The Standard 8

Pressure ulcer is fifth most common condition which needs to be prevented in case of older people according to the Australian commission on safety and quality in health care (ACSQHC). It is possible to prevent pressure ulcer and the healing time of this condition is long which causes problem for older people like disturbances in sleep and moving ability (Smith, 2014) Older people are at risk of pressure ulcers due to changes in their body system because the older peoplestarts loosing their skin based adipose tissue. Thus preventive measures are required for these. Everyone including staff, patients himself or paid helper have to play a role in prevention of pressure ulcer. The policy used for this purpose is Pressure injury prevention and Management policy (Haesler, Kottner and Cuddigan, 2017). The policy directive describes the procedural approaches which are according with the ACSQHC, National Safety and Quality Health service standards (NSQHSS), Standard 8-preventing and managing pressure injuries, 2012. The (NSQHSS) started on 1 January 2013. The standard 8 includes those systems and strategies to prevent old people who develop pressure ulcers and management of those injuries. The purpose of this policy

1. Health service provider should provide the government structure and system related to it for prevention of pressure ulcer.
2. Screening of patients and implementation of the strategies are required for prevention of pressure ulcer.
3. Proper practice guidelines are used for management of patients with pressure ulcer.
4. The patients and the paid helpers should be informed about the risks and strategies for prevention and managing of that pressure ulcer.

The main purpose of this policy is to:-

1. To reduce the occurrence of pressure ulcer of older people of NSW by having risk assessment and management of risks and the following treatment.
2. To establish a consistent systematic practice procedure for preventing and management around NSW health.
3. National Safety and Quality Heath Service Standards (NSQHSS) should be followed by health services in accordance to preventing of pressure injury and its managing.
4. To enhance the awareness of staffs paid helpers, patients and the public about the importance of prevention strategies of pressure ulcer in old people.

This policy helps the older people suffering from pressure ulcers by prevention and managing of the risk factors involved. The screening of the patients is done and then the planning for the prevention is too made following the NSQHSS. The older patients are normally prone to this pressure ulcer and thus the paid helper and staff and public are given valid information for the prevention of this condition. The prevention strategies include routine for mobility which involves manual tasks (Clarkson et al., 2016). The pain involved in this condition is managed and monitored. The skin which is fragile is protected and moisture is reduced. The nutrition and hydration is taken care of the older patient (Neilson et al. 2014) Management of the pressure ulcer is also taken care by this policy because the patients who have this type of injury are at risk of injury worsening or developing any other injuries related to it. The proper care planning is done with assessment of the pressure ulcer and assessment of the pain (Ghaisas et al., 2014).

In our workplace which is private hospital a survey of some older patients in acute care unit and some of our colleagues and found out that some of the policy strategies needs to be updated and to be planned for providing care for prevention of pressure ulcer in case of older patients. The patients who were surveyed were admitted to the hospital for various problems like spine problem or other issues. The older people were main in the risk for developing of pressure ulcer as they can hardly move their body freely as compared to the older people. We surveyed our colleagues mainly nurses and tried to find out the main causes of increasing pressure ulcer in old patients.  In our workplace we surveyed all the old patients who are admitted in the hospital and needs care for pressure injury and also those who does not need it for the time being. The nurses and the ward boy who are employed for taking care of patients before and after treatment has been surveyed and asked for the problems they are facing in providing of care. The main reason is the incomplete knowledge of the nurses. The nurses and ward boy have no proper (limited) education for the care which they have to do for prevention of the pressure ulcer in case of older patient (Dealey et al., 2013). The prevention of pressure ulcer needs proper risk assessment first within 8 hrs of admission of patients. But due to lack of knowledge it is not identified. There is a need for updating the policy for structured risk assessment in case of this pressure ulcer (McBride and Richardson, 2015). Recommendation is being made for updating this policy.

Overview of Current Policy

The second point which the patients and the nurses pointed out was the provision of special mattresses which will cause relief from pressure ulcers and keep the skin moist (Pagnamenta, 2017). Provision of these mattresses to each old age patient is very costly. There should be some provision by which the cost of these mattresses to be used can be reduced and numbers increased in each health care unit. As these mattresses are required for reducing the pressure ulcer we need to provide it to each patient who absolutely requires it. But according to survey in our workplace among 100 patients only 45 people can be provided with these mattresses. The patients complained that all are not provided with the specific mattresses as it gets costly for the organization to provision of care. The third main reason is low workforce in the hospital especially for only providing care for pressure ulcer for older patient. The work like moving the patient every 2 hr and then providing proper diet needs extra workforce which is not present. The older people need to be repositioned so that no place gets extra pressure for long time and the skin remains dry in that case (Bradford, 2016). The nurses who are engaged in this type of activity needs proper training by qualified personnel so that the nurses get trained and proper care can be provided to the older patients. So some policies should be updated to remove these barriers.  

