Patient Support Surfaces available? PRESSURE REDUCING? PRESSURE RELIEVING?
    • 36. Prevention and Management Support Surfaces • Static foam mattresses • Huntleigh Rentals Contract – Resource pack on intranet • Nimbus III – alternating airflow, has heel guard • Breeze – low air loss, light weight patients • Aura cushion • Consider when to step down!
    • 37. Observation / Skin Assessment © Mark Collier
    • 38. Prevention and Management Skin Inspection • At least daily, frequency will depend on vulnerability and condition of patient • Pay particular attention to: – Areas of healed ulceration – Bony prominences • Look for – Discolouration – Redness that doesn’t blanche with light pressure – Blisters – Localised heat – Localised oedema
    • 39. Risk Assessment Tools NICE Guideline No.7 Pressure Ulcer Prevention ‘Whilst there is little evidence to support one tool over another, there is evidence to suggest that an assessment process that incorporates a risk assessment tool improves the patients outcomes’ Which one do we use? WATERLOW (2005)
    • 40. Prevention and Management Positioning • Regular repositioning to avoid pressure on bony prominences and existing pressure ulcers • Turning/30 degree tilt • Avoid direct contact between bony prominences to avoid friction and shear – consider use of pillows • Consider – Seating – Spinal injuries – Bariatric patients
    • 41. Prevention and Management • Use of appropriate patient support surfaces • Skin assessment and good hygiene • Evidence based moving and handling practice • Nutrition • Hydration • Incontinence
    • 42. Categories (Grading) of Pressure Ulcers: GRADE 1 GRADE 2 GRADE 3 GRADE 4 © Mark Collier
    • 43. Pressure Ulcer Categories Category 1 • Non-blanchable hyperaemia (of intact skin) • Discolouration of the skin • Warmth • Oedema • Hardening
    • 44. Pressure Ulcer Categories Category 2 • Partial thickness skin loss or damage involving the epidermis andor the dermis. • The ulcer is superficial and presents clinically as an abrasion or a blister.
    • 45. Pressure Ulcer Categories Category 3 • Full thickness skin loss involving damage to or necrosis of subcutaneous tissue. • This may extend down to but not through the underlying fascia.
    • 46. Pressure Ulcer Categories Category 4 • Extensive destruction and tissue necrosis or damage to bone, muscle or supporting structures with or without full thickness skin loss
    • 47. Deep Tissue Injury • May appear as a purple, deep bruise, often mistaken for a Grade 1 pressure ulcer • Skin is intact • Occur over bony prominences • Tissue damage that occurs from the inside out • May quickly progress to Grade 3 / 4 pressure ulcers
    • 48. © Mark Collier
    • 49. Guidelines within ULHT for…. • Pressure Ulcer Prevention • Equipment Provision (Support Surfaces) • Pressure Ulcer reporting (PUNT) • Pressure Ulcer Management
    • 50. Current ULHT Documentation • Patient assessment/admission documentation that incorporates all of the principles of SSKIN • Waterlow Assessment Tool • Tissue Viability Care Pathway • PUNT (e-reporting tool on intranet) • Wound Assessment and Management Chart
    • 51. ANY QUESTIONS?
