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Article  in  Journal of Wound Care · September 2012

DOI: 10.12968/jowc.2012.21.Sup9a.S35 · Source: PubMed

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 supplement

Introduction
Maureen Benbow & Sharon Bateman

O
M. Benbow, MSc, ne of the most important indicators of risk assessment, and the implementation of
BA (Hons), RGN, of effective practice is the number consistent preventive care.
HERC, Senior
Lecturer;1 and severity of preventable This supplement describes the improvements
S.D. Bateman, MA, pressure ulcers that develop in made at South Tees Hospitals NHS Foundation
BSc (Hons), RGN, Dip, health-care settings. The key to pressure ulcer Trust following a shift from a target-based
Wound Care Lead
Nurse;2 prevention is assessment, which should seek approach, to a greater emphasis on patient safety
1 University of Chester, to improve patient care and outcomes through and quality of care. This supplement aims to
UK.
2 South Tees NHS systematic review of care against explicit criteria provide a detailed illustration of how health-
Hospitals Foundation and the implementation of change. Given the care clinicians, industry and service providers
Trust, UK. humanitarian and financial costs of pressure have worked collaboratively to improve patient
ulcers, and the fact that they are largely avoidable, outcomes and provide safe, effective, cost-effective
the current health-care reforms in the UK are pressure ulcer prevention and management
making pressure ulcer prevention a key policy strategies that are acceptable to patients in the
and professional target. South Tees Hospitals NHS Foundation Trust, UK.
Quality improvement must be demonstrated It will demonstrate how a productive working
throughout health-care service delivery; it partnership between key clinicians and industry
should incorporate measurement of privacy, led to an improvement in services and a reduction
dignity, patient safety, the patient experience in the incidence of pressure ulcers. It achieved
and clinical outcomes, and not just concentrate this through intensive and sustained staff
on pressure ulcer prevalence or incidence audits. education, sound clinical leadership, and by
The key drivers should focus on metrics that monitoring and measuring progress, with the
have the greatest all-round impact, such as the ultimate aim being to have the right care for the
delivery of evidence-based practice, the timing right patient at the right time. n

Declaration of interest
This supplement was commissioned and supported by ArjoHuntleigh. M. Benbow and S. Bateman are independent
consultants, who received a fee for their contribution.

© 2012 MA Healthcare Ltd

All rights reserved. No reproduction, transmission or copying of this publication is allowed without written permission from MA Healthcare Ltd. No
part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photo-
copying, recording, or otherwise without prior written permission of the MA Healthcare Ltd, or in accordance with the relevant copyright legislation.
Although the editor, MA Healthcare Ltd and ArjoHuntleigh have taken great care to ensure accuracy, neither MA Healthcare Ltd nor ArjoHuntleigh
will be liable for any errors of omission or inaccuracies in this publication.
Published on behalf of ArjoHuntleigh by MA Healthcare Ltd.

Publisher Anthony Kerr

Associate publisher and editor Tracy Cowan
Designer Bexi Harris
Sub editor Daniel Shanahan
Published by MA Healthcare Ltd, St Jude’s Church, Dulwich Road, London SE24 0PB, UK
Tel: +44 (0)20 7738 5454 Email: anthony.kerr@markallengroup.com

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 supplement

National and local drivers

for change
Maureen Benbow

I
n 2005, the National Institute for Health Agency selected PU prevention and treatment M. Benbow, MSc,
and Clinical Excellence (NICE) published its as one of its ‘10 for 2010: Reducing Harm to BA (Hons), RGN,
HERC, Senior Lecturer,
guidance on pressure ulcer (PU) management Patients’ plans.4 The ambitious aim was to University of Chester,
in primary and secondary care. Four years eliminate avoidable PUs in all health-care settings UK.
later, the European Pressure Ulcer Advisory Panel/ by focusing on key aspects of prevention: patient
National Pressure Ulcer Advisory Panel (EPUAP/ repositioning, nutritional assessment, hydration,
NPUAP) published recommendations on the and monitoring and assessment. The view was that
management and prevention of PUs,1 which ‘one patient needlessly being harmed by a safety
were then integrated into UK practice. As a result, incident is one patient too many’, and the aim is
PU prevention finally became a priority within the to transform the patient safety culture through
UK health service. government support and targeted leadership.
The Department of Health made PU prevention Improved quality and efficiency are the key
one of its high impact actions (HIAs) for nursing concepts underpinning the current major reforms
and midwifery.2 The challenge is to eliminate of the NHS. The Operating Framework for the
all avoidable PUs in the national health service NHS in England for 2012–13 requires that service
(NHS), which will significantly reduce expenditure quality and the patient experience must improve,
and improve patient outcomes. and productivity increase.5 The premise is that,
This vision is based on the assumption that with a robust management style, the increase
most PUs can be prevented through risk assessment in demand for services will still be affordable, as
and pressure-redistributing strategies. However, demonstrated by the recent reductions achieved in
experience shows that, due to comorbidities such emergency admissions and length of stay.
as vascular insufficiency, unstable diabetes and The main objectives of the reforms are to achieve
increased body mass index, there will always be ‘equity and excellence’, ‘put patients at the heart of
increasing numbers of at-risk patients, despite the everything the NHS does’ and ‘empower clinicians
provision of evidence-based care. to innovate’ in health care.6 For this to happen,
Nevertheless, it is possible to reduce the the processes involved need to be transparent, and
incidence and costs of PUs in hospital settings there must be a commitment to share experiences.
with the judicious use of pressure-redistributing However, the government’s demand for
surfaces and excellent basic nursing care.3 The efficiency savings of £15–20  billion per year by
emphasis here is on ‘judicious’ as these reductions 2013–2014 make achieving these goals a real
and savings can only be achieved if use of these challenge. There are incentives, though. Savings
surfaces is monitored and managed efficiently. made by preventing avoidable complications
of care, such as pressure ulceration and venous
A safe patient experience  thromboembolism, will be reinvested through
at no extra cost the Commissioning for Quality and Innovation
Health ministers have realised that, in order to (CQUIN) payment framework. Meanwhile, NHS
embed a consistent safety culture across health- staff are expected to implement the latest national
care organisations in England and Wales, it is guidance on best practice, with benchmarking and
necessary to work in partnership with the NHS life-long learning viewed as important enabling
and its staff. In 2010, the National Patient Safety tactics. The Care Quality Commission (CQC) will

