Joint Working for Successful Pressure Ulcer Management Bill Cox-Martin Clinical Nurse Specialist, Pressure Ulcer Outreach Service, Salisbury NHS Foundation Trust Megan Dale Researcher and Clinical Scientist, Cedar, Cardiff and Vale University Health Board

Innovation project Funded by Chief Scientific Officer South West of England Roles of healthcare scientists 6 months

What happened before the Outreach Service? Patient population: Wheelchair dependent Wheelchair dependent 33% with spinal cord injury 33% with spinal cord injury 16% with MS 16% with MS

Patient X, wheelchair user, high risk of pressure ulcers Grade 4 pressure ulcer develops Treatment fails to heal pressure ulcer after 6 months Patient X referred for surgical closure Long waiting list, ulcer still not healed Surgical closure of pressure ulcer + inpatient stay Patient discharged home Increased risk

Patient X, wheelchair user, high risk of pressure ulcers Grade 4 pressure ulcer develops Treatment fails to heal pressure ulcer after 6 months Patient X referred for surgical closure Long waiting list, ulcer still not healed Surgical closure of pressure ulcer + inpatient stay Patient discharged home Increased risk Outreach Service

Patient X, wheelchair user, high risk of pressure ulcers Grade 4 pressure ulcer develops Treatment fails to heal pressure ulcer after 6 months Specialist advice Non surgical healing Surgical closure of pressure ulcer + inpatient stay Ulcer healed Risk reduced as far as possible Ongoing advice available Reduced risk Outreach Service

Wait Community treatment Outreach Service Surgery for 27% Wait Surgery + inpatient Cost per patient £1000s

Wait Community treatment Outreach Service Surgery for 27% Wait Surgery + inpatient Recurrence 4% Recurrence 35% Cost per patient £1000s

Patient X, wheelchair user, high risk of pressure ulcers Grade 4 pressure ulcer develops Treatment fails to heal pressure ulcer after 6 months Patient X referred for surgical closure Long waiting list, ulcer still not healed Surgical closure of pressure ulcer + inpatient stay Patient discharged home Increased risk Outreach Service

£81.5 K to run Outreach Service per year 6 ulcers > Outreach Service In the UK, a grade 4 pressure ulcer costs £14,108 to treat (Dealy 2012) In our model, chronic grade 4 pressure ulcer costs £26,000 4 ulcers > Outreach Service £1000s

Paula Shaw, Outreach Service Sister Bill Cox-Martin, Tissue Viability Nurse Response to long surgical waiting lists and re-referrals Since 2001 Multi disciplinary Pressure Ulcer Outreach Service Salisbury NHS Foundation Trust Pressure Ulcer Outreach Service Salisbury NHS Foundation Trust

Varying roles within the Outreach team Experience of physical disability and its additional problems Mobility Wheelchair prescription Pressure mapping Pressure area care Wound care Bladder care Bowel care Psychosocial needs

Service Aims appropriate treatment for their pressure ulcers patients requiring surgical intervention are seen as per Trust guidelines resource to provide immediate support and guidance follow up service to patients with healed pressure ulcers

Date referral received See within 3 weeks Review all care including: Current dressings, pressure relieving equipment, mobility aids, continence, nutritional status Improvement Review 4-6 weeks Maintain treatment regime Make recommendations Review in 4-6 weeks No improvement Healing, continue with plan until healed Supervise mobilisation – see mobilisation plan Add to list for surgical closure Review treatment regime and alter where necessary Not healing or deteriorating Set in motion admission plan 3 weeks prior to admission See inpatient flowchart Overview of the Service

Referral process Telephone referrals accepted but ideally backed up in writing All patients entered on iPM Accepted from GPs Consultants Nurses Accepted from GPs Consultants Nurses

Mobilisation plan Very slow mobilisation following healing to reduce the risk of irreversible recurrence

If red mark Check pressure areas for any marking on return to bed Day 1 Recommence mobilisation at stage prior to marking. Stay at that level for 3 days before increasing 30 minutes max Mobilisation plan post surgery Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 60 minutes max 2 x daily Discharge home Encourage to follow mobilisation plan at home 3 hours daily 4 hours daily 90 minutes max 2 x daily 2 hours max 2 x daily 2.5 hours max 2 x daily 60 minutes max Monitor time to fade If more than 20 min If less than 20 min At least 2 hours bedrest off wound site before remobilising Continue mobilisation at same rate Bedrest until mark completely clear