    • 52. Living with a pressure ulcer – a patient and carer perspective Brian and Yvonne Rawson In conversation with Delia Muir Patient and Public Involvement Lead Institute of Clinical Trials Research University of Leeds
    • 53. Living With a Pressure Ulcer – a patient and carer perspective. Brian and Yvonne Rawson - PURSUN UK Delia Muir - Patient and Public Involvement Officer, University of Leeds
    • 54. PURSUN UK • A network of people with some personal experience of pressure ulcers or pressure ulcer prevention • We work on pressure ulcer related research projects • Our members are also involved in education and professional development projects
    • 55. Patient Stories • Real life stories are powerful and can create a common focus • Patients and their families are often the only constant thing in their journey through services, therefore their perspective very valuable • We hope that hearing about the impact that a pressure ulcer can have will help to drive home important prevention messages
    • 56. Brian and Yvonne’s Story
    • 57. For more information contact: Delia Muir (PPI Officer) d.p.muir@leeds.ac.uk www.pursun.org.uk Twitter @PURSUN_UK Or talk to us over lunch
    • 58. Comfort Break
    • 59. SSKIN mini quiz Mark Collier Tissue Viability Nurse Consultant United Lincoln Hospitals NHS Trust
    • 60. STOP THE PRESSURE... SSKIN Mini-Quiz United Lincolnshire Hospitals NHS Trust Mark Collier, Lead Nurse/Consultant - Tissue Viability, United Lincolnshire Hospitals NHS Trust mark.collier@ulh.nhs.uk
    • 61. Question 1 What does the second S of SSKIN stand for? • Surface (green) • Skin Inspection (red)
    • 62. Question 2 What is the prime function of an alternating pressure mattress (APM), such as a Nimbus III? • Pressure reduction (green) • Pressure relief (red)
    • 63. Question 3 Which of the following skin discolouration is the most important to identify and report when inspecting a patient’s skin? • Blanching (green) • Non-blanching (red)
    • 64. Question 4 How would you categorise? • Pressure ulcer (green) • Moisture lesion (red)
    • 65. Question 5 All pressure ulcers are preventable? • True (green) • False (red)
    • 66. Question 5: Answer Hibbs, P. (1988) suggested that 95% of all pressure ulcers are avoidable. Although everybody would agree that ALL avoidable pressure ulcers should be prevented, there is now evidence in the literature to suggest that around 43% of all pressure ulcers can be deemed to be avoidable. Dowie F, Guy H et al (2013) Are 95% of hospital acquired pressure ulcers avoidable? Wounds 9:3 16-22
    • 67. Question 6 Who is responsible for the application of the principles that underpin SSKIN in clinical settings? • Everybody (green) • All healthcare professionals (red)
    • 68. ANY QUESTIONS?
    • 69. Impact of good nutrition and hydration on pressure ulcer prevention and care Dr Ailsa Brotherton Director for Clinical Engagement and Leadership NHS QUEST PMO
    • 70. Ailsa Brotherton BAPEN Secretary
    • 71. British Association for Parenteral and Enteral Nutrition A multi-disciplinary charity committed to raising awareness of malnutrition and options for nutritional treatment, along with consequent impacts on health outcomes, resource utilization, and health & social care budgets. BAPEN Malnutrition Matters
    • 72. Malnutrition in the UK PHYSICAL Disease related malnutrition PSYCHOLOGICAL Mobility Depression/bereavement Feeding Dementia Swallowing Low activity Decreased organ reserve Specific disease Multiple drugs (taste) Alcohol SOCIAL Isolation Poverty
    • 73. Malnutrition is both a cause and a consequence of disease Psychology – depression & apathy Poor breathing and cough from loss of muscle strength Liver fatty change, functional decline necrosis, fibrosis Impaired wound healing and susceptibility to pressure ulcers Impaired gut integrity and immunity Poor Immunity and infections Decreased Cardiac output Hypothermia – decline in all functions Renal function – limited ability to excrete salt and water Loss of muscle and bone strength – Immobility, falls, fractures and VTE
    • 74. The Malnutrition Carousel NURSING HOME PRIMARY CARE  dependency  GP visits  prescription costs  hospital admissions CARE HOME malnutrition HOSPITAL SECONDARY CARE  complications  length of stay  readmissions  mortality HOME BAPEN Malnutrition Matters
    • 75. Nutrition support in adults 2006 February 2006
    • 76. The effectiveness of Nutrition Support (Stratton et al) 10 RCT, n = 494; RR 0.29 (CI 0.18 to 0.47) 30 RCT, n = 3258 RR 0.59 (CI 0.48 to 0.72) Controls Controls Treatment Treatment 0 10 20 30 Complications % 40 50 0 5 10 15 20 25 Mortality % >70% reduction in complications and >40% reduction in mortality 30
    • 77. NICE ONS and length of stay Standardised Mean diff. (95% CI) % Weight Study {HARTSELL1997} -0.32 (-0.83,0.20) 12.3 {PEARL1998} -0.49 (-0.78,-0.21) 12.7 {REISSMAN1995} -3.00 (-3.45,-2.55) 12.4 Gist 2002 -0.03 (-0.39,0.33) 12.6 Gocmen 2002 -2.54 (-2.93,-2.15) 12.5 Burrows1995 -0.38 (-0.78,0.01) 12.5 Patolia2001 -2.08 (-2.53,-1.63) 12.4 Weinstein1993 0.11 (-0.25,0.47) 12.6 Overall (95% CI) -1.09 (-1.91,-0.27) -3.45185 0 3.45185 Standardised Mean diff.