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 supplement

then monitor implementation of such guidance. with no consideration of patient satisfaction or

In addition, policy initiatives have been quality of services. In contrast, payment will now
introduced focusing specifically on reducing depend on quality of care and patient outcomes.
risk and patient harm (Table  1). The Quality,
Innovation, Productivity and Prevention (QIPP) The PU challenge
Safe Care Workstream initiative7 was described as Scale of the problem
an ‘ambitious programme that aims to get NHS Despite this increased awareness, pressure
staff thinking differently about patient safety’. The ulceration remains a widespread, serious and
aim was to deliver care defined by the absence of potentially life-threatening problem across all
PUs, falls, venous thromboembolism and catheter- age groups, medical/surgical specialties and care
line infections by December 2012. It is a key settings around the world. One European pilot
framework through which NHS trusts can improve survey found alarming evidence that up to one
patient safety, decide how to deliver efficiency in five acute care patients suffered some degree
savings, and provide and maintain quality services of tissue damage.9 Of even more concern is the
despite tight budgetary constraints.5 finding that as many as three in four patients
On the front line, care bundles have been with PUs develop them in hospital.10 Various PU
introduced to prevent avoidable harm and deliver prevalence and incidence figures are given in
safer care. This approach involves the consistent the literature, from 20% reported in a European-
implementation of a small number of individually wide prevalence survey,9 to a 4–10% incidence
evidence-based interventions that reduce risk of rate,11 depending on the specialty.
harm.8 Such data is then submitted to the NHS Overall, in the UK, up to £4 billion (4% of
Safety Thermometer, which is a local improvement the NHS budget) is spent treating PUs and their
tool for measuring, monitoring and analysing related conditions annually,11 with costs for the
patient harms and ‘harm-free’ care. Submission most severe cases ranging from £11 000 to £40 000,
of data on PU prevalence rates to the NHS Safety depending on the complications; the cost of
Thermometer is rewarded through the CQUIN prevention is inestimable.12
scheme. This data will be published, in line with Daily costs for a patient with a PU are estimated
current policy on transparency. It will be presented to be between £38 and £196, with nursing and
alongside PU data from Hospital Episode Statistics health-care assistant time accounting for almost
and national incident reporting, to support the 90% of this. The costs increase with the category
wider government transparency agenda.5 of PU, as the higher categories tend to affect
All this is a welcome shift away from national individuals with pre-existing health problems, who
targets based solely on numbers and throughput, usually have more complex care requirements.13

Table 1. Main policy initiatives

Organisation Initiative
NICE (2005) Pressure Ulcers: Prevention and Treatment
DH (2009) High Impact Actions
EPUAP/NPUAP (2009) Prevention and treatment of pressure ulcers: quick reference guide.
NPSA (2010) 10 for 2010: Reducing Harm to Patients
DH (2009/10) Commissioning for Quality and Innovation (CQUIN)
Quality, Innovation, Productivity and Prevention (QIPP) Safe Care
DH (2010)
Workstream initiative
The Code: Standards of Conduct, Performance and Ethics for Nurses
NMC (2008)
and Midwives
DH (2011) Operating Framework for the NHS in England for 2012–13

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However, neither illness nor advancing age Measurement is the all-important foundation
should be used to justify PU development. to assessing change and improvement, and well-
It is unacceptable that an estimated 20% of developed systems must be in place to facilitate this.
hospitalised patients (approximately 20 000 Nevertheless, the core requirement is robust staff
inpatients at any one time) develop PUs,12 education to ensure that data input is valid, reliable
alongside many more (approximately 30 000) in and representative of the patient’s risk status.
the community and residential/care homes.4 This supplement describes how this concept of
Despite this, there is a lack of knowledge at trust high-quality PU care was put into place, with the
level about the extent of the problem, and how this help of industry, at a NHS Foundation Trust. The
compares with other trusts elsewhere. The Patients result was a downward year-on-year trend in PU
Association criticised trusts for not knowing how prevalence.
many patients with PUs they were treating, or how
their performance compared with other trusts.14 It The local background
also noted that data collection was not consistent The South Tees Hospitals NHS Foundation Trust, in
across all trusts and, when data was gathered, it was the north east of England, currently comprises the
not always used to improve services. James Cook University Hospital in Middlesbrough,
This is against of backdrop of significant the Friarage Hospital in Northallerton, and, since
concern about the abuse of older and vulnerable April 2011, local community services and seven
people in hospital and nursing care home community hospitals. It is the largest hospital
settings,15,16 and failure to keep adequate, up- trust in the Tees Valley, serving the populations of
to-date clinical records, particularly in relation Middlesbrough, Redcar and Cleveland, Hambleton
to pressure ulceration, which was a hallmark of and Richmondshire and beyond.
serious failings in care at Mid Staffordshire NHS Overall, hospital and community services
Foundation Trust. are provided to around 416 600 residents over
The key to providing high-quality, cost- a large geographical area, which increases to
effective care is, of course, to ensure that approximately 1.5 million when specialist regional
it is evidence-based, supported by practice services are included. Regional specialist expertise
development, and continually monitored and in cardiac care, spinal injuries, cancer services,
evaluated. All disciplines involved in the care of trauma, neurosciences, children’s services and
patients with PUs have a responsibility to deliver renal services, as well as general hospital and
care to this standard. As a more accurate picture community care, are delivered by almost 9000 staff
of the burden of PUs (and chronic wounds in in the trust. Links with the Universities of Teesside,
general) emerges in the UK, the importance of Durham and Newcastle are well established,
evidence-based guidance, being able to justify with medical, nursing and midwifery students
the choice of intervention, and having accurate undertaking clinical placements within the trust.
statistics on the size of the problem and patient The trust vision is to deliver world-class
outcomes is paramount. outcomes, dependable safety and an outstanding
High-quality, patient-centred care also involves experience for patients, their families and carers.
making every attempt to facilitate transparency, Trust values include putting patients’ needs at the
share positive experiences, eradicate poor centre of everything it does, seeking to improve
standards and establish standardised, best- service delivery, and encouraging its staff to support,
practice approaches to PU prevention and respect and value each other and the contributions
management. It is, by its nature, holistic, with made to team working.
patients’ best interests being maintained through
the assessment, planning, implementation,
The pre-existing 
evaluation and reassessment of care processes.17 system for monitoring 
Finally, there needs to be an underlying awareness PUs and equipment
of the importance of service development, Like most other health-care organisations,
coupled with the promotion of continuous South Tees Hospitals NHS Foundation Trust
improvements in the quality of care.17 has undergone significant change and major