A question arises in case of prevention of pressure ulcer in older patients. Whether there is a need for screening of the risk in getting pressure ulcer in older patient when admitted to hospital and importance of educating the workforce in the organization regarding that. Another question arises which involves the cost of materials providing prevention related care for the pressure ulcer. Thirdly whether there is a need for extra workforce for the clinical problem. The first question needs the employing of proper screening tool for identification of risks in case of older people for development of pressure ulcer. There have been cases in the clinical workplace the patients especially old are not being assessed properly for their chances of getting the pressure ulcer. Pressure ulcer is a state in which a skin gets fragile and causes injury of the skin due to prolonged pressure on a particular spot (Duffin, 2014). Older people find difficulty in mobility and unknowingly gives pressure on particular spot for long times which develops this injury. Thus to prevent this type of injury initial screening of the risk factors are required (Lachenbruch et al., 2016). For this a risk assessment tool (RAT) has to be employed in the organization for its screening process to be modified (Richardson and Barrow, 2015).

The Victoria Quality Council (VQC) of Australia conducted many surveys using prentice’s methodology to check prevalence of pressure ulcer. The survey was done in the year 2003, 2004 and 2006. It showed that use of RAT reduced the risk of pressure ulcer in older patients. It was found that almost 33 % of reduction in the prevalence of pressure ulcer. The survey list showed that in 2003 (26.5%), 2004 (20.8%) and finally in 2006(17.6%) prevalence of pressure ulcer. In the survey of 2006 it is also found that the use of RAT has increased by 25.1 % in the health organizations. The use of this tool is beneficial in the prevention of pressure ulcer (Roberts et al., 2017). If within 8 hrs a screening is done using some scale for the scope of pressure ulcer in older patients then it will be easy to prevent the injury. Survey was done in our workplace and almost same findings were found. Is screening is proper then the patients will be easily released without any injury related issues from the hospital and finally hospital will benefit and save readmission cost. The patient can also get easily mixed with the community without any further issues (Ellis, 2017). Another issue is regarding the education and training of the official staffs of the organization. The nurses and ward boy who are engaged in the care of patients should know how to use the RAT and check for the screening (Chou, 2013). The clinicians and paid helper and the nurses must be trained for the use of this risk assessment tool so that proper care can be provided to the patient. According to survey the incomplete knowledge of the hospital staff has lead to 40 % prevalence of pressure ulcer in 2006. Thus it is recommended that a timely training of the staffs should be taken in a fixed timeframe.  And a monthly small interview test should be done just to check the knowledge of the staff after training and to know how they are implementing it. A cross sectional study was done in our workplace. A pressure ulcer test was taken having 50 questions to be answered by the nurses and work staff. It was found that 50 % questions were answered by 60 % of the nurses. The mean score was 60%. The results prove need for proper training for the nurses (Lawrence, Fulbrook and Miles, 2015). Another policy to be updated is the use of pressure relieving devices like mattresses. The older patient who has difficulty in moving should be given proper mattresses of special quality which helps in removing the moisture from skins and benefit the patient. The staff should also be aware of the uses of these equipments as contamination should be avoided between patients. To perform all these tasks like screening using RAT and the proper handling of pressure releasing devices extra trained workforce is required (Padula, Wald and Makic, 2013). So if trained personnel’s are employed who will be deployed only for prevention care of pressure ulcer then it will give better benefits than the same staff doing all work.

Consultation Activities: Improving the Current Policy

The problems as discussed above needs to be solved along with developing the action plan for its implementation. For the problem related to the risk assessment tool following requires use of specific tool for screening of risk factors (Carreau et al., 2015). This can be achieved by use of Braden scale which consists of six criteria for checking of risk factors. The criteria are 1) checking of moisture of skin, 2) level of activity of patient, 3) to check capability of patient for adjusting the body movement, 4) checking the need for nutrition of the patient, 5) to check for friction of the skin, 6) to check the sense of pain of the patient. The score scale of the scale is from very high risk to no risk category. The use of this scale will ease out the assessing process of pressure ulcer and further problem relating to the injury can be avoided. This is successfully implemented and a reduction has been noticed in the prevalence of pressure injuries in older patients.