    • 78. 2013 - ?? Costs being recalculated 2007 - >£13 billion p.a. Public expenditure associated with disease related malnutrition 2003 - >£7.3 billion p.a Over 3 million individuals malnourished or at risk of malnutrition in the UK NICE Cost Saving Guidance places malnutrition as a potential large cost saving to the NHS
    • 79. PRIMARY CARE  hospital  dependency  GP visits  prescription costs HOME General population (adults) BMI <20kg/m2 : 5% BMI <18.5kg/m2 : 1.8% Elderly: 14% SHELTERED HOUSING 10-14% of tenants Prevalence of malnutrition in the UK HOSPITAL 28% of admissions SECONDARY CARE  complications  length of stay  readmissions  mortality CARE HOMES 30-42% of recently admitted residents
    • 80. The Challenge: We know what excellent nutritional care looks like
    • 81. The BAPEN Toolkit for Commissioners & Providers 2010 Malnutrition Matters Meeting Quality Standards in Nutritional Care Ailsa Brotherton, Nicola Simmonds and Mike Stroud on behalf of the BAPEN Quality Group
    • 82. 1) Identify those with malnutrition or risk of malnutrition by screening e.g. BAPEN‟s MUST Tool and assessment as appropriate 2) Implement „individualised‟ care pathways for the malnourished and those at risk, appropriate to the care setting 3) Provide training for all care staff on the importance of nutritional care appropriate to setting, profession and responsibilities 4) Ensure multidisciplinary structures to manage and monitor nutritional care ...but we struggle to deliver these reliably
    • 83.  Reliability is not about what clinical care should be given  Reliability is about the process of ensuring patients get best care consistently „Every patient, every setting, every day‟
    • 84. Local Improvement: Using standards and guidelines to drive quality improvements in nutritional care •Use the BAPEN toolkit which simplifies the plethora of standards and guidelines for improving nutritional care • Design systems based on the four tenets of nutritional care • Embed good nutritional care into everyday work flow • Use evidence based tools and e-learning to support front line staff • Work across organisational boundaries to ensure seamless nutritional care • Ensure Trust Board Level engagement •Identify a BAPEN rep in your organization
    • 85. Royal Devon and Exeter NHS Foundation Trust have designed a highly reliable electronic system for nutrition screening using ‘MUST’ MUST Compliance Mark Bellas Divisional Lead Nurse Critical Care/T&O
    • 86. Trajectory Results Trust-wide General Compliance with MUST Screening at Weekly Review 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May10 10 10 10 10 10 10 10 10 10 10 10 11 11 11 11 11 Position Target
    • 87. Screening alone is not enough Design systems to screen all patients using „MUST‟ Develop individualised nutritional care plans Design reliable systems to deliver care plans Monitor ongoing nutritional intake / status
    • 88. Now is the time to deliver good nutritional care in the UK to deliver ‘harm free’ and eliminate avoidable pressure ulcers. “You may never know what results come of your action, but if you do nothing there will be no result” Mahatma Gandhi
    • 89. Student nurse design for SSKIN Charlotte Johnston and student nurse colleagues University of Lincoln
    • 90. #stopthepressurelincoln #stopthepressure SSKIN: For Students, BY Students. University of Lincoln
    • 91. S - Shadow • Important to spend time shadowing a Tissue Viability Nurse: - When do you need their expertise? - Learn from their experiences. - Your responsibility to arrange to spend an insight day with TVN’s to supplement your university learning. 36. You must ensure any advice you give is evidence-based if you are suggesting healthcare products or services. NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013
