Evaluation of a multifactorial approach to reduce the prevalence of ...

International Wound Journal ISSN 1742-4801

ORIGINAL ARTICLE

Evaluation of a multifactorial approach to reduce the prevalence of pressure injuries in regional Australian acute inpatient care settings Sarah K Smith1 , Samantha E Ashby2 , Lynette Thomas3 & Felicity Williams3 1 St Joseph’s Hosptial, Auburn, NSW Australia 2 School of Health Sciences, University of Newcastle, Callaghan, NSW Australia 3 Professional Development, Nursing and Midwifery Services, Hunter New England Local Health District, Newcastle, NSW Australia

Key words Evidence-based practice; Knowledge translation; Pressure injury; Prevention; Staff behavioural change Correspondence to SE Ashby, Senior Lecturer School of Health Sciences University of Newcastle Callaghan NSW Australia E-mail: [email protected]

doi: 10.1111/iwj.12840

Smith SK, Ashby SE, Thomas L, Williams F. Evaluation of a multifactorial approach to reduce the prevalence of pressure injuries in regional Australian acute inpatient care settings. Int Wound J 2018; 15:95–105 Abstract The aim of the study was to compare the changes in the prevalence of pressure injuries from 2008 to 2014 in relation to staff behaviour in acute/subacute inpatient care settings. In 2008, the large regional health district Hunter New England Local Health District implemented an initiative called the Crystal Model which resulted in changes in their policy and an e-learning education program for all nursing staff. A retrospective cross sectional study compared data from the 2008, 2010 and 2014 point prevalence surveys of PI in acute services. These were collected as part of an annual pressure injury prevention and management quality audit for adult inpatients. The total number of participants included 1407 participants in 2008, 1331 participants in 2010 and 1199 participants in 2014. From 2008 to 2014 there was a 15.7% decrease in percentage of patients with hospital-acquired pressure injuries and the percentages of each stage of pressure of injury 1–4 decreased. From 2008 to 2014 the completion and documentation of risk assessment, the documentation of repositioning and the implementation of pressure-relieving equipment increased. A multifactorial model can reduce the prevalence of pressure injuries in acute inpatient settings. The theories of knowledge translation and the modified Theory of Planned Behaviour can be utilised to analyse changes in health professionals habituated pressure injury prevention practice

Introduction

The prevention and management of a PI is a prioritised area of care for health organisations (1). Internationally, the prevalence rates of PIs varies from 14% to 17% in an inpatient population in the USA (2) and to 26% from mixed settings in Canada (3). Within Australia, a study found a decrease in the point prevalence of PI from 26% to 17⋅6% between 2003 and 2006 (4). To address the ongoing issue, international evidence-based practice (EBP) PI prevention and management strategies have been developed to improve practice (5). While strategies to reduce this risk include training health professionals, promotion of the importance of nutrition and use of appropriate equipment, Harding and Queen argue that further research is required to analyse the impact of education on EBP (1,6–9). The importance of improving educational strategies for practitioners is © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd

Key Messages

• evidence-based practice methods have been applied to reduce the significant burden posed by Pressure Injures (PIs) on individuals and on one Australian health care organisation • the current study found that a multifactorial approach to pressure injury prevention and management reduced the prevalence of PIs over 6 years from 2008 to 2014 • a multifactorial approach to pressure injury prevention, including education for health professionals about risk assessment, repositioning, equipment prescription and documentation, can contribute to reducing the prevalence of PIs in an acute care health setting

95

A multifactorial approach to reduce the prevalence of pressure injuries

S. K. Smith et al.

Figure 1 Modiﬁed theory of planned behaviour (22).

highlighted by research which identified that hospital-acquired PIs can be caused by inconsistencies in practice (4) in addition to patient factors such as physical health and the length of admission (10). To reduce the prevalence of PIs, initiatives developed from evidence-based PI prevention and treatment strategies aim to reduce the health care costs and reduce the emotional, psychological and social burdens on patients who experience reduced quality of life, reduced functional performance and limitations in meaningful activity participation (1,8,9,11–14). Hurd et al. (1) evaluated the restructuring of community wound management practices in Niagara, Ontario and Canada. They found that the programme restructure and implementation of a staff training programme reduced costs and saved $3⋅8 million. In addition, average wound-healing time decreased from 51⋅5 weeks in 2005 to 20⋅9 weeks in 2006 (1). Research in a Swedish hospital evaluated a multifaceted, unit-specific intervention based on EBP for PIs (8). This intervention involved multidisciplinary teams (MDT), training and quality management of practice and resulted in improvements in the prevention of PIs (8). Further Australian research by Norman et al. (14) provided 23 recommendations to improve the economic and social outcomes of PIs. In terms of the structuring of health professional teams, the evidence suggests that interdisciplinary teams (IDT) or collaboration between health facilities and academic experts is required for PI prevention and management (1,6). However, a Cochrane review of the effectiveness of organisational infrastructure recognised the difficultly for health professionals to implement EBP into practice when organisational barriers exist (15). The translation of PI EBP research into clinical practice is referred to as knowledge translation (KT) (16). Research suggests that KT is the interface between EBP and its implementation in practice and involves active participation to synthesise, disseminate, exchange and ethically apply knowledge (16,17). Godin et al. (18) argued the modified Theory of Planned Behaviour (TPB) identifies the factors that shape the intentions and behaviours of health professionals (see Figure 1) (19–21). In health care organisations, practitioners have difficulty implementing new knowledge and changing habituated practice (17,22). The TPB suggests that a health professional’s 96

Figure 2 Crystal Model designed and implemented by HNELHD as part of the Pressure Ulcer Prevention Program (PUPP) (27).

