This work aimed to reduce the percentage of pressure ulcers across multiple care settings in NENC where the incidence of pressures ulcers was higher than the national average (1).
The PSC funded and supported a two-year Pressure Ulcer Collaborative (PUC), involving secondary care, community services, care homes and the ambulance service, where they had been developed by patients within their care.
The Breakthrough Series Collaborative Model from the Institute for Healthcare Improvement (IHI) (2) provided the implementation framework.
In year 1, pressure ulcers were reduced by 36%, and 33% in year 2 with an estimated cost saving of £513,000, and a reduction in the number of bed days between 220-352.
The PUC’s ambition was to reduce the percentage of pressure ulcers in participating teams across the NENC areas by:
- 50% in year 1 (over 12 months, July 2015 – June 2016)
- 20% in year 2 (over 9 months, March 2017 – November 2017)
Pressure ulcers are an unwanted and often avoidable complication of care (3, 4, 5, 6) that affect over 700,000 UK patients per year (3). They are a common occurrence, particularly in patients whose mobility is limited due to illness, severe physical disability, or increasing frailty (4, 7, 8). Pressure ulcers can lead to increased mortality, morbidity, and reduced quality of life for the patient (16).
Pressure ulcers can also result in longer hospital stays (7), with hospital acquired pressure ulcers increasing length of stay by an average of 5-8 days per pressure ulcer (9).
In addition, they represent a substantial financial cost to local NHS trusts and care providers. In 2015, the cost per pressure ulcer was estimated to vary between £1,214 and £14,108 depending on its severity (7).
Given the often preventable nature of pressure ulcers, the occurrence of this harm to patients is a key indicator of nursing standards (10).
The NENC region adopted a Quality Improvement Collaborative (QIC) approach, specifically the IHI Breakthrough Series (BTS) Model shown at Figure 1 (2). This approach brought together a diverse range of UK healthcare organisations from across the region, namely secondary care organisations, community services, care homes, and the North East Ambulance Service (NEAS).
Figure 1: The Breakthrough Series Collaborative Model
The BTS Collaborative framework recommends that collaboratives should range in size from 12–160 organisational teams, with short-term interventions being implemented over a 6 – 15 month period (2). As Figure 1 highlights, participants attend three learning sessions during the lifespan of the collaborative, and implement their learning between sessions, using the Model for Improvement methodology, shown in Figure 2.
Figure 2: The Model for Improvement
This Collaborative was initially planned to run for one year, however, it was felt that there was scope to build on the learning so it ran for a further year. A six month gap between year 1 and year 2 allowed for recruitment of teams and gave them the opportunity to collect their baseline data.
The Collaborative followed the Figure 1 Model above. This included the Director of Quality and Transformation at South Tyneside NHS Foundation Trust and City Hospitals Sunderland NHS Foundation Trust, leading the Collaborative and using preexisting relationships with healthcare organisations in the region to build a commitment to reducing pressure ulcers in NENC.
Information days were held, before the start of each Collaborative year, and representatives from all trusts were invited to attend. Learning sessions were delivered in the North East during each year of the Collaborative.
Teams involved in year 2 received a copy of ‘The Improvement Guide: A Practical Approach to Enhancing Organizational Performance’ (11), as well a process mapping guide developed by the Academic Health Science Network for North East and North Cumbria.
PDSA cycles were held, and resulted in:
- Local adaptation of existing models such as SKKIN (11).
- Time taken to understand what the key factors were to successful implementation, which included a patient safety culture and good leadership.
- Stakeholder analysis (13) was undertaken in teams where culture was affecting implementation. The levers/benefits for implementing good pressure ulcer care for these staff were identified.
- The implementation of pressure ulcer clocks, training of staff (both face-to-face and via e-learning), adding body maps to admission checklists, optimisation of nutrition and hydration, and involving patients and carers. This approach was successful as it enabled teams to identify tests of change within their own local setting.
Teams being asked to use the Institute for Innovation and Improvement (2007) Sustainability Model (14) to assess the likelihood of sustaining their changes, and from this identify areas which needed further attention. Action plans were subsequently developed to remove/reduce the barriers/challenges identified.
Number of pressure ulcers – the number of (avoidable) pressure ulcers was collected by participating teams and then translated into a percentage to assess achievement against the aims. For each year the percentage reduction is based on the mean from the three month baseline data compared to the mean from the final three months of data collected.