    • 92. S – Signs/Symptoms • Understand and recognise the early signs of pressure ulcers or potential/further damage: - Start to form a care plan and ensure appropriate action is taken. - To educate the patient and their families in ways to prevent potential/further damage. - Also improves patient-centred care – by improving nurse-patient communication. 54. You must act immediately to put matters right if someone in your care has suffered harm for any reason. NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013
    • 93. K - Knowledge • As new guidelines are coming out, we know and understand how to apply these in practice: - Read, Read, READ! - Challenge yourself and develop your own best methods of nursing based on your own evidence-based research. - Training doesn’t stop at the end of a module, end of the year or the end of training. 40. You must keep your knowledge and skills up to date throughout your working life. NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013
    • 94. I – Innovate/Implement • If you have any ideas to improve practice, share it! - If you observe something that could be improved on, go and speak to your mentor/ward manager. - Be the change you want to see. 22. You must work with colleagues to monitor the quality of your work and maintain the safety of those in your care. NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013
    • 95. N - NMC • Nurses are accountable for all action: - NMC Code of Conduct: YOU, as students, are accountable for all action/knowledge you have - This is equally important for all healthcare professionals regardless of level, branch or speciality. Page 1: We exist to safeguard the health and wellbeing of the public. NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013
    • 96. Change agents and boat rockers Video: Dr Helen Bevan Introduced by Lyn McIntyre Deputy Nurse Director, Midlands and
    • 97. Ready, set -PLEDGE Joe McCrea Film maker and Strategic Adviser NHS Change Day
    • 98. Lunch ……..and pledge, pledge, pledg e!
    • 99. Tweets Can we trend? Lynnette Leman Digital Communications Officer NHS Improving Quality
    • 100. Unique individuals that received a #stopthepressurelincoln tweet … 214,130 Total number of timeline deliveries… 1,610,570 Total number of tweets… 1,420
    • 101. Stop the pressure and nutrition: interactive session Lyn McIntyre Deputy Nurse Director Midlands and East Andy Yeoman Focus Active Learning
    • 102. Pressure ulcer conference Lincoln University 15th October 2013
    • 103. Introduction • Each table will play either; - The Nutrition Game or - Stop The Pressure Game • Games last for 30 minutes • Each table splits into 2 teams
    • 104. The Nutrition Game • 1 board • 1 set of question cards (face down) • 2 counters • 2 dice • 1 sand timer • 1 “Pee chart”
    • 105. Starting to play • Place counters on board • Roll dice; highest score starts • First team roll dice and move counter • Land on square; opposite team picks up a question card
    • 106. Answer questions • Team answers question (use timer) • Correct answer MOVE forward 2 squares • Opposite team roll dice and move • Repeat as before
    • 107. Up Straws & Down Carrots • Land on the bottom of a STRAW – move UP • Land on TOP of carrot - move DOWN • Do this before answering a question
    • 108. Winning • Get to FINISH first OR • Closest to FINISH
    • 109. Stop the Pressure Game • 1 board • 1 question pack • 1 SSKIN question pack • 2 counters • 1 dice • 1 sand timer • 10 SSKIN tokens
    • 110. Stop the Pressure Game • Place counter on Start (green square) • Roll dice; highest score starts • First team roll dice and move counter • Land on square; opposing team reads out a question
    • 111. Stop the Pressure Game • Team answers question (use timer) • Correct answer MOVE 2 squares • Opposing team roll dice and move • Repeat as before