behaviour change is shaped by beliefs or contextual factors such as the characteristics of a condition or illness, the acceptability of treatment to patients or external policy and organisation support (18,21). Thus, KT into practice requires organisational support, educational meetings and materials plus interactive and didactic learning techniques to increase the implementation of knowledge into practice (17,23). The focus of this paper is on the initiatives taken by the Hunter and New England Local Health District (HNELHD) to implement best practice in PI prevention and management (1,6,8,9,14). In 2008, HNELHD reviewed the prevalence rates of PIs across all its services. The HNELHD is a public health care organisation located in a regional area of New South Wales (NSW), Australia, that provides services to 658 000 people in a major metropolitan centre, regional communities and to a small percentage of people located in remote communities. In 2008, the organisation found that the prevalence of PIs was 29⋅4% across its inpatient services, with 79⋅5% of PIs being hospital-acquired PIs (4). The model designed by HNEHLD practitioners to reduce PIs is the HNELHD Pressure Ulcer Prevention Program’s Crystal Model (see Figure 2). The Crystal Model is a strategic approach to reduce the prevalence of PIs in the HNELHD. Since 2008, the model has evolved to ensure it reflects international guidelines and Australian and NSW policies required in public health settings (24,25). The model includes e-learning courses for health professionals combined with changes in policy for best practice, surveillance to provide evidence of PI prevention strategies, equipment for PI prevention and management, documentation of standardised PI prevention assessments, wound management to achieve best practice and communication to facilitate improvements (17,23). The e-learning package was implemented in 2008 (26). and includes information about causes of PIs and prevention strategies, which aim to change health professionals’ beliefs, intentions and behaviour (18). © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd

S. K. Smith et al.


External Factors

Hunter New England Local Health District

2005 NSW Health 2005 Policy Directive Clinical Practice- Pressure Ulcer prevention

2008 - Crystal Model developed - Survey into prevalence of PIs in HNELHD

2006 The Victorian Quality Council point prevalence study on pressure injuries

2009 - Crystal Model considered best practice - PI e-learning package developed for staff

2009 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance.First Edition Prevention and Treatment of Pressure Ulcers: Quick Reference Guide

2010 - Ethical approval for survey granted - 2010 annual PI prevalence survey HNELHD

2011- 2013: 2012

Annual PI prevalence survey HNELHD

2014:

Australian Commission on Safety and Quality in Health Care: Safety and Quality Improvement Guide Standard 8: Preventing and Managing Pressure Injuries

-

Annual PI prevalence survey HNELHD

2015: -

Ethical approval for variations to study granted Annual PI prevalence survey HNELHD

2014 NSW Health Policy Directive: Pressure Injury Prevention and Management

Figure 3 Study timeframe.

This paper aims to describe changes in the prevalence of PI, practice and the use of preventative pressure care equipment and devices, such as mattresses and cushions, in acute care settings within HNELHD from 2008, 2010 and 2014. To do so, it draws on the modified TPB to understand the impact of a multifactorial initiative to reduce the prevalence of PIs in the HNELHD.

Methods Ethical considerations

Prior to data collection for the HNELHD quality audit, ethical approval was provided by the Hunter New England Human Research Ethics Committee. To analyse the data collected from the surveys, variations to the original ethical approval to include © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd

2016 -

Comparison of 2008 and 2014 PI prevalence survey o Collation of similar survey questions o Implementation of data in table format

this study was provided in December 2015 by the Hunter New England Human Research Ethics Committee. Design

Point prevalence survey

The Crystal Model and its translation of evidence into practice is reviewed annually using data from an annual point prevalence survey (25). A point prevalence audit captures the proportion of patients with PIs within a specified time and population and is commonly used in epidemiological studies to monitor the rate of a disease or condition (27). The HNELHD quality audit for the prevention and management of PI utilised this study design to investigate the prevalence and management of PIs in acute 97

S. K. Smith et al.


inpatient settings in HNELHD for a 6-year period. The use of annual point prevalence audits is supported by Woodward (28) for use in a descriptive study and included a full-body inspection and audit of medical records. Current study

For this study, a cross-sectional retrospective quantitative research methodology was used to collect data using a point prevalence study within the HNELHD. The HNELHD provides services across 41 inpatient facilities to a population of 658 000 people (29). The survey monitors the behaviour of health professionals regarding pressure care practices. This study focused on a comparison between 2008, 2010 and 2014 survey data, particularly the prevalence of PIs and the provision of pressure-relieving equipment/devices (see Appendix). This study utilised quantitative research methods to conduct a retrospective data analysis with data from the 2008, 2010 and 2014 HNELHD annual point prevalence surveys. These years were chosen to reflect baseline data before the Crystal Model (2008) and the longitudinal impacts of the model. Initially, 2008 and 2014 were chosen for data analysis; however, due missing data in 2008, data from the 2010 survey was added to the data set and was also analysed. Figure 3 outlines the timeframe in which the survey was implemented and other factors such as local health district, state wide and international policies and practice guidelines, which influenced this study. Settings

HNELHD staff members, who are trained as surveyors, annually conducted the survey in 41 inpatient facilities of 80 facilities in total in HNELHD. The data collected from these surveys are the focus of this study. Sample

In 2008, there were 1407 participants (87⋅2% of inpatients); in 2010, there were 1331 participants (82⋅1% of inpatients); and in 2014, 1199 patients (90⋅2% of inpatients) consented to participate in the survey. The sample for the point prevalence audit included all acute ward inpatients on the day of the audit. The inclusion criteria were: (i) age 18+, (ii) verbally consenting adult inpatients and (iii) patients in acute/subacute beds. Exclusion criteria were patients in (i) paediatrics, (ii) obstetrics, (iii) psychiatric units, (iv) operating theatres and (v) undergoing day surgery. Point prevalence survey tool