Wheelchairs Pressure mapping help choose best cushion teach the patient methods of pressure relief Pressure mapping help choose best cushion teach the patient methods of pressure relief Set up is important High footplates put weight on ischiums Sagging back canvas encourages sacral sitting Set up is important High footplates put weight on ischiums Sagging back canvas encourages sacral sitting Planning Contact the wheelchair service early for any modifications, as it takes time Planning Contact the wheelchair service early for any modifications, as it takes time

Pressure Mapping Allows informed decisions to be made regarding cushion prescription

Red areas = high interface pressures Cushion unsuitable for use by this patient An alternative cushion failed to provide any improvement in interface pressures A correctly adjusted roho cushion provided by far the best level of pressure reduction and distribution

Wheelchair users Most people referred are wheelchair users Pressure ulcers have drastic implications for the rest of their lives Wheelchair users Most people referred are wheelchair users Pressure ulcers have drastic implications for the rest of their lives Catastrophic consequences Patient – long term implications Resource use Catastrophic consequences Patient – long term implications Resource use Inelastic scar tissue increases risk of further pressure ulcers Inelastic scar tissue increases risk of further pressure ulcers Surgery Large amount of time sitting on surgical site Plan flaps with care Surgery Large amount of time sitting on surgical site Plan flaps with care Physical disability Pressure ulcer It’s not inevitable

Prevention is not difficult Your eyes are the most useful preventative equipment available Other equipment is there to aid your practice, not replace it If you have concerns, however trivial they might seem, seek advice. Pressure sores are preventable

Extrinsic Factors Immobility Shear force Malnutrition Lack of sensation Poor circulation Moisture Friction Direct pressure

Cost Model Outreach Service vs Surgery only

Cost inputs and assumptions Input Costs:Source Daily cost of grade 4 ulcer without complications £56.77Dealy, 2012 Average cost UK wide Not specific to this patient group Includes all resources e.g. staff time, dressings, other equipment and different treatment settings. Staff Costs Grade 6£67,509.00PSSRU , 10.4 Nurse specialist (community Grade 7£81,354.00PSSRU , 10.7 Nurse (advanced) Travel costs per annum for outreach service £2,000.00Bill Cox-Martin, Salisbury NHS Foundation Trust Surgical cost£15,260.00NHS Reference costs JC02A - JC04C, Total calculated by adding excess bed days to surgery cost for each code. A weighted average is then obtained

Other assumptions The daily cost can be used for this group of patients There is a surgery only pathway Pressure Ulcer Outreach Service resources are used entirely for treatment, and not prevention Inpatient stay is 42 days, based on current pathway Following discharge home, no further intervention is required, other than the standard care when healthy Recurrence rate for surgery is 35% - actual rate not known

Cost of Pressure Ulcer Outreach Service per patient Cost of outreach service per annum:WTECost Grade 6 1/2 hours per week0.60£40, Grade 7 hours per week0.48£39, Travel£2, TOTAL (per annum)£81, Cost of service per patient (50 per year) This is conservative, as they will also advise a number of patients with problems prior to developing pressure ulcers. £1,607.72

Cost for waiting time = 186 days x £56.77 daily cost = £10, Cost per patient £1000s Surgery + inpatient cost = £15, Taken from NHS reference costs With additional bed days Total =£25,819.10

Cost for waiting time = 186 days x £56.77 daily cost = £10, Cost per patient £1000s Surgery + inpatient cost = £15, Taken from NHS reference costs With additional bed days 35% Recurrence Revised Total = £34,626.03

Cost for waiting time = 21 days x £56.77 = £1, Cost per patient £1000s Community treatment = 318 days x £56.77 = £18, Total =£25, Outreach Service = £1, Surgery for 27% =£4,102.15

Cost for waiting time = 21 days x £56.77 = £1, Cost per patient £1000s Community treatment = 318 days x £56.77 = £18, Total =£26, Outreach Service = £1, Surgery for 27% =£4, Recurrence 4%

Cost Saving = £8,598

Sensitivity analysis How robust is the model? What if we got one of the inputs wrong? Vary one of the inputs, examine the impact Repeat this for all of the inputs Two variables that are important and uncertain are: Recurrence rate for surgery Daily cost of treatment

If we took the daily rate for treatment as £60, what happens when the recurrence rate for surgery varies?

Varying recurrence rate for surgery Daily rate for treatment from £30 to £90

Cost Saving Cost Incurring

Preventing pressure ulcers £1000s

Conclusions Skills from wheelchair and seating disciplines combined with tissue viability skills allow assessment of the causes of the problem. Treat the causes and not just the symptoms Biggest gains may be found by moving the service into prevention of pressure ulcers.

More information: Cox-Martin B and Shaw P. Development of an outreach service to promote surgical/non-surgical treatment of pressure ulcers Wounds UK 6 (2): NHS Networks – Pressure Relief Equipment South West