Narelle Marshall (AARCS Nurse) & Darlene Saladine (Acute Pain Service Nurse) November 2012 ‘A Multidisciplinary Approach to the Prevention of Pressure Areas on Patients with Hip Fractures at Armidale Rural Referral Hospital.’

Prize-winning project

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

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

Process Strategies implemented by the Pressure Ulcer prevention Working Group demonstrated some improvement However it was evident that there was still room for improvement particularly with regard to referrals to Dietitian and Occupational Therapists

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)

The Extent of the Problem 18 (22.2%) of the 81 hip fracture patients from 1 st July 2009 – 30 th 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

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

Allevyn Heel with silicone border

Mepilex Heel

The dressings applied

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 1 st September 2010 Project monitored by Darlene Saladine on the wards to ensure compliance with application of dressings and completion of tracking sheets

Implementation cont. Feedback provided to staff using a wall chart & staff meetings Patient education re: rationale of the project

Outcomes & Evaluation Follow up audit of all hip fracture patients presenting from the 1 st September 2010 to 31 st 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 co- morbidities

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

Graphical data of reduced incidence of pressure ulcers

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

Our Multidisciplinary Team

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).

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, however… 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

Other observations we have made When dressings were unavailable, 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.

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.

Sustaining the Change Pressure Ulcer Prevention 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

Future Scope Share information with internal transport and ambulance re the benefits of repositioning in transit Share information with other Hospitals re the benefits of preventative dressings on high risk patients