The survey tool was designed in collaboration with wound management experts and service managers. It reflects best practice and was based on the validated point prevalence survey designed by Western Australia (WA) Health (30). The PI point prevalence survey records the implementation of PI risk assessment tools, use of pressure-relieving devices and the proportion of patients with institution-acquired PIs. While wound care experts determined whether the survey reflected current knowledge and practice, its validity and reliability were not tested (31). The suggestion that the survey tools 98

were based on bed practice was justified by Henzel et al. (32) The results of this study argue that PI practice guidelines are often a combination of psychometrically tested EBP and expert opinion. In addition, the survey includes best practice in acute care guidelines, including implementation and scoring of a validated risk assessment and use of prevention strategies (33). For each year’s quality audit, a new study-specific tool was designed by HNELHD staff. The initial point prevalence survey tool was developed in 2008 from the NSW Health 2005 Policy Directive Clinical Practice-Pressure Ulcer Prevention and the WA point prevalence study (24). Changes to survey tools were made to reflect policy developments, including the implementation of the NSW Health Policy Directive in 2014, and to explore emerging trends of previous survey data (25). As part of the 2005 NSW Health Policy Directive, risk assessments were recommended but not mandatory (24). The 2014 NSW Health Policy Directive formed the basis of subsequent annual point prevalence surveys as it mandated the assessment of patients for PIs with a validated risk assessment tool (25). Consequently, the Waterlow Scale to assess PI risk became mandatory to reflect the requirement of the NSW 2014 Policy Directive (25). The Waterlow Scale was utilised to assess PI risk levels from not at risk to very high risk. The questions and the structure of the survey tools fulfilled the surveillance component of the Crystal Model as part of the HNELHD Pressure Ulcer Prevention Program (see Figure 1). Procedure for point prevalence

Survey practitioners

Training was provided to surveyors prior to surveillance at a HNELHD facility and involved completion of pressure ulcer education modules and provision of ‘Surveyors Tool Kit’. Teams of two to three surveyors were trained in each ward to collect data within 1 day of service. One of the surveyors was independent (worked in a different service). This was to avoid potential bias when recruiting patients as participants. Surveyors included nursing clinicians, nurse managers and nurse unit managers. Point prevalence audit procedure

The survey was administered annually as part of an audit at HNELHD facilities and collected cross-sectional data from 1 day of service. In 2008, 2010 and 2014, in order to conduct the survey, two trained surveyors also completed the Waterlow Scale and a full-body inspection of consenting patients. One surveyor audited the patients’ medical records for necessary documentation. Each facility was required to complete the survey with a minimum of 75% of eligible patients, who provided verbal consent to participate in the survey to comply with audit standards. If the 75% consent rate was not obtained, the data from that facility was not analysed to maintain the validity of the study. Data analysis

To review the impact of the Crystal Model on practice, the data analysis focused on survey data from 2008, 2010 and 2014. © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd

S. K. Smith et al.

The survey evolved during this period as it is a ‘real-world’ audit tool and is subject to change due to policy and emerging trends. These changes required an analysis of the contents from the 2008, 2010 and 2014 surveys to identify similarities and pair comparable questions in a Microsoft Excel sheet (34). Data from the surveys were obtained from the original data sets. The data were expressed as means and percentages of categorical and numerical data. Statistical analysis for the purpose of this study involved the use of Microsoft Excel 2010 to review and compare the survey data (34). This analysis involved the use of descriptive statistics to identify changes and patterns in the data. Statistical analysis was based on the results of the survey, which identified prevalence, anatomical distribution and severity of PIs; PI risk assessment; the use of pressure-relieving devices and documentation.

A multifactorial approach to reduce the prevalence of pressure injuries 100 + 90-99 80-89 70-79 60-69 50-59 40-49 30-39 20-29 10-19. age 0

5

10

15 2014

20 2010

25

30

35

2008

Results

Incidence of PIs by medical specialty

Figure 5 demonstrates the variations in the percentage of patients by medical specialties in acute inpatient general adult populations.

Figure 4 Age as percentage of population.

rehabilitation

2014

surgical

Medical specialty

This study identified changes in the management of PI between 2008, 2010 and 2014 demonstrated changes in the management of PIs. The results of the current study are presented to reflect the components of the Crystal Model (4). Figure 4 presents the demographics of the patient population included in the surveys.

2010 palliative

2008

medical

emergency

Acquisition of PIs

Table 1 illustrates the percentage of patients admitted to acute facilities with PIs and the percentage of patients with hospital-acquired PIs. Each participant with PI had between 1 and 14 PIs identified.

critical care 0

10

20

30

40

50

60

Prevalence of pressure injuries (%)

Figure 5 Prevalence of pressure injury by medical specialty.

Stage of PIs

Table 2 illustrates the stages of PIs from one to four in the total survey population. Site of PIs

Table 3 illustrates the anatomical location of the PIs. Prevention strategies included in the crystal model Evidence of risk assessment and the tools implemented

Table 1 PIs present on admission and hospital-acquired PIs Percentage of patients with PI (n = number of PI)

2008

2010

2014

% (n = 414)

% (n = 173)

% (n = 130)

PI present on admission Hospital-acquired PI Missing data

16⋅9 (70) 79⋅5 (329) 3⋅6 (15)

38⋅7 (67) 61⋅3 (106) —

36⋅2 (47) 63⋅8 (83) —

Completion of risk assessment following admission

Table 4 presents evidence of documentation of risk assessments and the type of risk assessment utilised.

Table 6 presents the timeframe in which PI risk assessment was completed for each patient following admission or transfer.

PI risk level

Documentation of repositioning

Table 5 demonstrates the percentage of patients identified to be at risk of PIs using the Waterlow Scale.

Table 7 illustrates the percentage of patients with documented repositioning as a pressure-relieving strategy.

© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd

99

S. K. Smith et al.

A multifactorial approach to reduce the prevalence of pressure injuries Table 2 PIs classiﬁed according the National Pressure Ulcer Advisory Panel (NPUAP), which categorises PIs into stages 1 to 4, with 4 being the most severe (67). 2008 2010 2014 Stage of pressure injury (n = number of PI at each stage) % (n = 884) % (n = 344) % (n = 130) 1 2 3 4 Deep tissue injury Unstageable

35⋅0 (492) 18⋅5 (260) 4⋅5 (63) 4⋅9 (69) — —

14⋅1 (188) 8⋅1 (108) 2⋅0 (27) 1.6 (21) — —

60 (78) 30 (39) 5 (7) 1 (1) 1 (1) 3 (4)

Table 5 Waterlow Scale PI risk level Waterlow Pressure injury risk level % (n) Not at risk At risk High risk Very high risk Missing data

2008

2010

2014

% (n = 1407)

% (n = 1331)

% (n = 1199)

24⋅7 (347) 22⋅6 (318) 25⋅4 (357) 26⋅6 (374) 0⋅8 (11)

24⋅8 (330) 22⋅0 (293) 23⋅5 (313) 29⋅7 (395) 0

22 (266) 22 (269) 25 (299) 30 (365) —

Table 6 Timing risk assessment completed Timing of risk assessment following admission % (n)

Table 3 Site of PIs

Site of pressure injuries % (n) Sacrum Heel Toe Ischium Foot Elbow Ear Leg Malleolus Greater trochanter Spinal process Knee Scapula Iliac crest Other

2008 % (n = 884)

2010 % (n = 344)

2014 % (n = 130)

18⋅6 (164) 20⋅8 (184) 16⋅1 (142) 10⋅7 (95) 8⋅5 (75) 6⋅3 (56) 4⋅5 (40) 3⋅8 (34) 2⋅9 (26) 2⋅1 (19) 1⋅2 (11) 1 (9) 0⋅6 (5) — 2⋅7 (24)

27⋅9 (96) 24⋅4 (84) 10⋅2 (35) 2⋅6 (9) 9 (31) 4⋅1 (14) 7⋅6 (20) 2 (7) 1⋅5 (5) 1⋅5 (5) — — — 1⋅2 (4) 5⋅5 (19)

34 (44) 30 (39) 8 (10) 5 (6) — 3 (4) 12 (16) 1⋅5 (2) — 2 (2) — — — — 5 (7)

No assessment conducted On admission/at ED 8 hours of presentation 1–3 days from admission or transfer Missing data

2008

2010

2014

% (n = 1407) % (n = 1331) % (n = 1199) 13⋅8 (57) 67⋅9 (281) — 10⋅4 (43)

— 22⋅6 (301) — 64 (852)

— 71 (379) 100 (605) 66 (595)

5⋅1 (21)

—

—

NB, These results represent a moment in time versus accumulation of population.

Table 7 Documentation of repositioning Documentation of repositioning % (n)

2008

2010

2014

% (n = 1407)

% (n = 1331)

% (n = 784)

Yes No Not applicable Missing data

20⋅6 (290) 74 (1041) — 5⋅4 (76)

31⋅2 (415) 16⋅5 (219) 52⋅3 (697) —

74 (583) 26 (201) — —

Table 4 Documentation of risk assessment 2008 Evidence of risk assessment % (n)

2010

2014

% (n = 1407) % (n = 1331) % (n = 1113)

Yes No Missing data Type of pressure injury risk assessment tools % (n) Waterlow Norton

78⋅9 (1110) 17⋅2 (242) 3⋅9 (55)

80⋅6 (1073) 19⋅4 (258) —

84⋅3 (938) 15⋅7 (175) — (n = 1091)

74⋅8 (1052) 2⋅7 (38)

80⋅4 (1070) 0

Other Missing data Not done

8⋅5 (120) 14 (197) —

6⋅4 (85) 0 13⋅2 (176)

92⋅5 (1009) (n = 82) 62⋅2 (51) 37⋅8 (31)

Pressure-relieving devices

Table 8 illustrates the percentage of pressure-relieving devices in situ and the types of mattresses and cushions. Discussion

This retrospective study builds on previous studies that explored KT in wound management by reporting on the efficacy of a 100

multi-focused strategy to reduce the prevalence of PIs in an Australian public health care organisation (1,6,8,9,14,33). The study demonstrates that the Crystal Model can be associated with the reduction in the prevalence and severity of PIs in acute care settings in HNELHD. The modified TPB provides a framework for the discussion of the implementation of the Crystal Model into practice. Factors contributing to health on admission to health facility

Although the study was contextualised in one NSW health area, the demographics of patients involved in the Point Prevalence Surveys were consistent with Australian Bureau of Statistics (ABS) 2013–2014 statistics on the ages of patients admitted to health care facilities (35). Although the study focused on the outcomes of PI management in acute services, the results indicate that a key step in the process of PI prevention concerns patients admitted from the community. The surveys demonstrated that the percentage of patients with PIs admitted to inpatient facilities from the community increased from 2008 to 2010 and then remained consistent between 2010 and 2014 (see Table 1). This increase suggests it is imperative that PIs in acute settings are considered in a wider context with the © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd

S. K. Smith et al.


Table 8 Pressure-relieving devices in situ, including mattresses and cushions

Pressure-relieving devices in situ % Yes No Type of mattress in situ % (n) Non-powered air overlay Powered alternating air overlay High-density foam Air mattress replacement Other Pressure-relieving devices for chair % (n) High-density foam Non-powered air cushion Gel

2008 % (n = 1407)

2010 % (n = 1331)

59⋅9 (843) 40⋅1 (564)

39⋅1 (520) 60⋅9 (811)

44 (530) 56 (669)

— — — — —

0⋅9 (12) 3⋅7 (49) 64⋅2 (855) 15⋅0 (199) —

1 (12) 2⋅1 (25) 70⋅6 (847) 18⋅2 (218) 4⋅4 (53)

— — —

— 0⋅2 (2) 0 (1)

2014 % (n = 1199)

21⋅1 (253) 3⋅7 (44) 3⋅8 (45)

See appendix 1 for description of equipment.

community to reduce the prevalence of PIs in a period of time in acute settings. The need for improved PI prevention and management within community settings is within the scope of the Crystal Model (27). However, the difficulties in implementing PI prevention measures in the community include the extended periods of time for the prescription of pressure-relieving devices and long-term contextual factors such as chronic disease (36–38). Despite external factors, this study highlights consistent demographics of patients admitted to the inpatient services (see Figure 4), the percentage of patients at risk of PI (see Table 5) and the reduction of patients presenting with PIs from 29⋅4% in 2008 (4) to 10⋅8% in 2014. While 10⋅8% prevalence of PIs is below the 26% reported by Woodbury and Houghton (3) in mixed settings, it indicates that further initiatives are still required to promote change in pressure care practice, which is also reflected in the study by Asimus, Li (39).