Pressure ulcers are graded with increasing severity from categories 1-4, according to the European Pressure Ulcer Advisory Panel classification system (15). Teams were not asked to specify the grade of pressure ulcer to simplify the data collection process by teams. In year 1 teams were asked to submit the number of pressures from grades 1–4, and in year 2 grades 2–4. This change was made in year 2 because some organisational policies did not require teams to collect grade 1, and therefore aligning the data collection to that already in place simplified the process.
Teams were encouraged to use a safety calendar to record and monitor the number of pressure ulcers in their ward/area. When a pressure ulcer is classed as ‘avoidable’ this is coloured red on the safety calendar, and yellow when a pressure ulcer is classed as ‘unavoidable’. This method of data collection was chosen as it is simple to record, in real time, and easy to view, thereby encouraging frontline teams to take ownership of the data.
Collecting the number of pressure ulcers enabled cost impact and bed days saved to be calculated.
Cost impact – this was assessed using the Department of Health and Social Care Pressure Ulcer Productivity Calculator (16). The calculator attributes a cost to pressure ulcer care based upon the grade of the ulcer and the accompanying complications that arise. As pressure ulcer grades were not recorded by teams for this Collaborative, it has been impossible to identify actual cost. However, an estimate can be gained if all costs are based on grade 2 pressure ulcers using, for each year, the three month baseline data collected and the final three months data collected. Note: The Pressure Ulcer Productivity Calculator is based on the estimated cost of pressure ulcer care at 2008/09 prices, the cost will now inevitably be higher. Costs are based on grade 2 pressure ulcers. The cost for a grade 1 pressure ulcer is minimal (approximately £1,000) compared to that for grades 2, 3 and 4 (approximately £3,000, £4,000 and £5,000 respectively), and it was therefore felt that basing this calculation on grade 2 pressure ulcers would provide the best estimate, although it is acknowledged that this is imprecise.
Bed days saved – this was calculated on the number of bed days saved based on the NICE Guidance Costing Statement on pressure ulcers (9), which states that hospital-acquired pressure ulcers increase the length of stay by an average of 5–8 days per pressure ulcer. With all non-ward based data being removed (district nursing teams and care homes) the calculation for each year is based on three month baseline data compared to the final three months data collected.
Survey evaluation of approach adopted – staff were asked to complete a survey, which sought to gain both quantitative and qualitative feedback.
Data submission by teams – in year 1, 13 teams spanning 5 organisations submitted data. In year 2, 25 teams spanning 9 organisations submitted data.
Reduction in the percentage and number of pressure ulcers – the percentage/number reduction in pressure ulcers in year 1 was 36%/48 and in year 2 was 33%/38.
Figure 3: Year 1 – Number of pressure ulcers (monthly)
Figure 3 demonstrates that following the baseline data collection period there is a ‘shift’ (which is where there are 6 or more data points below or above the median line). Therefore, if the assumption is made that the baseline data is random, this graph suggests special cause variation, where the changes implemented have generated a change which is sustainable over time.
Figure 4: Year 2 – Number of pressure ulcers (Monthly)
Figure 4 also demonstrates a ‘shift’, but this forms part of the baseline data and was before the start of the first PDSA. Due to only three baseline data collection points being available, it is not known whether this is part of random variation or whether it is special cause variation. There is also no evidence of special cause variation following the start of the PDSA cycles.
There are reasons which could possibly be attributable to the reduction from January 2017. An engagement event was held not long before the start of the baseline data collection period, where the success stories from those involved in year 1 were shared. Some teams may have taken this learning and implemented changes before the start date of year 2. Also 8 of the 13 organisations involved in year 1 went on to take part in year 2. Although the majority of teams within these organisations changed in year 2, there may well have been some internal organisational dialogue/sharing because of increased interest gained at the engagement event, again resulting in changes being implemented before the start of year 2.
Estimated cost impact and reduction in bed days
|Year 1||Year 2|
|Reduction in pressure ulcers||36%||33%|
|Estimated cost reduction||£284,000||£229,000|
|Reduction of hospital acquired pressure ulcers||7||37|
|Bed days saved||35-56||185-296|
Design of the collaborative
- The collaborative approach worked well, as it provided teams/organisations with a forum to learn and share together.
- The Collaborative was purposely designed so the organisations/teams themselves decided what to implement and when the right time was to do this, taking into consideration their local context, rather than the Collaborative Faculty being prescriptive. This supported implementing change within a diverse range of organisations/teams but has the limitation that it is difficult to understand which interventions reaped the most benefit within certain settings.