    • 112. Stop the Pressure Game • Team LAND on an SSKIN square • Opposite TEAM picks up a SSKIN question card and reads out the question
    • 113. Stop the Pressure Game • Correctly answer WIN an SSKIN token • TEAM places SSKIN token on board
    • 114. Stop the Pressure Game • Correctly answer WIN an SSKIN token • TEAM places SSKIN token on board • Place SSKIN token on board
    • 115. Stop the Pressure Game • Correctly answer WIN an SSKIN token • Place SSKIN token on board • Collect 5 tokens to WIN • Facilitators will help and break up any fights
    • 116. Enjoy
    • 117. www.stopthepressure.com
    • 118. Making a difference through practice led pressure ulcer research Professor Jane Nixon Deputy Director Institute of Clinical Trials Research University of Leeds
    • 119. Making a difference through practice led pressure ulcer research Jane Nixon PhD, MA, BSc(Hons) RGN Professor of Tissue Viability and Clinical Trials Research Clinical Trials Research Unit School of Medicine University of Leeds © CTRU 2013
    • 120. Impact of Pressure Ulcers on QOL QOL Conceptual Framework Symptoms Physical Functioning Psychological Well-being Pain & Discomfort Mobility Mood Exudate Daily activities Anxiety & Worry Odour General malaise Self-efficacy & Dependence Sleep © CTRU 2013 Social Functioning Appearance & selfconsciousness Source: Gorecki, C et al Isolation Participation
    • 121. UK world leading pressure ulcer prevention clinical research Critical mass Australia, Japan, Germany, the Netherlands, Belgium and USA UK has 4 fundamental ingredients 1. Nursing research agenda 2. Research funding through National Institute for Health Research Large trials, Programme Grants, Research for Patient Benefit , Fellowships 3. Clinical Research Networks – Research Nurse infrastructure 4. Clinical Trials Units/Methodologists © CTRU 2013
    • 122. Research areas/pathways- Leeds Risk Factors QOL Living with a PU Pain Living with PU Severe Pu Erythema Imaging Mattress effectiveness OR mattress Case studies Conceptual Framework Outcome Measure Development QOL/Pain systematic reviews Epidemiology Risk Factor Studies Epidemiology Prevalence PUQOL Field Testing Epidemiology Risk Factor PUQOL Instrument Pain assessment and management © CTRU 2013 Systematic review Clinical Practice – NHS investigation Clinical Practice Service Development HTA Pressure HTA PRESSURE 2 Early phase trial design Risk Assessment
    • 123. Pain and pressure ulcers Living with a pressure ulcer Qualitative study Patients reported pain preceding PU development and said nurses ignored their concerns Living with a pressure ulcer QOL and Pain systematic reviews Pain worst symptom of having a pressure ulcer. Pain impacts upon quality of life and is not addressed by hcps © CTRU 2013
    • 124. Pain and pressure ulcers Extent of pressure area related pain Prevalence hospital and community populations 3397 hospital patients, 15.9% pressure area pain © CTRU 2013 287 community patients with PUs, 75.6% reported pain Severity not related to PU Category Pain reported on skin sites with no PUs Mix of inflammatory and neuropathic pain
    • 125. Pain and pressure ulcers Is pain important in predicting Category 2 PU development? Cohort study hospital and community populations 30+ centres, 634 patients analysis population 602 . © CTRU 2013 Variable Presence of category 1 PU(yes vs no) Odds Ratio 3.25 p-value <0.0001 Presence of skin alterations(yes vs no) 1.98 0.0014 Presence of pain on a normal, altered or Category 1.56 1 skin site(yes vs no) 0.0931
    • 126. Severe PU • • Inquiry style study (Laming Inquiry, 2003) Innovative retrospective case study design to examine whole system failures Results:  Clinicians fail to listen to patients/carers  Clinicians fail to assess risk/respond to superficial PUs  Co-ordination failures  Current practice of investigation does not include patient account and as a result there are gaps © CTRU 2013