Education

The e-learning package is a cornerstone of the Crystal Model. The e-learning content is consistent with EBP in PI prevention and management and informs staff to integrate multiple strategies into practice (4). The use of e-learning is supported by Sinclair et al. (40) who found that well-structured e-learning packages are as effective as the classroom environment for professional development. In PI management, Breseden et al. (41) noted that e-learning can increase the accuracy of PI classification, which is essential in the clinical reasoning for treatment. The development of the Crystal e-learning modules aimed to enhance health professionals’ reasoning and behaviours to prevent PIs (27). The changes in PI prevalence and in the supply of equipment in this study indicate a staff behavioural change (see Table 8). These results suggest that education improves practice by raising awareness of PIs and changing social norms of health professionals as per the modified TPB (18). These results are similar to Murray (42) and Law (43) who found that education programmes increase the standard of care and reduce the number and severity of PIs. © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd

Policy and auditing

The implementation of the Crystal Model was reinforced by the translation of relevant policy to establish changes in habituated staff behaviour to prevent PIs. The modified TPB indicates that health professionals’ behaviours are influenced by organisational support and policy change, with education alone insufficient to change practice (18). The implementation of annual point prevalence audits of PI incidence in the HNELHD (25) requires PI identification to become part of habituated practice (44). Ivers et al. (45) suggested that auditing measures can lead to improvements in professional practice; however, the effectiveness of auditing alone is variable. Although the audit was instigated in 2008, the results show that there was a social norm shift from 2010 to 2014 in the assessment of PI risk due to policy. Pressure care practices investigated in the 2008 and 2010 survey audits were influenced by the 2005 Policy Directive on Clinical Practices-Pressure Ulcer Prevention (24). In March 2014, the Policy Directive Pressure Injury Prevention and Management (25) was implemented based on the Australian Commission on Safety and Quality in Health Care Standard 8: Preventing and Managing Pressure Injuries (46). The impact of this policy is evident in the 2014 audit completed from October to December. In 2014, the implementation of the Waterlow Scale increased from 74⋅8% in 2008 to 100% (see Table 4). In addition, the completion of a PI risk assessment within 8 hours of admission to an inpatient facility increased to 100% in 2014 (see Table 6). While the reduction in PIs appears to be multifactorial, Anthony et al. (47) identified how the completion of risk assessments can reduce the prevalence of PIs by increasing health professionals’ awareness of PIs. In addition, in the study by Sayar et al. (48) patients with high Waterlow Scale values require increased care to prevent PIs. To ensure attention is given to patients at both a high and low risk of PIs, the 2014 Policy Directive mandated the implementation of routine repositioning for all patients at risk (25). The current study illustrates the impact of policy, with documentation of repositioning increasing from 20⋅6% in 2008 to 74% in 2014 (see Table 7). However, the results demonstrate 101

S. K. Smith et al.


the potential for further focus to be placed on the use of repositioning as a strategy to prevent PIs on the heel and sacrum (see Table 3). The 2014 Policy Directive also resulted in increased documentation of pressure care practices (see Table 7). Compliance with documentation requirements may have increased staff awareness of the identification of stage one PIs as illustrated in the reduction of the prevalence of PIs at each stage (see Table 2). However, only 84% of participants in 2014 documented evidence of PI risk assessments, which suggests that further education is required for health professionals to define PI risk and associate this with PI risk assessment tools (see Table 4). Literature supports the use of documentation to prevent PIs, with research providing recommendations for universal documentation procedures, including risk assessments and care plans (49).

2014. A contributing factor may be the changes in habituated behaviours of staff (see Table 8). Table 8 illustrates an increase in the use of high-density foam mattresses and air mattress replacements. Furthermore, Table 8 shows the increased percentage of patients with pressure-relieving devices for chairs in situ. It appears that the introduction of the mattress replacement scheme, alongside other measures such as pressure care education modules and international guidelines, contributed to changes in social norms and practitioners’ behaviour to improve pressure care practice (4,54). International practice guidelines justify the supply of pressure-relieving equipment to reduce pressure as it increases the surface area of pressure distribution or alternates the pressure placed on the body (see appendix) (54). Consequently, changes to staff behaviour with regards to equipment prescription reflect the ability of social norms to influence behaviour, as noted by Godin et al. (18) in the modified TPB.

Equipment

Theaker et al. (50) and Russell et al. (51) suggest that the prescription of correct pressure-relieving equipment, such as mattresses and cushions, assists the prevention of PIs. The implementation of the HNELHD Mattress Replacement Scheme in 2009 has resulted in the use of a high-density foam mattress as the standard mattress in HNELHD facilities. High-density foam mattresses were selected as evidence suggests that these mattresses improve pressure distribution (52) and consequently protect patients from hospital-acquired PIs. The implementation of the Mattress Replacement Scheme provides insight into the increase in high-density foam mattresses in 2014 to 70⋅6% (see Table 8) (27). These results highlight the impact of the Mattress Replacement Scheme on social norms and practitioners’ behaviour to improve pressure care practices. Habituated behaviours of health professionals

