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Quality & Safety - The ‘pressure ulcers to zero’ collaborative

A column by Maureen Flynn

Following last month’s column we are continuing to focus on the collaborative methodology for quality improvement (QI). The Quality and Patient Safety Division, HSE and the Royal College of Physicians of Ireland, as part of the National Quality Improvement Programme, have undertaken the first large-scale quality improvement Collaborative in Ireland in partnership with Dublin North East (DNE). The aim was to reduce the incidence of avoidable pressure ulcers across DNE by 50% during the six months of the Collaborative with an ultimate goal of reaching an avoidable pressure ulcer rate of 0%.

The Collaborative methodology was developed by the Institute for Healthcare Improvement (IHI) and is widely used within other healthcare systems to improve healthcare delivery and outcomes across different settings for a range of conditions. The ‘Pressure Ulcers to Zero’ collaborative facilitated healthcare services in the DNE region (acute and primary and community services), to adopt a structured approach to improvement. The approach adopted focused on bringing teams together to implement best practices through small tests of change (see Figure 1).

Focus on pressure ulcers
A pressure ulcer is an important complication not only in terms of patient safety but also in terms of patient experience of healthcare received. Pressure ulcer incidence in Ireland ranges from 8% to 14.4% depending on the patient group. There are no published incidence figures from paediatrics, hospice or obstetric services available for Ireland. It costs €119,000 to successfully treat one patient with a grade 4 pressure ulcer (grades range from 1-4). From this figure it is extrapolated that it would cost €250 million per annum to manage pressure ulcers across all care settings in Ireland.

Collaborative methods
An impressive 21 teams from acute hospitals, primary care, disability and older person’s residential services participated in the collaborative with support from their local management teams. Each team had three to five key staff (HCAs, nursing staff, physiotherapists, dieticians, catering staff) who tested, adapted and implemented changes in close co-ordination with their colleagues.

The improvement collaborative is based around three learning sessions where teams come together to learn the methodology, familiarise themselves with the change package for implementation and to network with other teams. Between the learning sessions the teams go back to their service, share their knowledge with their colleagues and implement and test the changes required. The change package in this collaborative was centred on the introduction of the SSKIN (surface, skin inspection, keep moving, incontinence, nutrition) bundle, an evidence-based tool to prevent pressure ulcers.

In addition to the learning sessions, each team was supported through one site visit, a monthly webex call of all participating teams to discuss progress and individual monthly calls to each team to discuss progress and to identify if any team needed particular support.

The participating teams achieved a 73% reduction in avoidable pressure ulcers. The main outcomes are as follows:

  • Increased awareness of pressure ulcers – not just the nurse’s job but the team’s job
  • Increased capability in using quality improvement tools and methodologies
  • Forging of stronger team working • Supporting integration – greater networking across the region
  • Creativity and innovation within the teams in supporting their colleagues to implement the changes for improvement.

To learn more?
Watch our video clip on the pressure collaborative on the HSE YouTube channel at http://bit.ly/ulcertozero or find more information on the HSE website at www.hse.ie/pressureulcerstozero You can also contact Cornelia Stuart, National Lead for Quality Improvement, Quality and Patient Safety Division, email: cornelia.stuart@hse.ie or Orla Mullally, National Quality Improvement Programme by email: orlamullally@rcpi.ie

Maureen Flynn is the director of nursing (national lead for quality and safety governance development) at the Office of the Nursing and Midwifery Services Director, Quality and Patient Safety Division, HSE

A special thanks to Dr Mary Browne, chair of the Pressure Ulcers to Zero working group, Quality and Patient Safety Division for preparing information for this column and particularly the National Quality Improvement Programme and all the teams involved in the collaborative

Quality & Safety - The ‘pressure ulcers to zero’ collaborative


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