English

Results in brief

The project ”Prevention of pressure ulcers by using new screening method and pressure sensing mats” tests implementation of a new method for systematic screening for pressure ulcers (risk assessment) of all new admitted patients combined with systematic preventive treatments related to patient risk. Moreover, sensing mats are used to translate the pressure of the patient’s body to an image on a monitor where colours indicate how high the pressure on the patient’s body is. Implementation of the screening method and pressure sensing mats is built on the assumption that these initiatives will reduce the number of pressure ulcers and thus reduce the total consumption of resources to prevent and treat pressure ulcers during hospital admission and after discharge in the patient’s own home.

kategori 3 sår

Evaluations were made in relation to the outcome measures of the project before the intervention (baseline evaluation), halfway through the project (midway evaluation) and after the intervention (final evaluation).

The project started 1 November 2009 and ended 1 October 2012. The Danish Public Welfare Technology Fund has financed 75% of the project from 1 January 2012 to 1 October 2012. The evaluation report and the tools used for data collection, screening and documentation can be found at www.trykskader.dk

Below the project results are presented under the following headlines:

  • Potential costsaving related to manpower – how large is the costsaving potential and in which way can it be realised? Which staff groups are involved? How is work processes affected
  • Are there other benefits – e.g. reduced waiting time, reduced transportation time, faster rehabilitation etc.?
  • Qualitative objectives – e.g. experienced service/quality for staff and citizens, respectively?
  • Management support – are project participants interested in continuing the work with the solution tested and how?
  • Realisation of benefits – has the management taken ownership concerning realisation of the demonstrated benefits and how?

The annual costsaving potential related to manpower was 83 fulltime equivalents for the three participating departments and discharge municipalities. At national level, the annual costsaving potential related to manpower would amount to approximately 5,000 fulltime equivalents.

The staff groups directly affected by the project were nurses (n=512), social and healthcare assistants (n=37), physiotherapists (n=32) and hospital porters (n=66). Indirectly affected staff groups counted wound nurses, social and healthcare assistants and helpers employed in the discharge municipalities. No direct measurements were made concerning the indirectly affected staff groups. The calculations concerning time consumption for these staff groups are based on literature concerning work load and expert consensus.

Work processes were changed from individual not based on an interprofessional preventive approach to an interprofessional and structured preventive approach. The intervention in the three affected departments lasted 2 x 14 days and five days intensive training of a total of five key persons functioning as counsellors in the individual departments/units.

Skemaer
Undervisning 1
Screening

Pressure sensing mattresses were used as a pedagogical tool. Pressure sensing mats translate the pressure of the patient’s body to an image on a monitor where colours indicate how high the pressure on the patient’s body is. The collar red indicates an unacceptably high pressure.

Chart

Pressure injuries incidence has been reduced by 20 percentage points from 26.7 to 6.7%. At baseline evaluation 19% of the pressure ulcer incidences were severe (categories 3 and 4). After the intervention there were no patients with severe pressure injuries; 5.7% developed category 1 injuries and 1.0% developed category 2 injuries. In other words, this means that these departments no longer discharge patients to primary care with severe pressure injuries where the pressure injury was acquired at the affected departments.

Patient i seng

Patients who developed pressure injuries had a median length of admission which was 37% longer (11;56) compared with patients without pressure injuries but with a comparable risk of developing pressure injuries; this difference was statistically significant. Patients who develop pressure injuries presumably have a prolonged hospital stay compared with patients with a comparable risk who do NOT develop pressure injuries.

In the participating departments a certain spirit has been formed attempting to expand the initiative to go across not only staff groups but also across work tasks. Instructors in transference are not only interested in transference but how do we show consideration for staff and prevent pressure injuries at the same time?

As an extra benefit there are now key staffs in the organisation with extensive knowledge of prevention of pressure injuries and local implementation processes.

The project has bought six pressure sensing mats; these will remain in the departments where they will continuously be used as a pedagogical and motivational tool in connection with positioning and transfers. In this way staff still has the possibility to evaluate their techniques.

In the next few years, all guidelines used and tested in the project will be implemented all over Aarhus University Hospital. The pedagogical and organisational strategies for this implementation are not decided yet. Aarhus University Hospital e-learning portals and interactive flowcharts will be adapted and thus implement the experiences from this project.