Within the modified TPB (3), the implementation of EBP strategies to reduce the prevalence of PI relies on health professionals’ changing habituated workplace behaviours and social norms (see Figure 1). Behaviour change may have contributed to the decrease of toe and sacrum PIs in 2010 (see Table 3). Changes in habituated staff behaviour may be linked with the education component of the Crystal Model. However, the results of the current study also demonstrate a need for further education to influence staff’s long-term behaviours as PIs at the sacrum and heel increased in 2014 (see Table 3). The prevalence of PIs on greater trochanters remained relatively consistent in the current study (see Table 3). These results provided insight into the habituated behaviours of staff in relation to repositioning and the use of pressure-relieving devices. In conjunction with these results, Scheffer et al. (53) suggest that a fear of falls results in reduced physical activity and movement. Consequently, fear of falls may lead to habitual positioning of patients in one position for extended periods of time. Equipment

The results of the current study highlight the changes that occurred in the use of pressure-relieving devices from 2008 to 102

Changes in documentation

The importance of comprehensive documentation, which includes PI risk assessment and care planning, to prevent and raise awareness of PIs was investigated by Vowden and Vowden (49) and was confirmed in the current study. Within the 2008 survey results, 74% of patients had no evidence of documentation for repositioning (see Table 7). This figure was reflected in an Irish study, which suggested that 76% of patient with PIs (n = 100) had no documented repositioning plan (55). Changes in practice following the Crystal Model’s implementation saw this fall to 26% by 2014. The increase in the repositioning documentation from 2008 to 2014 highlights the effect of the Crystal Model in raising awareness of pressure care practices for staff. Advocacy for documentation in the Crystal Model was reinforced with the 2014 Policy Directive, which mandated repositioning/mobilising as a routine PI prevention strategy (25). Role and identity of health professionals

Initiatives such as the Crystal Model reinforce the shared responsibilities of health professionals and development of collaborative goals promoted within the literature (56). The promotion of collaborative goals encourages the adoption of PI prevention and management strategies by all members within an MDT (57). Ashby et al. (58) further reinforced the role of collaboration in MDTs by recognising that the segregation of the roles of health professionals can result in professional silos, which create a barrier to the provision of services. Initiatives such as the Pressure Ulcer Prevention Program in the HNELHD may assist in the avoidance of professional silos in relation to wound care by promoting best practice with collaborative IDTs (1,6). The Crystal Model encourages practitioners to adopt EBP strategies to prevent PIs utilising a team approach. Moore et al. (59) found that the team of health professionals who contribute to the PI prevention include nurses, occupational therapists, physiotherapists, dieticians, doctors and pharmacists. This team approach requires practitioners to identify and incorporate wound management into their role and to regard it as © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd

S. K. Smith et al.

part of their disciplines and practical actions (18). In acute inpatient settings, the role of nurses may involve the implementation of regular repositioning, conduction of regular skin checks and provision wound care (57), while an occupational therapist may prescribe pressure care equipment, assess patient positioning and provide client education of PI prevention (60–65). The results of this study indicate that a team approach may be further utilised to extend best practice for wound care into the community, to further improve documentation of repositioning and to encourage further education. Limitations

While the findings are similar to other Australian and international studies (1,8,9,14,33), the study occurred in a regional area of NSW Australia, which may limit the generalisability of the results. Another limitation was the absence of psychometric testing for the survey tool, and consequently, the validity and reliability of the survey tool for data analysis was unknown. Furthermore, further statistical analysis of the survey data was limited as the data sets only included means and percentages. An improvement to this study would be to include the 2008 survey data relating to the types of equipment in situ, such as mattresses and cushions. Future studies

Following completion of this study, further research into shared responsibility within an MDT or IDT is required to prevent and manage PIs. Further research is also required into the use of repositioning to reduce the incidence of PIs. To reduce the prevalence of PIs present on patient admission in the HNELHD, future research may adopt initiatives similar to the community PI prevention programme in the Canadian study by Hurd et al. (1) Future research in the HNELHD community setting may also consider the application of the best practice measures currently implemented in HNELHD inpatient services investigated in this study. Future research on community PI prevention may also focus on the implications of patient education (66) or on community health services based on the principles of the modified TPB (18) applied in this study. Conclusion

In conclusion, a multifactorial model for PI prevention and management appears to reduce the prevalence of PIs in inpatient settings. The application of theories of KT (16) and the modified TPB (18) are useful ways to understand the factors that shape how health professionals implement the multifactorial model in the HNELHD and how to change habituated behaviours to improve PI practice. References 1. Hurd T, Zuiliani N, Posnett J. Evaluation of the impact of restructuring wound management practices in a community care provider in Niagara, Canada. Int Wound J 2008;5:296–304. 2. Whittington K, Briones R. National prevalence and incidence study: 6-year sequential acute care data. Adv Skin Wound Care 2004;17:490–4.



3. Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy Wound Manage 2004;50:22–39. 4. Asimus M, Li I, Williams F. Hunter New England Health pressure ulcer point prevalence survey report 2008. Hunter New England Area Health: Hunter New England (NSW), 2008. 5. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: quick reference guide. Perth: Cambridge Media, 2014. 6. Tetterton M, Parham IA, Coogle CL, Cash K, Lawson K, Benghauser K, Owens MG. The development of an educational collaborative to address comprehensive pressure ulcer prevention and treatment. Gerontol Geriatr Educ 2004;24:53–65. 7. Harding K, Queen D. Education and improved clinical outcomes. Int Wound Manag 2017;14(2):229. 8. Sving E, Högman M, Mamhidir A-G, Gunningberg L. Getting evidence-based pressure ulcer prevention into practice: a multi-faceted unit-tailored intervention in a hospital setting. Int Wound J 2014;11:1–10. 9. Sving E, Idvall E, Högberg H, Gunningberg L. Factors contributing to evidence-based pressure ulcer prevention. A cross-sectional study. Int J Nurs Stud 2014;51:717–25. 10. Alderden J, Whitney JD, Taylor SM, Zaratkiewicz S. Risk profile characteristics associated with outcomes of hospital-acquired pressure ulcers: a retrospective review. Crit Care Nurs 2011;30:30–43. 11. Lourenco L, Blanes L, Salomé GM, Ferreira LM. Quality of life and self-esteem in patients with paraplegia and pressure ulcers: a controlled cross-sectional study. J Wound Care 2014;23:331–7. 12. Graves N, Birrell FA, Whitby M. Modeling the economic losses from pressure ulcers among hospitalized patients in Australia. Wound Repair Regen 2005;13:462–7. 13. Woo KY, Sears K, Almost J, Wilson R, Whitehead M, VanDenKerkhof EG. Exploration of pressure ulcer and related skin problems across the spectrum of health care settings in Ontario using administrative data. Int Wound J 2015;12:1–7. 14. Norman RE, Gibb M, Dyer A, Prentice J, Yelland S, Cheng Q, Lazzarini PA, Carville K, Innes-Walker K, Finlayson K, Edwards H, Burn E, Graves N. Improved wound management at lower cost: a sensible goal for Australia. Int Wound J 2016;13:303–16. 15. Flodgren G, Ximena Rojas-Reyes M, Cole N. Foxcroft D. Cochrane Database Syst Rev: Effectiveness of organisational infrastructures to promote evidence-based nursing practice, 2012. 16. Canadian Institutes of Health Research. Knowledge translation - defintion. Canadian Institute of Health Research. URL http://www.cihrirsc.gc.ca/e/29418.html#2. Updated September 2015 [accessed on 23 November 2015]. 17. Schreiber J, Perry S, Downey P, Williamson A. Knowledge translation outcomes following innovative continuing education. J Phys Ther Educ 2015;29:42–51. 18. Godin G, Bélanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals’ intentions and behaviours: a systematic review of studies based on social cognitive theories. Implement Sci 2008;3(1):1–12. 19. Francis J, Eccles MP, Johnston M, Walker A E, Grimshaw JM, Foy R, Kaner EFS, Smith L, Bonetti D. Constructing questionnaires based on the theory of planned behaviour: a manual for health services researchers. Published May 2004. URL http://openaccess.city.ac.uk/ 1735/1/TPB%20Manual%20FINAL%20May2004.pdf [accessed on 17 November 2015]. 20. Ajzen I, Driver BL. Application of the theory of planned behaviour to leisure choice. J Leis Res 1992;24:207–24. 21. Armitage CJ, Conner M. Efficacy of the theory of planned behaviour: a meta-analytic review. Br J Soc Psychol 2001;40:471–99. 22. Graham I, Logan J, Harrison M, Straus SE, Tetroe J, Caswell W, Robinson N. Lost in knowledge translation: time for a map? J Contin Educ Heal Prof 2006;26:13–24. 23. Jones CA, Roop SC, Pohar SL, Albrecht L, Scott SD. Knowledge translation and implementation special series. Translating knowledge in rehabilitation: systematic review. Phys Ther 2015;95:663–77. 103


24. Clinical Excellence Commission. Clincal practices - pressure ulcer prevention. North Sydney: NSW Health, 2005. 25. Clinical Excellence Commission. Pressure injury prevention and management. North Sydney: NSW Health, 2014. 26. Health Education and Training Institute. About HETI. Health Education and Training Institute.URL http://www.heti.nsw.gov.au/. Published 2012 [accessed 25 May 2016]. 27. Asimus M, Williams F, Li I. A crystal clear answer for pressure injury prevention and management. Aust Hosp Health Bull 2014:54–7. 28. Woodward M. Epidemiology: study design and data analysis. Florida: CRC Press, 2013:9–10. 29. Australian Bureau of Statistics. Population estimates by statistical local area, 2001 to 2011. Canberra: Australian Bureau of Statistics, 2012 Report No.:3218.0. 30. Santamaria N. Woundswest: identifying the prevalence of wounds within Western Australia’s public health system. EWMA J 2009;9:13–8. 31. Rust J, Golombok S. Modern psychometrics: the science of psychological assessment, 2nd edn. New York: Routledge, 1999:72–8. 32. Henzel MK, Bogie KM, Guihan M, Ho CH. Guest editorial. Pressure ulcer management and research priorities for patients with spinal cord injury: consensus opinion from SCI QUERI expert panel on pressure ulcer research implementation. J Rehabil Res Dev 2011;48:11–31. 33. Barker AL, Kamar J, Tyndall TJ, White L, Hutchinson A, Klopfer N, Weller CD. Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study. Int Wound J 2013;10:313–20. 34. Microsoft Excel 2010 [computer program]. Redmond: Microsoft, 2010. 35. Australian Bureau of Statistics. Admitted patient care 2013–14: Australian hospital statistics. Canberra: Australian Institute of Health and Wellbeing, 2015 Report no.: HSE 156. 36. Asimus M, Li P, Kendall H. Pressure ulcer prevention interventions for community nursing patients. Wound Pract Res 2011;19:145–9. 37. Waterlow J. Waterlow pressure ulcer prevention/treatment policy. URL judy-waterlow.co.uk. http://www.judy-waterlow.co.uk/index .htm. Published 2005 [accessed 2 January 2016]. 38. Australian Institute of Health and Welfare. Chronic disease comorbidity. Australian Institute of Health and Welfare. URL http://www.aihw .gov.au/chronic-diseases/comorbidity/. Published 2016 [accessed 16 April 2016]. 39. Asimus M, Li P. Pressure ulcers in home care settings: is it overlooked? Wound Pract Res 2011;19:88–97. 40. Sinclair PM, Kable A, Levett-Jones T, Booth D. The effectiveness of internet-based e-learning on clinician behaviour and patient outcomes: a systematic review. Int J Nurs Stud 2016;57:70–81. 41. Bredesen IM, Bjøro K, Gunningberg L, Hofoss D. Effect of e-learning program on risk assessment and pressure ulcer classification: a randomized study. Nurse Educ Today 2016;40:191–7. 42. Murray E. Bridging the theory-practice gap in pressure injury prevention for assistants in nursing: the impact of a formal education program at St Vincent’s Private Hospital. Wound Pract Res 2012;20:124–8. 43. Law J. Pressure ulcer prevention: education for nursing home staff. Br J Nurs 2003;12:566–9. 44. Queensland Government. Queensland Health patient safety and quality plan 2008–2012. Queensland Government: Brisbane, 2009. 45. Ivers N, Jamtvedt G, Flottorp S, Young J, Odgaard-Jensen J, French S, O’brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012. https://doi.org/10.1002/14651858. CD000259.pub3. 46. Australian Commission on Safety and Quality in Health Care. Safety and quality improvement guide standard 8 – preventing and managing pressure injuries. Sydney: Australian Commission on Safety and Quality in Health Care, 2015. 47. Anthony D, Parboteeah S, Saleh M, Papanikolaou P. Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement. J Clin Nurs 2008;17:646–53. 104