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reconfiguration to meet financial challenges Furthermore, some nurses and doctors were
and improve services. Three high-maintenance unfamiliar with the pressure-redistributing
Victorian hospitals were closed and the key mattresses and their instructions for use once in
services centralised in the new James Cook situ. There was a common misconception that
Hospital site in Middlesbrough. Following the patients nursed on these mattresses did not need
reconfiguration, the number of hospital beds to be repositioned or could be repositioned less
reduced from 1400 to 1193. frequently. Patient assessments were inconsistent,
Traditionally, wound care and PU management partially completed or not implemented at all.
was delivered by clinical staff from various This was not ideal clinically or financially,
specialities with a keen interest in the subject. with poor correlation of data on patient
There was no consistent, centrally coordinated outcomes and rental costs resulting in
guidance, leadership or direction for PU care. The unnecessary financial expenditure. The situation
service was, at times, disjointed, erratic and ad was exposing the trust to possible complaints
hoc, despite the off-contract provision of pressure- and potential litigation. It should be noted that,
redistributing equipment from ArjoHuntleigh at this point, no national government agenda
(formerly Huntleigh Healthcare Ltd). targets, such as CQUIN, were in place.
ArjoHuntleigh had effectively provided a
supply of pressure-redistributing equipment in The appointment of a
response to requests from a range of grades of wound-care lead nurse
nursing and non-clinical staff. Annual prevalence In 2008, a designated wound-care lead nurse
data were collected, which included whether was appointed whose role focused on all aspects
or not there was appropriate use of pressure- of wound-care provision, education and related
redistribution surfaces against clinical need. This corporate agendas. She was instructed to focus
process was overseen by two clinical matrons on PU prevention and management input, with
with an indirect responsibility for managing support from the director of nursing and her line
PU prevention and treatment. The audit results manager (a senior trauma nurse). The wound-care
were discussed at quarterly meetings attended lead nurse believed that, to make progress, input
by the clinical matrons and ArjoHuntleigh, and needed to be steered from the ward right up to the
led to improvements in equipment choice and board and then back down to the ward again.
training, alongside the launch of a sponsored The wound-care lead nurse had a specialist
annual conference on basic wound care. At the clinical, academic (lecturer/practitioner) and
ward level, no structured cohesive process for managerial background. She was viewed as the
choosing equipment was in place, and staff of all architect of the PU service, and as a facilitator and
grades and designations, including ward clerks, expeditor. Her approach comprised negotiating,
were ordering pressure-redistributing equipment sharing and delegating responsibility for PU
directly from the company, often inappropriately prevention rather than blaming or berating
and without a sound rationale. nurses for ‘allowing’ PUs to develop. She
There was no discrimination between levels promoted the idea that ‘pressure ulcers are
of patient need, which meant that most patients everyone’s responsibility’, and said this concept
were placed on Nimbus 3 mattresses on the should underpin the wound-care service.
basis of Braden scores alone. In some cases, all The wound-care lead nurse was fully aware
patients were automatically placed on this high- of the imperfections in the service, and aimed
specification therapeutic surface ‘just in case’. to improve, in an upwards manner, clinical
This resulted in ‘over-treatment’ of patients, provision of wound care, education on it, and
who were often inaccurately risk assessed or not any related corporate governance. In addition,
risk assessed at all. Meanwhile, other patients her experience as a regional contact lead for
did not receive the appropriate equipment to wound care and equipment in the north east
manage their high-risk status. Over-spending procurement group enhanced her ability to
occurred without any rationale or demonstrable establish, lead and manage an effective and
improvement in patient outcomes. efficient service.

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The wound-care lead nurse was given the is a process that allows direct comparison to
authority and power to instigate change and the national profile. The ‘observed’ PU count is
ensure that it was an evolving process that met compared with the ‘expected’ ulcer rate within
the ever-changing needs of the patient, carer and the local population using a contemporary
organisation. Clearly, it would be a challenge to national reference containing subjects. Using
rationalise, agree and align the trust’s financial case-mix adjustment enables improvements to be
objectives with clinical need when there had tracked without undue influence from changing
been no formal system in place for so long. environmental factors, provides reliable trend
analysis and uses mobility as the key risk factor
Matching provision of care focusing directly on the major cause of ulcers. In
with clinical need addition, achievement of the key quality indicators
The whole system was quickly rationalised to for preventative care, compared over time, would
move away from focusing solely on mattress assist the Trust to monitor performance and to
expenditure to matching provision with address areas of improvement by targeting specific
clinical need. A contract meeting was held with areas of patient care as follows:
ArjoHuntleigh team members to discuss previous l PU risk assessment within 6 hours of admission

processes and prevalence history, and explore (Braden Risk assessment tool)
ways of moving this collaboration forward with l Plans for Preventative care