2. Recommendations concerning implementation of the new technology

Evaluation of solution
The evaluation of the implementation method is based on the main results from the user satisfaction surveys. Participants were very specific concerning which initiatives they believed could make a successful intervention. They emphasised the collaboration across professions, to have sufficient knowledge of how many patients develop a pressure ulcer during admission to hospital, and the consequences of pressure injuries for the patient. Moreover, they emphasised the necessity of audits, educated key persons, clear and precise demands to documentation, the drafting of a guideline to be used in connection with the screening tool, staff being educated in screening, staff being reminded through the electronic health record to screen patients and the management’s support of the initiative showing that prevention of pressure injuries is on the management’s agenda.

The method, the selected instruments and the process have given a fine result showing that systematic implementation of guidelines actually results in quality improvement in care.

Recommendations to others wishing to implement the tested solution
On the basis of the experiences from this project, recommendations are divided into organisational and pedagogical initiatives.

Organisational considerations and initiatives
Generate management support to signal management’s dedication and illustrate the commitment to staff to be part of the change process.

Be prepared that things take time and that time in terms of prioritisations often is pivotal when there is a lack of or no change. If the organisation does not define the quality demand, each individual employee will prioritise the individual effort.

Create an organisation which will ensure the presence of necessary resources when needed; also during weekends, evenings and nights.

Appoint qualified project staff and/or key persons to manage the local change process. Allocate funds for remuneration; the effort will demand 37-hour presence in and during the change process. This project has shown that this is cost effective.

Pay attention to cultural differences in the organisation and potential power structures.

Make collaboration agreements concerning the course of implementation and match mutual expectations.

Be aware that it is important with easy and fast access to enter data and tools for analyses when estimating audit results.

Pedagogical interventions
Beneficial pedagogical interventions could concern:

    1. Education of project employees and key staff

a. Project employees should be educated to become experts in initiatives to prevent pressure injuries, to collect data and to have a pedagogical approach to implementation. One or two persons in the whole organization.

b. Local key staff should be educated in: pressure ulcer physiology and categorisation of pressure ulcer injuries, implementation of preventive actions, use of standardised documentation tools as well as positioning techniques.

c. To facilitate the learning process an e-learning programme on preventing pressure injuries could be beneficial as well as an interactive internetbased programme on actions and methods.

 

  • Education of nursing staff, porters and physiotherapists

 

a. Project staff, key persons and external experts organised and conducted the education of nursing staff, physiotherapists and porters to give them prerequisites for following the recommendations to prevent pressure injuries and at the same time relate critically and constructively to the preventive recommendations, resources and implementation methods.

b. Pedagogical approach to education of staff in the individual departments should be organised to include local cultural and practical considerations both concerning approach and method.

c. Pedagogical means used in the presentation of pressure ulcer preventive initiatives were a combination of theoretical education, skills lab training in groups or individually.

 

  • Use pressure sensing mattresses which translate the pressure of the patient’s body and present it by a colour on a monitor.
  • Use standardised documentation tools.
  • Continuous presentation of results (audit) on number of pressure injuries locally in relation to risk of developing pressure injuries and number of correct preventive initiatives listed in the recommendations. It is recommended that audit is made during a period of time and not as single day measurements.

 

Project in brief

The project aims to evaluate whether it is possible to reduce the incidence of pressure ulcers during hospitalisation by introducing a new and unique screening method together with pressure sensing technology, and evaluate whether associated changes in working practice can reduce demands on care staff’s time. The project, which started on January 1st 2011, receives financial support from the publically financed The Public Welfare Technology Fund.

Pressure damage, also called pressure ulcers or bedsores, are a major problem. In 2010, a study of six Danish hospitals showed that 15-25 percent of hospitalized patients suffered from pressure damage, and that preventive intervention was necessary for over half of all patients during hospitalization.

Most pressure ulcers are only visible on the skin several days after they develop in the underlying tissue. As a result, care staff often reacts days after a pressure ulcer has developed. Pressure ulcer damage necessitates longterm treatment and care, also after the patient returns home from the hospital. By educating staff to make them more aware of the problem and using pressure sensing technology to visually highlight where patients are subject to the greatest pressure,  the aim is to reduce the incidence of milder pressure sores by 45% and of more severe pressure damage by up to 90%.

