Immobility predisposes patients who are already at a high risk of skin breakdown to develop pressure ulceration. Being able to assess and monitor patients at an elevated risk of tissue breakdown is one way to reduce the overall number of patients who progress to the stage of pre-ulcerative or ulcerative conditions—both of which significantly reduce quality of life.
The current report describes a small-scale quality improvement pilot intervention study designed to minimise the risk of pressure ulcer (PU) development or a deterioration of tissue viability in patients of a regional ambulance service in the north east of England. The study was conducted between October and December 2017.
This intervention included the introduction of a ‘pressure ulcer alert’ bracelet by paramedic practitioners working for the North East Ambulance Service (NEAS), who also implemented a PU risk assessment tool for patients who had to be admitted to an acute hospital trust. The project was part of a pressure ulcer collaborative intervention facilitated by the Academic & Health Science Network for the North East and North Cumbria using a recognised quality improvement methodology.
The NHS Safety Thermometer (Public Health England (PHE), 2015) reported that between April 2014 and March 2015, 25 000 patients had developed new pressure ulceration. This is an average of 2000 newly acquired PUs each month in the NHS in England. The financial cost to the NHS varies depending on the severity of the PU and likelihood of complications but was estimated as £1214–14 108 per patient. Emergency department (ED) winter pressures and delayed ambulance responses have been identified as potentially detrimental contributory factors to patients at risk of pressure damage. National Institute of Health and Care Excellence (NICE) (2014) guidance recommends that practitioners should be aware that all patients are potentially at risk of developing a PU.
Multivariate logistic regression analyses undertaken as part of confirming studies have identified several risk factors for the development of pressure ulceration in people who are immobile: being aged 75 years or over; being female; having a BMI of less than 23 and/or a Braden score of 14 or less; anaemia; respiratory disease; and a pre-existing diagnosis of hypertension (Ladd et al, 2018; Aloweni et al, 2019). These are important indicators for multi- and interdisciplinary health professionals whose recognition of the risk of tissue breakdown and interventions can play a pivotal role in preventing mortality and morbidity (Smith et al, 2018).
A key example of this work is evident in paramedic practice, where paramedics' identification of potentially or actual compromised tissue viability and a good awareness of risk status can make the difference between preventing tissue breakdown and epithelial breach occurring. NEAS is at the forefront of changing the service model from traditional ambulance transport to emergency care provision. Recognising patients at risk of developing PUs is a new challenge for NEAS staff.
An increasing number of patients being transferred to hospitals are at risk of developing a PU as defined by NICE (2014). Immobility—a main risk factor for pressure damage—could affect patients who have fallen and are unable to move.
A discussion at the Northern Directors of Nursing Forum in 2017 outlined the potential for NEAS to lead the way in the early identification of patients at risk of developing PUs and prompting ED staff to start interventions early. It was proposed that paramedics could identify patients at risk and fit them with a straightforward PU alert bracelet before they were handed over to the ED. The aim was to educate paramedics to better identify patients with PUs or those who were at risk of tissue damage.
Materials and methods
The project adopted a pragmatic, systematic approach to methods and used a formal ‘Plan, Do, Study, Act’ improvement methodology. This was influenced by traditional models of quality and safety advocated by Polancich et al (2012) (Figure 1).
Ethical approval
Formal ethical approval for this study was granted by the University of Sunderland institutional ethics committee. All data collection was undertaken with the informed consent of participating staff and patients. Participants were given an information sheet about the study before signing a consent form.
Methodology
The infection prevention and control (IPC) manager liaised with 12 clinical care managers from three geographical clusters in the Sunderland area. A formal cascade methodology (Table 1) was employed to provide teams with PU awareness training and pilot information to ensure parity and equity in the pedagogical underpinning of the intervention strategy (Byrne et al, 2008).