    • 127. Risk Assessment Which of your patients are at risk? Multiple risk factors – which risk factors are most important? Only 0.34% of hospital patient admissions will develop a pressure ulcer. © CTRU 2013
    • 128. PU Risk Factor Systematic Review Research Question: Which risk factors are independently predictive of PU development in surgical, medical and community-based populations? Result 15 Risk factor Domains 46 Sub-Domains How useful is this for clinical practice? © CTRU 2013 Flow of studies: 5,462 5,097 Abstracts/papers retrieved Excluded – not satisfying eligibility criteria 365 311 Potentially relevant, obtained in full for further scrutiny Excluded – not satisfying inclusion criteria Included 54 Studies 34 Prospective cohort 9 Record Review 11 RCTs
    • 129. PU Risk Factor Systematic Review Key Risk Factor Themes included:  Immobility  Skin condition  Perfusion (including diabetes) Less consistently emerging themes included: Moisture Body temperature Nutrition Age Gender Mental Status Race Sensory Perception Medication General Health Status Haematological measures © CTRU 2013
    • 130. Risk Assessment Framework Aim: to agree a pressure ulcer risk factor minimum data set (MDS) to underpin the development & validation of a risk assessment framework (RAF) for use in clinical practice. Phase 1 Development of evidence base Phase 2 Consensus study Phase 3 Design & Pre-Test PU Risk Factor Systematic Review to identify risk factors independently predictive of PU development Agree: - risk factors & assessment items for inclusion in draft risk factor MDS & RAF - Conceptual framework development - RAF Design - Assess & improve acceptability, usabilit y, format, design, cla rity, comprehension language & data completeness of draft RAF with clinical nurses Clinical Pre-Clinical © CTRU 2013 Pre-Clinical Phase 4 Clinical Evaluation - Evaluate reliability, data completeness, clinica l usability, & validity (convergent & known groups) of preliminary RAF Clinical Phase 5 Long-term Implementation & Clinical Evaluation - Dissemination of RAF into routine NHS care - Predictive Validity testing - Multivariable modelling & revision of RAF Clinical
    • 131. Consensus methods Questionnaires Face to face meetings © CTRU 2013
    • 132. Risk Factor Progression 15 Risk factor domains & 46 sub-domains of the systematic review reduced to 26 risk factors following initial expert group meeting 1. Immobility 2. Existing PU 3. Previous PU 4. General skin status 5. Chronic wound 6. Friction & shear 7. Sensory Perception 8. Diabetes 9. Pitting oedema 10. Lowering BP 11. Smoking 12. Cardiovascular disease 13. Albumin 14. Haemoglobin 15. Skin moisture 16. Dual incontinence 17. Medication 18. Acute illness 19. Infection 20. Body Temp 21. General health status 22. Nutrition 23. Mental status 24. Race 25. Gender 26. Age Cycle 1: Risk factor premeeting questionnaire 1. Immobility 2. Existing PU 3. Previous PU 4. General skin status 5. Diabetes 6. Nutrition 7. Sensory Perception 8. Dual incontinence 9. Skin Moisture 10. Acute Illness 11. Body Temp 12. Albumin Cycle 1: Risk factor postmeeting questionnaire 1. Immobility 2. Existing PU 3. Previous PU 4. General skin status 5. Perfusion 6. Diabetes 7. Nutrition 8. Sensory Perception 9. Skin Moisture 10. Dual incontinence 11. Albumin Cycle 2: Minor Refinement of Risk Factors (incorporated in pre-meeting questionnaire) 1. Immobility 2. Existing PU 3. Previous PU 4. General skin status 5. Perfusion 6. Diabetes 7. Nutrition 8. Sensory Perception 9. Moisture Risk Factors for Screening & Full Assessment Stage of MDS and RAF Screening Stage Immobility PU Status (existing & previous) Full Assessment Stage Immobility PU Status (existing & previous) General skin status Perfusion Diabetes Sensory perception Moisture Nutrition
