Narelle Marshall and Darlene Saladine - NSW Health - Reducing Pressure Ulcers in Hip Fracture Patients


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Narelle Marshall, Acute to Aged Related Care – AARCS Nurse, Hunter New England Local Health District, NSW Health and Darlene Saladine, Acting Health Service Educator, Hunter New England Local Health District, NSW Health delivered this presentation at the 2nd Annual Hip Fracture Management Conference 2013. This conference is the only regional event to discuss practical innovations and improvement processes for the management of Hip Fractures in the hospital setting.

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Narelle Marshall and Darlene Saladine - NSW Health - Reducing Pressure Ulcers in Hip Fracture Patients

  1. 1. ‘A Multidisciplinary Approach to the Prevention of Pressure Areas on Patients with Hip Fractures at Armidale Rural Referral Hospital.’ Narelle Marshall (AARCS Nurse) & Darlene Saladine (Acute Pain Service Nurse) December 2013
  2. 2. Welcome!
  3. 3. Prize-winning project
  4. 4. Hunter New England Local Health District
  5. 5. Trauma Weekend • Orthopaedic cover shared between Armidale and Tamworth – 110km apart – 90 mins by road • Increased rate of pressure ulcers following time spent in transport and delay to theatre • Outlying areas, eg Narrabri 282km – 3.5hrs; Gunnedah 186km – 2.5hrs
  6. 6. Number of Hip Fractures per year at Armidale • During the 12 months of our project (2010/11), there were 81 hip fractures treated at Armidale Hospital • How does this compare with the orthopaedic service in your area? • Do you know what is the incidence of pressure ulcers in your hip fracture patient group?
  7. 7. So, “What is a Pressure Ulcer?”
  8. 8. Introduction • Wound dressing Inservice • Decision to trial the use of preventative wound dressings • Acknowledging a high prevalence of pressure ulcers in hip fracture patients. • Had an existing multidisciplinary pressure ulcer prevention working group
  9. 9. Aim To determine whether the use of preventative dressings will reduce the incidence of hospital acquired pressure ulcers in patients who present with a hip fracture
  10. 10. Process • Strategies implemented by the Pressure Ulcer prevention Working Group demonstrated marginal improvement • It was evident that there was still room for improvement particularly with regard to referrals to Dietician and Occupational Therapists
  11. 11. Determining the extent of the Problem • Baseline data: - IIMS and coding identified the patient group • File audit to determine major contributing factors : - Injury to ED time - Injury to surgery time - Co-morbidities eg diabetes, anaemia, dementia, diarrhoea (incontinent)
  12. 12. The Extent of the Problem • 18 (22.2%) of the 81 hip fracture patients from 1st July 2009 – 30th June 2010 developed at least 1 pressure ulcer • Baseline audit indicated poor compliance with risk assessment on admission and timely referral to Dietitian and Occupational Therapist • 44% took more than 5 hours getting to ED and 72% waited more than 24hrs for surgery
  13. 13. Planning & Implementation • Consultation with management, NUMs and orthopaedic surgeons • Ascertain dressings to be used: - Allevyn heel (with silicone border) for sacral/buttock area - Mölnlycke Mepilex heel dressings (adhesive foam) • Templates to track the use of the dressings
  14. 14. Allevyn Heel with silicone border
  15. 15. Mepilex Heel
  16. 16. The dressings applied
  17. 17. Implementation cont. • Education to nursing staff of ED, surgical, ICU, operating theatres & rehab unit • OT’s, Dietitian’s, Physio’s and CSO’s informed of their roles • Commenced 1st September 2010 • Project monitored by Darlene Saladine on the wards to ensure compliance with application of dressings and completion of tracking sheets
  18. 18. Implementation cont. • Feedback provided to staff using a wall chart & staff meetings • Patient education re: rationale of the project
  19. 19. Outcomes & Evaluation • Follow up audit of all hip fracture patients presenting from the 1st September 2010 to 31st March 2011 • Incidence of pressure ulcers reduced from 22.2% to 8.8% with only 3 out of 34 having hospital acquired pressure ulcers during the project • These 3 patients all had multiple comorbidities
  20. 20. Outcomes & Evaluation cont. • Once identified none of the pressure ulcers deteriorated further • 1 patient with bilateral heel stage 1 pressure ulcers who continued to use the Mepilex heel dressings was discharged with skin intact