| Phase | Factors |
|---|---|
| Phase 1 Selection of pressure ulceration prevention guidelines for standardisation in clinical practice for multidisciplinary team use | Factors pertaining to the selection of pressure ulcer prevention guidelines |
| Epidemiology/demographic characteristics | |
| Relative interdependence regarding resourcing the project and funding opportunities | |
| Availability of discipline-specific tissue viability experts to substantiate the proposal of added interventions in practice | |
| Phase 2 Identification and selection of target staff groups | Key practice-based experts: emergency department personnel; hospital trusts; ambulance service personnel; infection control and prevention manager; clinical care managers |
| Phase 3 Identifying the level of resources required for each level of intervention with the pressure ulceration prevention bracelet | Basic, core resources or fundamental services essential to the pressure ulcer prevention scheme becoming operational (i.e. incorporation of the pressure ulcer risk assessment) |
| Provision of colour-coded pressure ulcer alert bracelets | |
| Interdisciplinary referral to specialist care for pressure ulceration intervention where necessary | |
| Phase 4 Adaptation of intervention according to the level of resources | Specific factors to be considered |
| Cost and funding of overall project | |
| Media production (short film): https://www.youtube.com/embed/yNSz4mlU4hM?rel=0 | |
| Resource implications | |
| Infrastructure barriers and enablers | |
| Pragmatic issues | |
| Professional practice issues/interprofessional communication | |
| Training and education | |
| Modified Delphi process | Local experts who are representative of different contexts (geographical, level of resources etc) |
A PU awareness booklet, aide-memoire and a supply of PU alert bracelets and paper risk assessments were given to all staff at the time of their training for future use in paramedic practice. PU bracelets were coded as follows:
Posters explaining the nature and purpose of the pilot were placed in all participating ambulance stations and information was sent out via internal information bulletins to NEAS staff. Risks were calculated using the PU assessment tool and patients at risk were identified to ED staff at handover and with the use of a PU alert bracelet placed by paramedics. Prior to this, PU awareness education had been introduced in NEAS as mandatory training over the period from April 2016 to March 2017. A PU risk assessment (PURA) tool for paramedics to use was ratified by the hospital trust ambulance service patient safety group in May 2017. In September 2017, NEAS joined a PU project called PROACT—a group committed to raising awareness of the signs and symptoms of PUs in different health and social care settings, facilitated by Sunderland Clinical Commissioning Group, which augmented the collaboration between NEAS and Sunderland Royal Hospital, part of City Hospitals Sunderland NHS Foundation Trust and the site of the ED piloting the PU alert bracelet. This pilot intervention to introduce the PU alert bracelet was carried out over a 3-month period from October to December 2017.
ED staff and the tissue viability team at City Hospitals Sunderland NHS Foundation Trust supported the pilot. Information was provided to ED staff using posters, and the NEAS IPC manager visited the ED and formally discussed the project with staff. A short film made by the PROACT project showed ambulance and ED staff how the alert bracelet was used, and is available at https://www.youtube.com/embed/yNSz4mlU4hM?rel=0.
Cascade training was provided to 112 NEAS crew members, facilitated by the clinical care managers from the three geographical cluster areas involved; the IPC manager, assisted by a paramedic, facilitated training on site at the ED.
The PURA baseline questions give a choice of three risk factors, which are further subdivided, as shown in Table 2.
| Query | Further query |
|---|---|
| Has the patient a pressure ulcer? | Is there evidence of pressure damage/skin breakdown, bruising, blistering or wounds (check underneath medical devices) |
| Has the patient had a pressure ulcer or bed sore in the past? | If so, where? |
| Is the patient immobile and been lying for more than 20 minutes? | If so, for approximately how long? |
Results
Data were collected from the records of 130 patients who had been fitted with a PU alert bracelet. The patient information used in data analysis included the NEAS PURA, the electronic patient clinical record (EPCR) and hospital inpatient records. Three sets of records were excluded from the analysis, as two patients were admitted to other hospitals in the area, and the third patient's records were excluded as the EPCR had not been completed correctly. The records of the remaining 127 patients were included in the data analysis.
Sixty five (51%) women and 62 (49%) men were identified as being at risk and were fitted with a PU alert bracelet by ambulance crew. They were aged between 23 years and 100 years, with the majority (85%) being aged 70 years and above.
Demographics, reasons for call-out and pressure ulcer risk factors
Breakdown by sex is shown in Figure 2 and the living circumstances of each participant are presented in Figure 3.