Intelligent Lagen

The introduction of systematic patient screening and increased focus on prevention rather than treatment is expected to result in savings equivalent to 29 years work or 10.5 million DKK for patients admitted to Aarhus University Hospital Skejby alone.

Three wards are participating in the project; Heart, Lung and Circulatory Dept., Thorax Surgical Dept., Intensive Care & Anaesthesia Dept. All of the involved personnel on these wards contribute daily to prevention and treatment of pressure ulcers. None of the wards involved currently deploy a systematic and validated screening method for early identification of patients at risk or uses sensor technology for this purpose. As a result, preventive activities and treatment are ad-hoc and based on individual appraisal and experience.

Prior to the main study, a recently developed and validated risk assessment tool, “ADHOC” was revalidated. The incidence and severity of pressure ulcers, presence of individual risk factors,  and performance of correct preventive actions will be recorded in a baseline study over a one month period. In addition, time spent on prevention and treatment was measured over a 14 day period.

Following the baseline evaluation, care staff, physiotherapists and hospital porters are trained in use of the screening method and employment of preventive actions in a structured way. Risk, incidence,  category of pressure ulcer severity and presence of correct preventive actions are again recorded in a “cross over” study lasting one month and focusing on patients with an identified medium to high risk of pressure ulcer development.

The third part of the study evaluates whether or not use of advanced pressure sensing technologies to visually demonstrate where and how much interface pressure patients are subject to, has an educational value and stimulates staff to take corrective actions that result in a reduction of the incidence and severity of pressure ulcers. Following system introduction, a renewed evaluation on effect parameters over a one month period will be undertaken. The user friendliness of the systems is evaluated, both in relation to comfort and to patient and staff needs.

The final part of the project will assess opportunity for combining pressure measurement data (pressure over time) with the risk factors of the validated screenings method in order to demonstrate an intelligent alerting system based upon a patient’s individual risk profile.

Tidtagning

The project will also look at how results compare with experience from hospitals abroad. While studies abroad show that the introduction of systematic activities can reduce incidence of pressure damage by more than half, no equivalent studies exist evaluating the use of pressure sensing technologies. Until recently these technologies were primarily used for research purposes and this is the first time that their use in clinical practice is truly tested.

A dedicated demonstration room will be set up at Aarhus University Hospital Skejby. Equipped with a hospital bed and the latest in commercially available pressure sensing mats including an especially developed alerting system, interested parties can see the products without disturbing patients and their relatives.

Experiences with use of the intelligent sensor mats and the alerting system will be collated in a folder that is published in English, as well as Danish. The folder may be used to guide developers working with sensing system development and leaders of institutions working with pressure damage etc.

A foresight workshop will held for participants from the mattress and hospital bed sectors to discuss the perspectives for intelligent sensing and associated alerting systems. Discussions will also consider whether technological developments will make possible automated posture repositioning in the future.

An evaluation of the project will calculate how the introduction of the screenings method, intelligent sensor mats and alerting system can affect the quality of care for both patients and staff by looking at how much time nurses, care staff, porters and physiotherapists can save when time is spent on preventive actions rather than treatment. It will also investigate how much extra time porters spend on fetching special mattresses and other aids, when care staff is more aware of the risk to patients.

The health economic costs of introducing the new methods and technical aids will also be calculated. Prior to the project start, it was estimated that the introduction of the screening method and intelligent sensor mats would lead to savings on personnel resources equivalent to 29 fulltime employees, or 10.5 million Danish crowns or over 2 million US dollars per year.

Four private companies are involved in the research project. Two companies supply the commercially available pressure sensing technologies used to draw staff attention to the need for preventive actions to avoid patients being subject to pressure on specific areas of the body for unduly long periods of time;   Vista Medical  and XSensor.

Ohmatex, an independent specialist in smart textile technologies, is responsible for designing an alerting system which uses the risk profile determined by the screening method to set a time limit for pressure on a specific part of the body and alert nursing staff when repositioning is due.

CAP Partner and EWMA, The European Wound Management Association, are responsible for the timestudies and calculation of health economic consequences based upon collected data.

Participation in the project will provide these partners with a unique knowledge that can benefit both future pressure sensing products and users alike, but does not infer special status in relation to future supply of these types of system.