Data collection and analysis
- Teams were asked to submit the number of pressure ulcers on a monthly basis, rather than using the prevalence data available through the Safety Thermometer. This means the data collected is not directly comparable to nationally collected data.
- Not including the grade of pressure ulcers was a limitation in understanding the precise impact this study has had on patient care as well as costs, as there may have been a reduction in the more severe grades of pressure ulcers (grades 3 and 4) but this information was not captured.
- Changing the data collection requirements for Year 1 (grades 1-4) and Year 2 (grades 2-4) makes understanding the true impact of the Collaborative challenging. However, this change was made to ensure data was collected in line with the majority of organisational policies and to increase data submissions.
- Not all year 1 teams collected data for the purpose of this Collaborative. This is a limitation for these teams in understanding whether the changes they made resulted in the most positive outcome. In addition, it made it difficult to share their learning with other teams as they did not have the data to support their assumptions. It has also been a limitation for the Collaborative in understanding overall impact.
- The use of surveys proved beneficial in understanding staff views on the Collaborative, but it would have been useful to have had before and after surveys undertaken at the start and end of each Collaborative year to further help in understanding impact.
Sustainability and spread
- Sustainability was introduced at the start of each year and discussed throughout.
- Learning Session 3 built on this, with teams being asked to use the Institute for Innovation and Improvement (2007) Sustainability Model (15) to assess the likelihood of sustaining their changes, and from this identify areas which needed further attention. Action plans were subsequently developed to remove/reduce the barriers/challenges identified.
- The expectation was clearly made that those teams involved in the Collaborative would share and spread their learning to other teams within their organisations.
- Relationships have been built across participating organisations and teams which helps with spread.
- Collaborative teams were encouraged to invite a wider audience from their organisation to the Celebration Event, where teams shared their learning and progress.
- Posters and film clips from the Celebration event are available for spread teams to view.
- Organisations need to continue to report prevalence of pressure ulcers to the NHS Safety Thermometer, which should ensure pressure ulcers are viewed as a priority.
Adoption – top tips
- Develop a compelling narrative, which will win hearts and minds
- Understand the baseline
- Continue to measure, and analyse results
- Choose a model/framework, such as the IHI BST model, which has been tried and tested in making improvements
- Leadership buy-in is key
- Recognise that time is needed to implement changes
- Recognise that anything implemented will be influenced by local factors, so implement and test changes using The Model for Improvement
- Celebrate success/learning
2015 to 2017
Julie Wood, Pressure Ulcer Lead, NENC AHSN
- Safety Thermometer. (2015). Classic Thermometer Dashboard. [Accessed 24 February 2018].
- Institute for Healthcare Improvement. (2003) The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. Boston.
- Stop the Pressure. [Accessed 24 February 2018].
- React to Red Skin. [Accessed 24 February 2018].
- (2015) Pressure ulcers: Quality standard. London.
- Improvement Academy. Patient Safety. [Accessed 24 February 2018]
- UK, (2015) Pressure Ulcers: Applying All Our Health [Accessed 24 February 2018].
- Zena, M., Haynes. J.K. and Callaghan, R. (2014) ‘Prevention and management of pressure ulcers: support surfaces’, British Journal of Nursing, Vol. 23:sup6, pp. S36-S34.
- NICE, (2014) Costing Statement: Pressure Ulcers. Implementing the NICE guidance on pressure ulcers (CG179). London.
- Heede, K.V., Wermeus, W., Diya, L., Clarke, S.P., Lesaffre, E., Vieugels, A. and Aiken, L.H. (2009) ‘Nursing staffing and patient outcomes in Belgian acute hospital: Cross -sectional analysis of administrative data’, International Journal of Nursing Studies, Vol. 46, Issue 7, pp. 928-93
- Langley, G.J., Moen, R.D., Nolan, K.M., Nolan, T.W., Norman, C.L. and Provost, L.P. (2009) The Improvement Guide, 2nd Edn. San Francisco, Jossey-Bass.
- Healthcare Improvement Scotland. SSKIN Care Bundle. [Accessed 24 February 2018].
- Institute for Innovation and Improvement. (2010) The Handbook of Quality and Service Improvement Tools. Coventry.
- Institute for Innovation and Improvement. (2007) Sustainability Model and Guide. Coventry.
- European Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Prague
- UK, (2010) Pressure Ulcers: Productivity Calculator. [Accessed 24 February 2018].
- Institute for Healthcare Improvement, (2011) How-to Guide: Prevent Pressure Ulcers. Boston.