a greater clinical focus. While this dynamic new l Nutritional assessment — using the MUST score

approach was partly inspired by the government l Repositioning

policy agenda and trust targets, it also reflected l Timely and appropriate equipment allocation
a willingness to share ideas and concepts. against patient need.
ArjoHuntleigh team members contributed In addition to the above, the trust also collated
commercial expertise to this collaboration, information for staff on how to differentiate
identifying how existing resources could be better between moisture lesions and PUs. By using a
used to achieve these goals. quality management approach, this supported
This new approach was reflected in the the trust to understand nurses’ decision-making
agendas for the quarterly review meetings with processes and patient outcomes.
ArjoHuntleigh, where the emphasis changed to Clearly, this needed to be supported by
gaining an accurate, clinically focused picture of educational training, including one-to-one updates
the number of patients with trust-acquired PUs, in clinical ward areas. To achieve this, ArjoHuntleigh
the number admitted with PUs, their severity specialist nurses were allocated to the trust to help
and whether or not equipment was being the wound-care lead nurse and clinical matrons
appropriately allocated. The need for better data ensure that all staff were aware of the rationale for
on PU documentation, risk assessment, nutritional change and understood the national/international
values and skin integrity was also noted. guidelines and audit processes.
Wound care link nurses were appointed to
Implementation of an improved audit tool facilitate the prevalence audit process. One week
A priority was to review the data previously collected before the audit, they received a one-hour training
for the prevalence audit and include more patient- session, organised and directed by ArjoHuntleigh
specific data, in order to enable a broader view of and the wound-care lead nurse, to prepare them for
activity in the trust and then use this as the basis this role. In addition, wound care and PU training
for change in line with current NICE guidelines.18 workshops were held every month. These were
This priority coincided with the introduction of attended by members of the multidisciplinary
the ArjoHuntleigh Quality Management Audit team, including medical/surgical colleagues.
tool, which considers quality, patient safety, The audit was led by the wound-care lead
preventative care and financial impacts. An nurse, with support from ArjoHuntleigh
integral part of the quality management audit tool representatives. Ward staff were asked to
was the use of case-mix adjustment against the complete an audit form for every patient in a bed
company’s national data set. Case mix adjustment space on the day of the audit. To minimise the

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impact of any changes in ward composition, data data is collected at ward level on a trust-wide basis
were collected on all individuals on each ward and stored in a central database.
at an agreed time (usually 06:00). Data collected
included patient age, gender, weight, patient Establishing a new data pool
mobility and sitting out times, the category, body Ongoing audit results have highlighted changes
location and origin of each established PU (if it from which comparisons and trends can be
occurred before or during the current episode of identified, analysed and used to inform action
care), the presence of reduced skin integrity, such plans. The wound-care lead nurse and key
as a moisture lesion, and the patient’s likelihood representatives from ArjoHuntleigh review both
of developing a PU. The current provision of a the audit and CQUIN data, derived from NHS
pressure-redistributing mattress replacement Safety Thermometer database, at the quarterly
and/or a seat cushion, and how appropriate the audit meetings. Concerns are discussed, and an
provision of pressure-redistributing equipment action plan is formulated and shared with senior
was to each patient, were also recorded. trust colleagues, including local and regional
These data items were gathered through procurement leads.
discussion with relevant staff and from the In addition, local Datix PU (all categories),
nursing records. Patients were not asked any excoriation and moisture lesion incidence data
questions, and pressure areas were visually are analysed by the wound-care lead nurse,
inspected, as appropriate, by trust staff. reviewed and monitored in monthly meetings
In addition to the above data, further aspects with the Datix lead and then disseminated to the
of PU prevention and management were recorded, clinical matron forum and nursing and midwifery
such as evidence of a PU-specific care plan (wound professional group.
care continuum). The severity of established This invaluable data informs the wound-
ulcers was primarily reported using the EPUAP care lead nurse of the PU category, whether the
classification system,1 which describes PUs as patient developed the PU(s) in hospital or if it
belonging to one of four categories (Table 2). was present on admission, and whether moisture
These prevalence audits took place annually lesions are being reported inappropriately. One
up to 2011 and every 6  months thereafter. The concern was that staff were categorising moisture
audit results provide a detailed, accurate and useful lesions as category II PUs. The data is also shared
representation of PU care and equipment use in the with the patient safety team, and strategies for
trust, and form the basis from which action plans reduction are developed.
can be developed, with a view to improving practice PU incidence data is also compared with
in a series of stages. The audit results compared and prevalence data for reliability and accuracy, and to
analysed with the monthly PU prevalence data highlight themes and trends that can be linked to
submitted to the NHS Safety Thermometer. This the root cause analysis process, particularly within

Table 2. EPUAP and NPUAP pressure ulcer classification system1

Category Type of reaction

Category I Non-blanchable erythema of intact skin. Discolouration of the skin, warmth,
oedema, indurations or hardness may also be used
as indicators, particularly on individuals with darker skin.
Category II Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an abrasion or blister.
Category III Full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that
may extend down to, but not through, underlying fascia.
Category IV Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting
structures with or without full-thickness skin loss.

