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Preventing Pressure Ulcers

With a single-minded mission of eliminating bed sores, SPS Apollo, Ludhiana is a good example of how sensitising and mobilising the entire staff can produce excellent results. Rita Dutta showcases this success story

Quality is what the state-of-the art tertiary care hospital, SPS Apollo Hospital, Ludhiana, vouches for, having a long list of medical marvels attached to its name and also being JCI-accredited. So, when the 350-bed hospital realised that the shadow of pressure ulcers (commonly known as bed sores) was looming large on it, the first reaction was that of panic.

The First Case

It was in January 2008, during a routine meeting of the Infection Control Committee (ICC), the shocking revelation emerged that pressure ulcer was on un upward swing every month in the hospital. A quick survey by infection control nurses revealed that the prevalence rate of hospital-acquired pressure ulcer were 8.2 per cent, 8.5 per cent and 7.1 per cent for February, March and April 2008 respectively. This was higher compared to the international benchmark. Says Dr Muktanjali Arya, Microbiologist and Infection Control Officer, Apollo Hospital, Ludhiana, "International healthcare publications report the incidence rates of pressure ulcer to be between one to 11 per cent and prevalence rates of three per cent to 22 per cent. The benchmark of National Database of Nursing Quality Indicators (NDNQI), 2006 is 5.21 per cent for hospital- acquired pressure ulcers."

The Rapid Action Force

The journey towards controlling the menace of pressure ulcer began with an ICC meeting in March 2008. The first step was to constitute a pressure ulcer prevention team, which comprised Dr SP Singh (Chief Operating Officer), Sister Soosama Varghese (Nursing Superintendent), Dr Vinay Singhal, (Consultant-Critical Care) and Dr Muktanjali Arya (Microbiologist and Infection Control Officer).

Not seeking any external help, the team reviewed international literature and after some brainstorming sessions, devised guidelines which they refer as 'pressure ulcer initiatives'.

The Guidelines

Pressure ulcer poster

Though a number of diverse etiopathologic factors interact to cause pressure ulcer (for more info see box), the most important is unrelieved pressure. So, the prevention guidelines were aimed at relieving this pressure. With 70 per cent hospital-acquired pressure ulcers being seen in critical area patients and the rest in non-critical areas, the drive was focused on patients in critical areas. Other areas of caution were of patients with major surgery who are likely to stay for more than a week, on physical restraints and complaints of incontinence.

Risk Assessment Form

A risk assessment form based on Braden scale was introduced. The Braden Scale is a simple and easy-to-use tool which allows nurses to quickly assess the risk of ulcer development, as well as modify care and interventions to target those specific factors which put patients in danger. This form is maintained for every patient.

Says Dr SP Singh, COO, Apollo Hospital, Ludhiana, "If the score was 16 or less, pressure ulcer prevention protocols were initiated. Risk assessment was done on admission and thereafter, once in a day. Each pressure ulcer site was given a number and is encircled on the picture. Pressure ulcer stages (I-IV) were also explained."

If a patient already has pressure ulcer on admission or develops it later- the stage, site number, type of dressing, antibiotics given and surgical interventions done are documented on the form. The treating consultant is notified and the nurse concerned signs the form.

Turn-Clock Position Method

Turn clock position method

Studies suggest that a regimen should be established in which pressure is completely relieved on all areas of the body at regular intervals. So, position changes, every two hours, according to turn clock position method, were introduced.

This clock shows a different position for every two hours. For instance, supine from 12 pm to 2 pm and also, 12 am-2 am. It is followed, unless contraindicated, in which case, the intensivist or primary consultant decides the positions.

Informs Col Neera Devi, Chief of Nursing Services, Apollo Hospital, Ludhiana, "Following the turn clock makes it easier for nurses. Also, it makes our pressure ulcer prevention team's job easier as we can easily catch a patient whose position has not been changed." For example, if the team is on rounds at 7 am and finds that a patient at risk is in supine position, but according to turn clock the patient was supposed to be in lateral position, the nurse responsible is called and questioned.

Introducing the turn clock position method met with resistance from nurses as they felt it was difficult to remember and also that not all patients can be put in these positions. The hospital now is in the process of simplifying the turn clock position.

Back Care

For maintaining a healthy skin, back care is given every four hours. "A mild soap is used for cleaning. It is important that the skin is clean and dry. The entire body is checked for spots, colour changes and any other signs especially, pressure points over bony parts. If a discoloured area is noticed, it is checked for blanching of that area by pressure and then releasing, as it is a sign of skin breakdown if it does not blanch," informs Col Neera Devi.

Patient Care

The hospital used a slew of other preventive measures. It used pillows and cushions to keep patients' knees and ankles apart. When lying on back, a pillow is placed under lower calves to ankles, to keep heels off the bed.

Malnutrition is an important underlying risks factor for the development of pressure ulcer. So, diet with adequate calories, protein, vitamin C and other nutrients is recommended by dieticians. Providing toileting needs is also important to prevent pressure ulcers— wet diapers/ clothes are changed often to avoid skin contact with urine/ faeces.

Training

"After May 2008, the rates for hospital acquired pressure ulcer initiative is below one per cent" - Muktanjali Arya Infection Control Officer Apollo Hospital, Ludhiana

"Following the turn clock methods we can easily catch a patient whose position has not been changed" - Col Neera Devi Chief of Nursing Services Apollo Hospital, Ludhiana

Training was critical to the success of the pressure ulcer prevention drive. A detailed content was developed by the pressure ulcer prevention team. The contents for the trainings were questions like — what are pressure ulcers, causes for pressure ulcers, patho-physiology, stages of pressure sore, risk factors for pressure ulcers, clinical manifestations, how to prevent pressure ulcers, turn clock position method, medical and surgical management and nursing care for pressure ulcers. Training was imparted in the form of classroom training, 'nukkad' and on-round trainings. Says Chandneet Bindra, HR-Manager, Apollo Hospital, Ludhiana, "The Capability Management Department scheduled sessions and was made responsible to ensure that all the nurses undergo these trainings. In order to ensure overall coverage, we decided to have a combination of training methods— nukkad sessions and on round trainings."

About nukkad session, Bindra explains, "Infection control nurse/ infection control officer would go to each nursing station, collect all the nurses and teach them. This was done in busy wards where the nurses could not leave their work and go to the classrooms." Additionally, infection control team while, on hospital rounds, would ask questions and impart training. This was used to assess the knowledge of the nurses on pressure ulcers and also to reinforce what was taught earlier.

Pressure ulcer was made an integral part of infection control training programme. So, all new recruitments and old employees are regularly trained on pressure ulcer protocols.

Posters

Various posters, which included guidelines for pressure ulcer prevention and also explained the turn clock position method, were displayed at all the nursing stations and patient care areas.

Mission Successful

The interventions were started in April 2008 and the hospital experienced encouraging results by next month itself. "Hospital-acquired pressure ulcer reduced from 7.1 per cent in April, 2008 to 1.4 per cent in May 2008. Thereafter, till now, the rates have been maintained below one per cent," informs Dr Arya.

The hospital is still continuing with training and continuous monitoring. Besides infection control nurses, some additional nurses have been assigned the duty for round-the-clock monitoring.

With the battle on pressure ulcers waged successfully, the hospital is raring to go. By next year, the hospital plans to scale up its ICU beds from 60 to 100.

rita.dutta@expressindia.com