    • 133. Initial draft of the RAF and underpinning MDS © CTRU 2013
    • 134. Pre-test - Focus Groups © CTRU 2013
    • 135. Take home messages at your patients skin Ask and listen to patients Problem solve for complex patients
    • 136. References Pain Briggs M, Collinson M, Wilson L, Rivers C, McGinnis E, Dealey C, Brown JM, Coleman SB, Stubbs N, Stevenson R, Nelson EA, Nixon J (2013) The prevalence of pain at pressure areas and pressure ulcers in hospitalised patients BMC Nursing Vol 12 (1), p19 http://www.biomedcentral.com/1472-6955/12/19 Stevenson R, Collinson M, Henderson V, Wilson L, Dealey C, McGinnis E, et al. The prevalence of pressure ulcers in community settings: An observational study. International Journal of Nursing Studies 2013;DOI: http://dx.doi.org/10.1016/j.ijnurstu.2013.04.001. Gorecki C, Closs J, Nixon J, Briggs M. (2011) Pressure ulcer pain: a mixed method systematic review. Journal of Pain and Symptom Management. Journal of Pain and Symptom Management Vol 42(3):443-59 Risk factors Coleman S, Gorecki C, Nelson EA, Closs J, Defloor T, Halfens R, Farrin A, Brown JM, Schoonhoven L and Nixon J. Patient Risk Factors for Pressure Ulcer Development: Systematic Review International Journal of Nursing Studies Vol 50 (7) p9741003 http://www.sciencedirect.com/science/article/pii/S002074891200421X Nixon, J., Cranny, G. and Bond, S. (2007) Skin alterations of intact skin and risk factors associated with pressure ulcer development in surgical patients. International Journal Nursing Studies Vol 44: 655-663 Nixon, J., Nelson, E. A., Cranny, G., Iglesias, C., Hawkins, K., Cullum, N., et al on behalf of the Pressure Trial Group. (2006) Pressure Trial: Pressure RElieving Support SUrfaces: a Randomised Evaluation. Health Technol Assess Vol 10 (22).
    • 137. References QOL Gorecki C, Brown JM, Cano S, Lamping DL, Briggs M, Coleman S, Dealey C, McGinnis E, Nelson EA, Stubbs N, Wilson L, Nixon J (2013) Development and validation of a new patient-reported outcome measure for patients with pressure ulcers: The PU-QOL instrument. Health & Quality of Life Outcomes, DOI: 10.1186/1477-7525-11-95 Gorecki C, Lamping D, Alvari Y, Brown J, Nixon J (2013) Patient-reported outcome measures for chronic wounds with particular reference to pressure ulcer research: A systematic review. International Journal of Nursing Studies, DOI: 10.1616/j.ijnurstu.2013.03.004 Gorecki C, Nixon J, Madill A, Firth J, Brown JM (2012) What influences the impact of pressure ulcers on health-related quality of life? A patient-focused exploration of contributory factors. Journal Tissue Viability Vol 21: 3-12 Gorecki C, Closs J, Nixon J, Briggs M. (2011) Pressure ulcer pain: a mixed method systematic review. Journal of Pain and Symptom Management. Journal of Pain and Symptom Management Vol 42(3):443-59 Gorecki C, Lamping DL, Brown J, Madill A, Firth J, Nixon J. (2010) Development of a conceptual framework of health-related quality of life in pressure ulcers: a patient-focused approach. International Journal of Nursing Studies, 47: 1525-1534. Gorecki CA, Brown JM, Briggs M, Nixon J. (2010) Evaluation of five search strategies in retrieving qualitative patient-reported electronic data on the impact of pressure ulcers on quality of life. Journal of Advanced Nursing, 66 (3): 645-652. Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, Defloor T, and Nixon J on behalf of the European Quality of Life Pressure Ulcer Project Group (2009). Impact of pressure ulcers on quality of life in older patients: a systematic review JAGS 57: 1175-1183 Spilsbury K, Petherick E, Cullum N, Nelson EA, Nixon J and Mason S. (2008) The role and potential contribution of clinical research nurses to clinical trials. Journal of Clinical Nursing 17 (4), 549–557.