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the remit of safeguarding adults. Prevalence data the audit data results and trust audit action plan.
is collected within the ArjoHuntleigh audits and The wound-care lead nurse carries out one-to-
monthly by the patient safety team as part of its one PU and moisture lesion training in the trust’s
submission to NHS Safety. Incidence is correlated ‘hotspots’, usually the three clinical areas whose
daily as the incident report forms are generated. patients have been shown to be, through data
There is also a built-in mechanism to submit collection, at greatest risk of hospital-acquired
data to the NHS Information Centre for inclusion PUs. This training involves working with ward
and publication in the national database. The teams on the ‘shop floor’, demonstrating how
NHS Information Centre has a responsibility to to apply theory to practice, and answering any
publish the NHS Safety Thermometer data as questions and problem-solving as they occur.
‘experimental official statistics’ when sufficient The lead nurse is also known as an accessible
data has been accumulated and its quality is good clinical resource and active participant in
enough for national statistical analysis.19 care. ArjoHuntleigh was invited to attend the
clinical areas when there were issues relating to
Education equipment usage or product selection.
It was quickly realised that, in order to ensure Before 2008, ArjoHuntleigh had run an annual
that accurate data was being recorded, structured, wound care conference with several clinical
mandatory education needed to be delivered to matrons from various care settings. After 2008,
all grades of nurses, from health-care assistants the wound-care lead nurse and ArjoHuntleigh
to clinical matrons, therapists and medical/ thought it would be beneficial to all concerned
surgical staff, to guarantee consistent assessment to hold a company exhibition alongside it.
and documentation, and accurate, informed The annual conference is in its sixth year and
deployment of the pressure-redistributing is very well attended. Occupational therapists,
devices. Since April 2010, all health-care staff physiotherapists, medical staff, including general
have been required to report Serious Untoward practitioners, are encouraged to attend to ensure
Incident (SUI) reports about category III–IV PUs, a streamlined and consistent approach across all
so needed to be conversant with the consistent clinical divides.
detail of PU development and reporting.
A complete culture change was needed, moving Changing prevalence trends
away from a lack of focus on PU prevention to Since 2005, ArjoHuntleigh and trust staff have
more proactive prevention thought processes that collaborated to conduct the annual (and,
embraced detailed holistic assessment, accurate more recently, 6-monthly) prevalence audits.
PU identification and categorising, an awareness ArjoHuntleigh has also produced summaries of
and understanding of risk factors and the rental costs, savings and usage, as well as clinical
importance of clear, timely and comprehensive and technical updates on areas of good practice
documentation. and where further development and support are
Within 1 month of her appointment, the needed. These annual reports provide data on
wound-care lead nurse started delivering total mattress, seating, bed frame and specialist
monthly PU prevention and management therapy bed usage, plus costs broken down by
education sessions. Topics included patient and month and trust site.
skin assessment, PU grading, identification of To date, the audit results show a downward
moisture lesions, information about pressure- trend in the prevalence of hospital- and
redistributing equipment and how to access it, community-acquired PUs (Tables  3 and  4). For
and documentation. The sessions were supported, acute hospital-acquired PUs, prevalence has
and equipment sourced, by the ArjoHuntleigh reduced from 8.88% in 2008 to 2.82% in 2012.
specialist nurse, who jointly presented them in Prevalence of PU categories I and II have also
the first year of the programme. largely decreased in this time, from 7.88% to
Aide memoires were produced by the wound- 2.82%, with the only exception being a rise from
care lead nurse to supplement the training 4.3% to 5.2% in 2009–2010. Category III and IV
sessions. Their content was partly informed by PUs reduced to 0% in both 2011 and 2012.

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Table 3. Acute hospital-acquired pressure ulcer prevalence

2008 2009 2010 2011 2012

Number of patients audited 901 879 949 917 850
% with hospital-acquired pressure ulcer 8.88% 5.4% 5.8% 3.3% 2.82%
% with a category 1/II hospital-acquired pressure ulcer 7.88% 4.3% 5.2% 3.3% 2.82%
% with a category III /IV hospital-acquired pressure ulcer 1% 1% 0.6% 0% 0%

Table 4. Community hospital-acquired pressure ulcer prevalence

2011 2012
Number of patients audited 151 125
% with hospital-acquired pressure ulcer 10.60% 3.20%
% with a category 1/II hospital-acquired pressure ulcer 10.60% 3.20%
% with a category III /IV hospital-acquired pressure ulcer 0% 0%

Table 5.The costs of pressure ulcers 2009–2012

2009 2010 2011 2012
Number of patients developing PUs 100 95 57 83
Cost (based on NHS Calculator 2012) £502 000 £504 000 £278 000 £481 000

Community prevalence rates are only available not available (n=81) and/or were in a state of
from 2011, when the trust was reconfigured disrepair (n=35), with the vast majority not having
(Table 4). These show that acquired prevalence fell integrated pressure-redistributing cushions. While
from 10.60% to 3.20%, with similar rates for PU this is probably true of many hospital trusts, it
categories I and II. raises safety issues in the form of increased risk
In terms of total expenditure, the overall cost of pressure damage and spread of infection, and
of renting mattresses, seating, specialist therapy undermines patient rehabilitation.
beds (air-fluidised, bariatric) and beds had risen
from £113 058 in 2007 to £117 683 in 2008. Moving the agenda forward
Management concerns had been raised about The northeast collaborative procurement hub
the consistent rise in Trust mattress usage each (CPH) aimsf to enhance the strategic procurement
month in 2008 on both sites and its cost. capabilities and performance of all NHS trusts and
Based on the NHS Calculator 2012 costings primary care trusts in the region. It undertakes
(2008–2009 prices), the 100 patients with PUs spend analysis across the regional health
in 2009 cost the trust £502 000; 95 patients in economy to identify and assess opportunities
2010 cost £504 000; in 2011, 57 patients cost for savings, advise stakeholders which existing
£278 000. The downward trend in numbers and contracts offer best value, aggregate demand and
costs between 2009 and 2011 was desirable but, negotiate contracts on a regional basis
following community integration into the trust, The north east CPH invited trusts to nominate
in 2012 the figure rose to 83 patients costing representatives to become members. As a result,
£481 000 (Table 5). the wound-care lead nurse, procurement lead
A chair audit carried out in November 2011 and trust finance representative became actively
showed that, in many clinical areas, chairs were involved in the group. They took a proactive

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approach to procurement, including the progress made, a tender process had to be

acquisition of PU prevention and management initiated. Tender documents detailing the level
equipment at a competitive price. of service provision required were submitted
To achieve this, trust meetings were held to the procurement group. The tender process
to review trends in the PU prevalence and started and bids were invited from the various
incidence data, and identify equipment needs. equipment companies. The next article describes
It was felt that, in order to consolidate the this tender process in more detail. n