The home circumstances of patients at risk demonstrate the vulnerability of those living alone, with only one patient recorded as independent. The majority of patients lived alone or in warden-controlled accommodation (43%). Patients assessed at risk who were living in nursing homes or residential homes accounted for 27% of the study population.
The reasons documented by ambulance crew for initial call-outs generated multiple responses, with the greatest number being for falls (Figure 4). The ambulance crew often chose more than one risk factor when assessing patients, and included combinations of all three risk factors. This could be interpreted as paramedics identifying patients with multifactorial conditions, placing them at increased risk of the development of PUs (Figure 5).
Findings using the PURA tool
PURA question 1: has the patient a pressure ulcer?
Crew reported that 67 (53%) of patients had a PU and were identified to ED staff on transfer.
Thirty-one (24%) patients were assessed as having all three risk factors of:
Fifteen (12%) patients were assessed as having a PU and were also immobile. Eighteen (14%) patients were assessed as having a PU. NEAS crews documented the grade of PU from patient care records, district nurse documentation and by taking a history from patient carers.
PURA question 2: has the patient had a pressure ulcer or bed sore in the past?
Ambulance crews documented that 49 (38%) patients had a history of PUs. Three were identified as being at risk because they had a history of PUs, and a further 12 were immobile and had a history of PUs. These 15 patients (12%) were fitted with an alert bracelet to notify ED staff about the history of PUs and that they were at increased risk.
PURA question 3: is the patient immobile and been lying for more than 20 minutes?
Immobility (where patients have been lying for 20 minutes or more) was the most commonly reported risk factor by paramedic practitioners. A total of 103 (81%) patients were assessed as being immobile or having fallen and been lying for a sustained period of time. Of these, 45 (35%) were identified as being immobile and/or been lying for 20 minutes or more; this included those who had fallen. Although this evaluation did not record the length of time patients had been lying, some crew documented estimated times, which included overnight.
EPCR pressure ulcer documentation
A key objective of the pilot was to improve the documentation of PUs by ambulance staff, using the existing PU function on the EPCR when a patient with a PU was identified. Instructions for this were included in the PU awareness training booklet crews had been given. While there was a clear rise in the use of the EPCR PU function reporting during the 3 pilot months (October-December 2017), this might also realistically indicate a natural variation or simply that the incidence of PUs peaks in the autumn and winter months (Figure 8) (Rodrigues et al, 2019).
Findings from ED records
The pilot aimed to educate ambulance crews to identify patients at risk of pressure damage. This should ensure that patients at risk were promptly identified to hospital staff and a correspondingly prompt PURA would follow. The need for a prompt PU assessment was the message relayed verbally to the ED and integrated admission unit nurses, and this was reinforced beyond the immediate interaction of personnel with the display of posters detailing the same information.
Figures 4 and 6 provide an insight into the reasons given for calling the ambulance service and the presence of existing PUs. Both indicate the relationship between immobility and falls in relation to cases presenting in the EDs that took part in the study. Of the 127 patients admitted with a PU risk alert bracelet:
PU training was introduced as part of NEAS mandatory training for a 12-month period (April 2016 to March 2017). Further training was delivered to the crews within the pilot area; this did not include training to differentially diagnose the existence of moisture lesions.
Three (2%) patients were assessed as having a hospital-acquired PU, which was verified by the hospital tissue viability nurse:
The costs associated with PU care and hospitalisation have been identified by PHE (2015). Within the context of this pilot study, costs associated with the timings of inpatient stays for patients could also be considered by crews using the PU alert bracelets, as the savings and shorter lengths of stay that result from identifying PU risk would motivate practitioners to use them.
The pilot initiative could be viewed as successful. The risk assessment was used appropriately by ambulance crew, which was confirmed by reviewing the records of the patients who were given an alert bracelet. Ambulance crew also significantly increased their documentation of PUs in the EPCR, which indicated training was effective. Ambulance crew verbally reported they thought the initiative to place an alert bracelet on at-risk patients would be beneficial as this would alert ED staff. The acute trust staff evaluation from the ED and integrated admission unit nurses reported that 82% thought the initiative would benefit patients.
Discussion
The PU alert pilot arose from a straightforward idea that identification bracelets could be used to help identify at-risk patients to ED staff. This meant an educational intervention was implemented to equip paramedics in the use of a risk assessment tool to facilitate the identification of patients at risk of compromised tissue viability.