    • 138. Acknowledgement PURSUN (Pressure UlceR Service User Network) NIHR: This presentation presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (RP-PG-0407-10056). The views expressed in this presentation are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. © CTRU 2013
    • 139. Student Competition to be launched Student Rate £35.00 per day
    • 140. On the couch: an interview Video: Dr Helen Bevan Introduced by Charlotte Johnston Student nurse University of Lincoln
    • 141. 6 c’s – aims, website and Care Makers Dr Ruth May Chief Nurse NHS England Midlands and East and Care Makers
    • 142. Compassion in Practice Progress and Developments Presented by Ruth May Regional Chief Nurse NHS England (Midlands & East) October 2013
    • 143. The Nursing Narrative 156 NHS England | Ruth May | Twitter: RMayNurseDir
    • 144. The Keogh Review • A limited understanding of and failure to genuinely listen to patients and staff • The lack of value and support being given to frontline clinicians, particularly junior nurses and doctors • More work needed at some trusts on issues such as reducing incidents of pressure ulcers • Essential standards for staffing 157 NHS England | Ruth May | Twitter: RMayNurseDir
    • 145. Developing the culture of compassionate care 158 NHS England | Ruth May | RMayNurseDir
    • 146. Our values and behaviours are at the heart of the vision and all we do Care Compassion Competence Communication Courage Commitment 159 NHS England | Ruth May | Tw itter:RMayNurseDir
    • 147. Six Areas for Action Helping people to stay independent, maximising well-being and improving health outcomes Working with people to provide a positive experience of care Delivering high quality care and measuring impact Building and strengthening leadership Ensuring we have the right staff, with the right skills in the right place Supporting positive staff experience 160 NHS England | Ruth May | RMayNurseDir
    • 148. The children’s community nursing team at Cambridgeshire Community Services NHS Trust has been announced as the winner of NHS England’s 6C’s Live! September Story of the Month 161 NHS England | Ruth May | RMayNurseDir Catherine Ray, a senior sister at Solihull Hospital, has been picked as the first ever winner of NHS England’s 6C’s Live! And Nursing Times’ story of the month competition
    • 149. 162 NHS England | Ruth May | Twitter: RMayNurseDir
    • 150. What are Care Makers? • We are looking for individuals who can be ambassadors for compassion in practice and who can demonstrate and advocate the 6C’s in their practice • Care makers are ambassadors for the 6C’s • The first cohort of 55 Care Makers were recruited prior to the CNO Conference in 2012 of newly qualified nurses, student nurses, midwives, and healthcare assistants • Principles for creating this network include To inspire young people A shared purpose to transform the NHS Culture in Nursing, midwifery and care staff To be advocates for compassion in practice 163 NHS England | Ruth May | RMayNurseDir
    • 151. How to become a Care Maker • From mid-October applications can be downloaded from http://www.nhsemployers.org/caremakers/Pages/How-do-I-become-a-caremaker.aspx • Applications should be submitted, including a reference from an appropriate senior representative, to caremakers@nhsemployers.org • NHS Employers sift through applications into yes – queries to go to Region • On a set day every month NHS Employers will send applications to regional nurses for review with partner organisations if agreed • Applications will be assessed against the definitions of the 6C’s • We need to recruit 350 in the next round; the national target is 1000 by the end of March 2014 164 NHS England | Ruth May | Twit ter:RMayNurseDir
    • 152. Tweets and Pledges: how have we done? Lynnette Leman Digital Communications Officer NHS Improving Quality Joe McCrea Film maker and Strategic Adviser NHS Change Day
    • 153. Wrap up, thanks, reflections on the day and looking to the future Professor Sara Owen and Charlotte Johnston University of Lincoln Dr Ruth May and Lyn McIntyre NHS England Midlands and East