The tender process

Maureen Benbow & Sharon Bateman

O
ut of 12 possible bids for the calculated on past expenditure before the M. Benbow, MSc,
contract, only five companies met integration of hospital and community, the cost BA (Hons), RGN,
HERC, Senior
the requirements of the tender saving was approximately £22 000. The contract Lecturer;1
specification and submitted a bid. was awarded to the second company. S.D. Bateman, MA,
BSc (Hons), RGN, Dip,
The wound-care lead nurse and trust procurement The second decision the trust had to make Wound Care Lead
lead arranged an industry roadshow at which in relation to the supply of pressure-relieving Nurse;2
the five companies were invited to exhibit their equipment and beds was whether to opt for a sole 1 University of Chester,
UK.
key products. A regional evaluation form was tender offering or framework contract (taking 2 South Tees NHS
devised to assist with the selection of products and rental equipment from two or more companies). Hospitals Foundation
company offerings, taking into account service Following the integration of community services Trust, UK.
requirements and the companies’ ability to fulfil into the new combined trust, community
them. The tender specification included individual patients’ needs would have to be carefully
items such as mattress/bed cleaning arrangements, considered to ensure seamless service provision
delivery and removal times, equipment guarantees, across care sectors while maintaining the same
the scope for and timing of repairs, and related standards throughout.
costs. The forum group considered the evaluations It was decided that a framework agreement
for their clinical suitability. that included bed frames, pressure-relieving
The bids of two companies were considered mattresses, cushions and specialised therapy
suitable for the needs of the trust. One company equipment, such as bariatric, intensive therapy
had a long-established track record of supplying a beds and associated equipment, was the best
wide range of equipment, mainly to hospitals; the option for the whole trust.
second company’s supply experience was mainly The trust beds were audited around the same
community based. The former company would time and found to be in dire need of improvement.
have had no problem supplying and managing The bed audit showed that only 60% of the total
the service, but its bid was the higher of the two. were electric profiling beds. Replacing so many
Decisions had to be made based on quality and beds would be a gradual and very costly process.
track record as well as cost, as the objective data The tender process was conducted in a
on cost was somewhat imprecise. transparent and logical way, and considered the
In the bids, the first company based its costs needs of patients across different settings and
on an average acute hospital stay of 13 days and specialties. It resulted in significantly improved,
the second company on an average community cost-effective service provision. The keys to
figure of 96 days, which was obviously more success, as evidence by the downward trend in
expensive. Based on these figures, which were prevalence rates, were robust communication,

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both during and after the contract was awarded, prevalence).20 Prevalence reflects the number, but
a well-established, equal working partnership not the origin, of the PUs surveyed.21 Measuring
with ArjoHuntleigh staff, a team approach and point prevalence data is described as an efficient
discussion of progress and issues at the quarterly method of assessing patients’ need for resources.22
rental contract meetings. Other significant The main disadvantage, though, is that a badly
factors related to good user knowledge of designed data-collection tool, when used under
equipment and processes on the clinical floor, tight time constraints, will not provide detailed
robust ongoing educational programmes, and quality data.
trust in and reliability of the current provider, Incidence is defined as the number of persons
alongside the regular clinical presence of its in a particular population who develop a new
specialist nursing team. PU within a particular time period.23 Increas­
ingly, the more demanding task of collecting
A goal-focused strategy PU incidence data over time is considered the
Numerous benefits have materialised as a result survey of choice. Repeat data for individual
of the significant changes made in the 4 years patients allows for a dynamic overview of
since the appointment of the wound-care lead improvement or deterioration, any related risk
nurse. These can be mainly attributed to the factors and contributing influences, and case-
streamlining of the service achieved by agreeing mix analysis of heterogeneous populations.
a contract in 2010 with ArjoHuntleigh, and The process of collecting and collating PU
a suitable service level agreement. This was incidence data at South Tees is progressing well
underpinned by ongoing, mandatory education as a result of education, improved reporting and
and analysis of reliable, objective data with company support.
ArjoHuntleigh. This involved introducing
processes for validating the correlation of audit Factors that contributed to success
data, checking the data form content at the time The downward trend in PU prevalence reported
of data entry, and clinical discussions with the above can be attributed to various factors. They
wound-care lead nurse on the audit day to clarify also, of course, form the foundation for future
any data anomalies or omissions. success. These are outlined below.
The data enabled us to reflect on how national As part of the Quality Management audit tool,
trends were affecting patient profiles. For a risk assessment and mobility matrix were used
example, the data revealed an increased demand to reflect on local trends and identify both trust-
for bariatric equipment, along with other changes wide and ward-level hotspots, using case-mix
in patient demographics and needs. adjustment against the national dataset. These
‘hotspots’ can be targeted for improvement
Prevalence versus incidence through more frequent audits. Hot spots include
PU prevalence surveys have been conducted acute medical wards, cardiac high dependency
throughout UK trusts for many years. wards, critical care and orthopaedics. The matrix
ArjoHuntleigh has an impressive track record also identifies overall standards of care and
of conducting PU prevalence surveys from its clinical outcomes, and so can be used to highlight
database, which collates annual data from up areas for improvement.
to 44 acute NHS trusts in England and Wales, Clearly defined responsibilities for PU
out of approximately 167  trusts, covering up to prevention/management were assigned to
30 000  patients. The national database is one of employees at all levels of the organisation, from the
the most reliable data collections on PUs, and can chief executive down to health-care staff and the
be used as a template for comparing prevalence multidisciplinary team. Assisted by the wound-care
rates using the case-mix adjustment process. lead nurse, the operational clinical lead, managers
Prevalence is defined as the measure of the and clinical matron were given responsibility for
number of people with a disease in a defined training and access to it, facilitating one-to-one
population, either within a certain time (period support when required, and providing appropriate
prevalence) or at a specific point in time (point pressure care equipment (Box 1).