Consistent with literature in the field of tissue viability, the study revealed that the majority of patients were aged over 70 years. There was also evidence that paramedic practitioners had risk assessed patients across a relatively wide age range, including patients as young as 23.
From the data collected, it was evident that patient falls were the commonest reason for transfer to EDs but, overall, clinical reasons for call-outs were diverse.
Figure 9 shows the PU count on electronic patient clinical records at the time the study was carried out. Figure 10 shows the degree of inpatient skin damage and consequent PU grading.
This indicated that ambulance crews were assessing patients for pressure damage on an entirely individual basis and were also considering pressure damage for patients with comorbidities whose main complaints included conditions such as chest infections and urinary tract infections, and who may not necessarily have fallen.
It is notable that this evaluation did not gather information on the exact time that patients had fallen but it was noted that ambulance crew frequently documented the approximate time that patients had been lying on hard surfaces before they had reached them. The increased vulnerability of patients living alone was apparent from the data.
Ambulance crews often indicated that more than one risk factor was evident in the patients they assessed. The identification by ambulance crews of 67 (53%) patients having a PU was supported by hospital PU assessments. Ambulance staff did not often grade PUs; although PU grading was included in the training pack, ambulance staff said reporting their presence was more important. There was evidence that ambulance staff documented PUs that had been graded by district nurses. Documented evidence in EPCRs could be found in all 127 cases where it was appropriate for patients to have an alert bracelet.
Limitations
As noted, the current pilot did not include information regarding time patients spent on the floor. In any further studies, this would be a useful adjunct set of data.
As noted above, a lack of pre-study statistics meant that benchmarking data was impossible. In any full study in future, this would be a meaningful source for comparison.
The evidence that ambulance crews were also identifying the high risk factor of patients having had a PU in the past indicated that training in risk factors was successful.
However, it should be acknowledged that potential numbers of missed patients (i.e. false negatives) were not included in the pilot study. The approach failed to account for patients who were not fitted with PU bracelets, so it is not possible to measure non-compliance within this pilot study. Again, this is an area that could be addressed in any full study undertaken to follow this pilot.
The authors acknowledge that subjective verbal reports were obtained from the ambulance crews rather than structured interviews, since pragmatically the project offered no scope for this. Furthermore, their position as participants with an embedded stance in paramedic practice is fully acknowledged in relation to the potential for epistemological bias.
This is information that ED staff could use to help prevent further pressure damage. The intervention of using a PU risk assessment and an alert bracelet is therefore useful; how effective it is in minimising the risk of patients developing further tissue damage relies on hospital staff acting on information that ambulance crews can provide.
Conclusions
The current study showed that NEAS formally recognised the need for and implemented a PU care strategy. As part of this process, PU awareness training will continue on a mandatory basis and will be extended to incorporate further information on pressure-relieving interventions that can minimise the risk of PU development for vulnerable patients in their care.
Monitoring those identified as being at risk was an aspect of care provision highlighted for extension. It can be concluded that PU alert bracelets for patients being admitted to hospitals were beneficial in facilitating pragmatic and quick identification by ED nurses of those at risk of pressure damage, and this included alerting them to people who had a history of PUs.
The pilot intervention also successfully increased collaborative working with service providers, including communication between ambulance staff and ED staff. Collaborative work with academic health science networks and regional PU collaborative partnerships is recommended, with frontline staff from NEAS and EDs included in projects. As a longer term plan, it may be possible to develop the scheme so that there is more effective collaboration between NEAS staff and the primary care teams who may be able to intervene to prevent pressure ulceration in vulnerable patients.
The present study also highlighted the need to make pressure reduction equipment available to paramedics, as this would minimise risk and potentially improve outcomes.
Most importantly, this initial small-scale pilot study showed that the scheme could potentially be transferred to other ambulance services to help prevent PUs over a much wider geographical area.
This raises important questions regarding how the education and training of the future paramedic workforce will ensure knowledge and practical experience in the prevention of pressure ulceration in practice. The authors warmly welcome academic and pedagogical debate about how this might best be achieved in relation to their ongoing work in the context of health services research and health professions pedagogy.