S. K. Smith et al.

48. Sayar S, Turgut S, Dogan H, Ekici A, Yurtsever S, Demirkan F, Doruk N, Tasdelen B. Incidence of pressure ulcers in intensive care unit patients at risk according to the Waterlow scale and factors influencing the development of pressure ulcers. J Clin Nur 2009;18:765–74. 49. Vowden K, Vowden P. Documentation in pressure ulcer prevention and management. Wounds UK 2015;11:6–9. 50. Theaker C, Kuper M, Soni N. Pressure ulcer prevention in intensive care – a randomised control trial of two pressure-relieving devices. Anaesthesia 2005;60:395–9. 51. Russell L, Reynolds TM, Carr J, Evans A, Holmes M. Randomised controlled trial of two pressure-relieving systems. J Wound Care 2000;9:52–5. 52. Bergstrom N, Horn SD. Racial disparities in rates of pressure ulcers in nursing homes and site of care. JAMA 2011;306:211–2. 53. Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, de Rooij SE. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing 2008;37(1):19–24. 54. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington: Pressure Ulcer Advisory Panel, 2009. 55. Moore Z, Cowman S. Pressure ulcer prevalence and prevention practices in care of the older person in the Republic of Ireland. J Clin Nurs 2012;21:362–71. 56. Korner M. Interprofessional teamwork in medical rehabilitation: a comparison of multidisciplinary and interdisciplinary team approach. Clin Rehabil 2010;24:745–55. 57. Asimus M, MacLellan L, Li P. Pressure ulcer prevention in Australia: the role of the nurse practitioner in changing practice and saving lives. Int Wound J 2011;8:508–13. 58. Ashby S, James C, Plotnikoff R, Collins C, Guest M, Kable A, Snodgrass S. Survey of Australian practitioners’ provision of healthy lifestyle advice to clients who are obese. Nurs Health Sci 2012;14:189–96. 59. Moore Z, Webster J, Samuriwo R. Wound-care teams for preventing and treating pressure ulcers. Cochrane Database Syst Rev 2015. https:// doi.org/10.1002/14651858.CD011011.pub2. 60. Amini D. The role of Occupational Therapy in wound management. Am J Occup Ther 2013;67:60–8. 61. Stinson M, Gillan C, Porter-Armstrong A. A literature review of pressure ulcer prevention: weight shift activity, cost of pressure care and role of the occupational therapist. Br J Occup Ther 2013;76: 169–78. 62. Rose A, Mackenzie L. ‘Beyond the cushion’: a study of occupational therapists’ perceptions of their role and clinical decisions in pressure care. Disabil Rehabil 2010;32:1099–108. 63. Giesbrecht E. Pressure ulcers and occupational therapy practice: a Canadian perspective. Can J Occup Ther 2006;73(1):56–63. 64. Evers S, Anderson K, Pagel L. Occupational therapy’s role in pressure care. OT Pract 2015;20:13–5. 65. Macens K, Rose A, Mackenzie L. Pressure care practice and occupational therapy: findings of an exploratory study. Aust Occup Ther J 2011;58:346–54. 66. Rintala DH, Garber SL, Friedman JD, Holmes SA. Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention. Arch Phys Med Rehabil 2008;89:1429–41. 67. Australian Wound Management Association. Pan Pacific clinical practice guideline for the prevention and management of pressure injury. Osborne Park: Cambridge Media, 2012. 68. Asimus M. Policy Compliance procedure. Pressure injuries: prediction, prevention and management. Hunter New England: NSW Health, 2015 Report no.: 15/43–2-46. 69. Health Share Enable NSW. Powered air alternating overlay mattress. Health Share Enable NSW. URL http://www.enable.health.nsw.gov .au/__data/assets/pdf_file/0009/262845/air-mattress-overlay.pdf. Published February 2016 [accessed 26 June 2016].


S. K. Smith et al.

Appendix

Mattresses and cushions Non-powered air mattress overlay and cushion: Non-powered support surface is made up of one air cell or air cells, which provide optimal pressure redistribution across the total body contact area, for example, Repose mattress overlay and Waffle cushion (68). Powered alternating air mattress overlay and air mattress replacement: Powered support surface includes the following: • Mattresses – Powered alternating air mattress replacement and powered alternating air mattress overlay. Some powered air mattresses consist of foam. A powered air overlay is strapped over the existing mattress for medium-level pressure relief (68). • Seating – Powered alternating air cushion (68).


High-density foam mattress and cushion: Consist of three layers of static high-density foam with two-way stretch, water-resistant, vapour-permeable cover. Includes the following: • Top layer being the comfort layer – Soft memory foam that conforms to the patients’ body (68). • Middle layer – High density, suitable for pressure redistribution (68). • Bottom layer for support: Firm/highly rigid foam designed to provide full-body support (68). Gel cushion: Static Mattress Overlays/seating include gel or fluid pads, which are not used for pressure reduction purposes but may assist with patients comfort (68).

Alternating air cells rotate on a 1:2 or 1:4 ratio where one cell is deflated and one or three cells are inflated (69) to redistribute pressure.


105