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Box 1.Therapeutic surfaces

Nimbus 3 — a mattress replacement systems provides an effective active1 pressure redistribution

(alternating therapy) combined with automatic adjustment to the weight, size and position of the
individual, ensuring optimum pressure relief and comfort.This is a zoned mattress which includes
a dedicated healguard section which keeps pressure at the heel lower for longer. Supports the
prevention and management of all categories of pressure ulcers with repositioning and monitoring

Auto Logic 200 — a mattress replacement system offers dual modalities in active (alternating)
and reactive therapy (constant low pressure). An automatic, self setting mattress and seat cushion
combination with active transport. Supports the prevention and management of all categories of
pressure ulcers with repositioning and monitoring

Breeze — a low air loss mattress replacement system provide pressure redistribution and is
suitable for the prevention and management of pressure ulcers with repositioning and monitoring.
This mattress can be used across a wide range of patient groups including patients unable to
tolerate a moving surface, low weight or end of life care.

To improve categorisation, all clinical staff walks’ to check that equipment is being used
with patient care responsibilities are required to appropriately, using this an opportunity for ad
attend an annual PU/moisture lesion workshop hoc opportunistic training. Staff are therefore
delivered by the wound-care lead nurse, patient supported in their learning and skills base,
safety advisor and a member of the ArjoHuntleigh enabling them to use resources more clinically
team. In addition, all newly appointed first-level and cost effectively. In addition, the new
nurses receive training on PU prevention on contract has made it easier to order, maintain,
induction into the trust. decontaminate and repair equipment.
The trust’s commitment to improve PU care is As part of the contract, a simple product
clear from its policy, which states that staff must be selection guide was produced on how to order the
able to carry out a full assessment to determine if a correct mattress/bed/cushion, based on the Braden
patient is at risk of developing PUs/moisture lesions, score, the presence/absence of a PU or moisture
and demonstrate and maintain competence in lesion, and the PU category. This was prompted by
planning, implementation and evaluation of care the inappropriate choice of Nimbus 3 mattresses
processes. Staff must work to the most up-to-date for all patients at risk and/or with PUs, and so helps
evidence-based recommendations and guidelines reassure staff that it is acceptable to nurse patients
for prevention, treatment, categorisation, and on good-quality foam mattresses in certain
reporting of safeguarding issues, and maintain circumstances: if patients have no PUs or category I
accurate, concise PU/wound care records. and II PUs, moisture lesions, are at low risk (Braden
Considerable attention was paid to the 17–23) or medium risk (Braden 12–16). Rather than
selection and use of equipment. The equipment placing all patients on the more expensive Nimbus
standard highlighted the need for safety checks, 3 mattress, Auto Logic  200 mattresses should be
information on appropriate decontamination, chosen for patients with category III and IV ulcers,
mechanisms for ordering/returning devices and multiple PUs and/or at high risk (Braden 9–15).
a specialist support service for staff, patients and The Nimbus 3, Breeze and bariatric equipment
carers on all aspects of PU management. To help are recommended for specialist requirements,
achieve this, clinical area/ward-based clinical such as patients weighing 30 stone or more, those
support is provided by the wound-care lead receiving palliative care, those with category III
nurse, clinical matrons, patient safety advisor and IV ulcers, multiple PUs and/or heel PUs, and
and ArjoHuntleigh staff, who also conduct ‘ward those requiring bariatric care. The system now

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supports the appropriate allocation and removal of Notable improvements seen since the service
pressure-relieving equipment. Staff are reminded was rationalised include the reduction in the
to adhere to the core care plan. percentage of patients with hospital-acquired
An indicator of the effectiveness of this PUs from 7.63% in 2005 to 5.80% in 2010. The
proactive, collaborative approach is that the percentage of severe ulcers (categories III and IV)
trust’s CQUIN targets have been achieved for the also reduced, from 24% in 2005 to 15% in 2010.
past 3 years and currently run at 3.3%. This partly
reflects the fact that PUs are high on the agenda Other trust strategies
at the regular matron’s meetings, and monthly The South Tees Hospitals NHS Foundation Trust
PU training is mandatory. Wound Care Strategy 2010–2013 vision for the
In summary, the benefits to the trust, patients future wound care service is characterised by strong
and multidisciplinary team are clear. Improved, leadership, consistent dissemination of research,
regular, mandatory, targeted education across and coordination across all trust boundaries.
all disciplines, combined with raised awareness To achieve this, service provision includes up-
of evidence-based interventions, followed by to-date advice on the care of patients with leg
evaluation, has improved standards of care and ulcers, stomas, skin tears, burns, grafts, surgical
reduced the incidence of PUs. site dehiscence, reconstructive and traumatic
wounds, and PU prevention and management.
Other benefits for the trust The wound-care lead nurse’s role encompasses not
A proficient wound care service not only aims only the promotion of high standards of wound-
to improve local patient outcomes, but also care provision and management, but also senior
to contribute to the trust’s productivity and clinical leadership, clarification of staff roles and
efficiency agenda. This has been achieved by responsibilities, application of evidence-based
improving referral rates and treatment choices, policy and robust training programmes.
optimising recovery times, and reducing adverse An ongoing ‘portfolio of evidence’ collated
incidents and antibiotics usage. This has required by the trust’s health-care governance directorate
commitment at every level in the trust, while the includes up-to-date policies, minutes of relevant
collaboration with ArjoHuntleigh has also been a trust group meetings, audit and surveillance reports
significant advantage. and trust and divisional annual delivery plans.
Patient benefits include avoidance of pain, In January 2012, the South Tees Hospitals NHS
discomfort and extended length of hospital stay Foundation Trust Pressure Ulcer/Moisture Lesion
resulting from delayed wound healing, infection Prevention and Management Policy G119 was
or incorrect management in the community. The approved. It aimed to standardise care across all
reduction in complaints reflects the increased settings and environments, and promote best
patient confidence in the care received. practice in the prevention and management of
As stated above, the CQUIN payment PUs/moisture lesions. It is anticipated that this
framework makes a proportion of providers’ will lead to more accurate auditing of moisture
income conditional on locally agreed goals lesions and category II PUs.
around quality and innovation. The trust’s The world does not stand still and improvements
CQUIN agenda agreement for 2010–2011 need to be maintained, and policies, guidance and
comprised a 25% reduction in hospital-acquired educational support updated. The current plans are
category III and IV PUs and 95% compliance to establish a trust-wide wound-care practitioner
with the target that all patients should undergo forum to facilitate dissemination of evidence and
a Braden risk assessment within 6 hours of improvements. A register of named wound-care
admission.18 The trust Nursing and Midwifery practitioners will be educated to a higher level
Strategy required a 25% reduction in hospital- of knowledge and skills through regular wound-
acquired category I PUs, and that Braden scores care update meetings. Responsibility for reviews
should be documented and root cause analysis of existing and gap analysis on key health-care
undertaken on 95% and 100% of hospital- documents, audits and policies will remain with
acquired PUs within 14 days of classification. the wound-care lead nurse.