  21. 21. Graphical data of reduced incidence of pressure ulcers July 2009 - June 2010 Sept 2010 - March 2011 Hip fracture pts without pressure ulcers Hip fracture pts without pressure ulcers Hip fracture pts with pressure ulcers Hip fracture pts with pressure ulcers
  22. 22. Variables • It is acknowledged that the reduction in pressure ulcers should not be wholly attributed to the use of preventative dressings as this project also resulted in raised awareness of, and compliance with existing strategies eg: the use of pressure reduction equipment, High Protein diet/supplements and increased repositioning
  23. 23. Input from the Dietitian
  24. 24. Our Multidisciplinary Team
  25. 25. Ongoing data • Latest audit of hip fracture presentations for the period 1/10/11 – 30/9/12 showed further reduction to 2.5% = 2 patients with pressure ulcers from 78 hip presentations (compared to the initial 22.2% in 2010 and 8.8% in 2011). • This has since reduced to 2.2% in 2012/13
  26. 26. Cost Savings • This reduction means that about 16 patients p.a. who previously would have suffered a pressure ulcer, now won’t!!!! • This represents a cost saving of approximately $250,000 p.a. for our Health Service, based on case-mix funding model, not to mention the immeasurable savings in increased LOS and patient suffering
  27. 27. Flow on Impact • Staff now tend to apply preventative dressings to other high risk patients eg. Palliative care and frail elderly as a routine measure; • Still no evidence to demonstrate reduced incidence of hospital-wide pressure ulcers – but we now have more Stage 1 pressure ulcers and less Stage 2 & 3, so our approach is now more PREVENTATIVE than REACTIVE
  28. 28. Other observations we have made • When dressings were unavailable through stores for a period of time last year, the incidence of pressure ulcers increased which confirms our view that the dressings are effective in reducing pressure ulcers • All audits have shown that there is a definite correlation between the incidence of pressure ulcers and the time spent in transit from outlying towns, to access orthopaedic care.
  29. 29. More observations we have made • Men in the # NOF group seem to be at a greater risk of pressure ulcers than women; • Co-morbidities play a definite role in the incidence of pressure ulcers; • Time is of the essence when it comes to applying the dressings.
  30. 30. Sustaining the Change • Skin Integrity Working Group continues to monitor data monthly • Review of the hip fracture clinical pathway to prompt regular Waterlow scoring, referrals to Dietitian and OT and application of preventative dressings on admission • The use of dressings for all high risk patients • A smaller version of the sacral dressing has been added to our “arsenal” for better managing those skinny little butts
  31. 31. Butt, which dressing do we use now? • Skinny butt vs not-so-skinny butt
  32. 32. Sustaining the Change cont’d • Ongoing education for all staff: eg Nurses orientation, Grand Rounds, ward inservice. • Education re TED stockings • Patient Education using laminated factsheet ‘Move Move Move’ (acknowledgement to Queensland Health)
  33. 33. Sustaining the Change cont’d • All hip fracture patients are now routinely commenced on TwoCal • All hip fracture patients are routinely referred to physician to better manage comorbidities aimed at decreasing delay to theatre • Pressure reduction mattresses being “rolled out” in HNELHD transport vans • ‘Repose’ pressure reduction mattresses recently introduced in all HNELHD ED’s
  34. 34. Repose overlay for ED trolleys
  35. 35. Sustaining the Change cont’d • Continue to share information with internal transport and ambulance re the benefits of repositioning in transit • Continue to share information with other Hospitals re the benefits of preventative dressings on high risk patients
  36. 36. Future Scope • Still need to improve our compliance with Waterlow assessment, hospital-wide • Working towards the development and implementation of a skin inspection template, as per National Standard 8
  37. 37. In Conclusion • We are very proud of the achievements of the staff at Armidale Rural Referral Hospital with their commitment to this project and the resulting improved patient outcomes. • We would like to think that many more hip fracture patients throughout Australia will benefit from our success at Armidale.
  38. 38. ? Questions