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The aim now is to maintain and refine the current

The future systems for future improvements.
The benefits for service users of the South Tees Lord Kelvin (of the Kelvin Scale) stated that
Hospitals NHS Foundation Trust cannot be ‘If you can’t measure it, you can’t improve it’.
denied and have accrued as a result of focused However, that does not consider what effects
service development, collaboration with industry the improvement has on the individual which,
and planned improvement. Strong leadership, in health care particularly, has to be the test of
management support and ongoing, mandatory change. With a renewed focus on the patient
education for all staff have formed the experience and satisfaction, and patients’
foundation from which appropriate, evidence- increased awareness of what ‘should be done’,
based clinical management and PU prevention we have no choice but to ‘get it right first time’
has materialised. Government drivers for change to protect not only their safety but also the
have been embraced, and targets have been and reputation and financial integrity of the health-
will continue to be met with positive outcomes. care organisation. n

References
1 European Pressure Ulcer Liberating the NHS. DH, 2010. ulcers in the UK. Age Ageing. Secondary Care. CG29. NICE,
Advisory Panel (EPUAP), 2004; 33: 3, 2390–2395. 2005.
National Pressure Ulcer 7 Department of Health
Advisory Panel (NPUAP). (DH). The NHS Quality, 14 The Patients Association. 19 NHS Information Centre.
Treatment of Pressure Ulcers: Innovation, Productivity and Meaningful and comparable NHS Safety Thermometer.
Quick Reference Guide. Prevention Challenge: An information? Tissue viability London: The Health and Social
Available from: http://tinyurl. Introduction for Clinicians. nursing services and Pressure Care Information Centre.
com/ygjykjx [Accessed August DH, 2010. Ulcers. Available from: http:// Available from: http://tinyurl.
2012]. www.wcauk.org/downloads/ com/79zr7r5 [Accessed
8 Kiernan, M., Downie, F. tvn_report.pdf [Accessed August 2012].
2 Department of Health Prevention of pressure ulcers: August 2012].
(DH). High Impact Actions could a care bundle approach 20 Donaldson, R., Donaldson,
for Nursing and Midwifery. be a success? Wounds UK. 15 Department of Health R. Essential Community
DH, 2009. Available from: 2011; 7: 1, 157–158. (DH). National Service Medicine (including relevant
http://tinyurl.com/265h3v6 Framework for Older People. social sciences). MTP Press,
9 Vanderwee, K., Clark, M., DH, 2001. 1985.
[Accessed August 2012]. Dealey, C. et al. Pressure ulcer
3 Trueman, P., Whitehead, S.J. prevalence in Europe: a pilot 16 Department of 21 Maklebust, J., Siegreen, M.
The economics of pressure- study. J Eval Clin Prac. 2007; Health (DH). No Secrets: Pressure Ulcers. Guidelines for
relieving surfaces: an illustrative 13: 2, 227–235. Guidance on developing and Prevention and Management.
case study of the impact of Implementing Multi-agency Springhouse, 2000.
10 Gallagher, P., Barry, P., policies and Procedures to
high-specification surfaces on Hartigan, I. et al. Prevalence 22 Williams, S., Watret, L., Pell,
hospital finances. Int Wound J. Protect Vulnerable Adults
of pressure ulcers in three from Abuse. DH, 2001. J. Case mix adjusted incidence
2010; 7: 1, 48–54. university teaching hospitals in of pressure ulcers in acute
4 National Patient Safety Ireland. J Tissue Viability. 2008; 17 Department of Health medical and surgical wards. In:
Agency. 10 for 2010 Initiative. 17: 4, 103–109. (DH). Essence of Care Clark, M. (ed). Pressure Ulcers.
Available from: http://tinyurl. 2010. Benchmarks for the Recent Advances in Tissue
11 Clark, M. Pressure Ulcers. Fundamental aspects of Care. Viability. Quay Books, 2004.
com/2axrnqx [Accessed Smith & Nephew Foundation,
August 2012]. Benchmarks for Prevention
2007. and Management of Pressure 23 Defloor, T., Clark, M.,
5 Department of Health Ulcers. DH, 2010. Witherow, A. et al. EPUAP
12 Posnett, J., Franks, P.J. The statement on prevalence
(DH).The Operating costs of skin breakdown and
Framework for the NHS in 18 National Institute for and incidence monitoring of
ulceration in the UK. Smith & Health and Clinical Excellence pressure ulcer occurrence
England 2012/13. DH, 2012. Nephew Foundation, 2007. (NICE). Pressure Ulcers: The 2005. European Pressure
6 Department of Health 13 Bennett, G., Dealey, C., Management of Pressure Ulcer Advisory Panel Review.
(DH). Equity and Excellence. Posnett, J. The cost of pressure Ulcers in Primary and 2005; 6: 3, 74–80.

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