The second updating required is regarding the training provided to the staffs and the nurses about the steps involved for proper care for the prevention of injury in older patient. There should be some training program which should be taken by qualified personnel or some online training program should be implemented for this process. The education program of Western Australia is online education program which should be implemented for training of staffs. It has education modules which helps clinicians and staffs.  This implementation has brought confidence in staffs in our workplace. Also an update is required to be implemented regarding the uses of pressure relieving mattresses and its using techniques need to be informed to staffs of healthcare. Wherever there is possibility of changing the mattresses for patients it should be done through mattresses replacement program. The staffs and patient will be benefited from this (Hampton, 2017). Another implementation required use of recruitment of volunteers who can help in the care for prevention of pressure injuries. Proper campaigning of pressure ulcer and its need of prevention and care for older patients can be done. This will help in finding volunteers who can help in care of older patients and reduce the workload of regular staffs and nurses. The volunteers can help in changing of position of patients in fixed time frame and then helping with their activity and small activities which will help the regular nurses to concentrate on serious issues of the pressure ulcers (Shannon, Brown and Chakravarthy, 2012). This implementation of these actions are necessary so that the prevalence of pressure ulcer is reduced in older patients which will help the patients and the organization by reducing the costs involved in treating of this injury symptom.

Task /Activity	Resources	Timeframe	Outcome measures of success
Use of Braden scale for the screening of the risk factors involved in prevention of pressure ulcer in older patients.	ACSQHC	Within 8 hr from the time of admission of the patient	Decreases the prevalence of pressure ulcer in older patient.
Training for the staffs and paid helpers for the prevention.	ACSQHC and western Australia wounds west online wound management education program.	Every 2 months	The staffs and nurses gained confidence in the providing care for the older patients.
Training and information to be provided to the staffs and nurses regarding use of pressure reliving devices like mattresses. Use of mattresses related programs.	ACSQHC	Every month	The patients showed improvement and were relieved from pressure related issues. The older mattresses were replaced with new mattresses.
Employing trained personnel only for providing proper care in pressure ulcer. Campaigning and giving information regarding this disease will help in getting trained volunteers for this work.	ACSQHC	Within a year	This step eased out loads from regular staffs and nurses and helped in proper management of care of pressure ulcer.

Conclusion:-

The three main learning’s are one is that any disease can be preventing if initially it is screened properly. Secondly the use of proper equipment can increase the initial cost of the organization but will prevent the costs which involves after occurrence of pressure ulcers. Thirdly proper education and training is the main hindrance in providing care of any disease. Thus proper trained staff can be beneficial in this case.

Literature Review

This report consist of the changes in policy which done to improve some measures in the prevention of pressure ulcers in older patients. The policy used in case of pressure ulcer in Australia is the standard 8 of ACSQHC which is followed. Some changes have been done in the policy to improve the quality in case of pressure injury. The changes have been implemented in our workplace and positive outcomes have been noticed. Pressure ulcer is a condition which is normally found in the case of older people as they are unable for activity and mobility which creates pressure in certain places which causes injury. Pressure ulcer is a big issue in Australia and it leads to formation of strategies which are used for its care. Proper care has to be taken for prevention of such condition. If the screening is proper in the initial stage it helps in proper management to be followed in according to avoiding of the injury. The use of proper pressure relieving equipment also helps in the avoidance of this injury.

References:-

Bradford, N., 2016. Repositioning for pressure ulcer prevention in adults-A Cochrane review. International Journal of Nursing Practice, 22(1), pp.108-109.

Carreau, L., Niezgoda, H., Trainor, A., Parent, M. and Woodbury, M., 2015. Pilot Study Compares Scores of the Resident Assessment Instrument Minimum Data Set Version 2.0 (MDS 2.0) Pressure Ulcer Risk Scale with the Braden Pressure Ulcer Risk Assessment for Patients in Complex Continuing Care. Advances in Skin & Wound Care, 28(1), pp.28-33.

Chou, R., 2013. Pressure Ulcer Risk Assessment and Prevention. Annals of Internal Medicine, 159(10), p.718.

Clarkson, P., Bader, D., Schoonhoven, L. and Worsley, P., 2016. A multidisciplinary approach to pressure ulcer prevention: exploring healthcare professionals’ knowledge and attitudes to pressure ulcer prevention in the community. Physiotherapy, 102, pp.e256-e257.

Dealey, C., Brindle, C., Black, J., Alves, P., Santamaria, N., Call, E. and Clark, M., 2013. Challenges in pressure ulcer prevention. International Wound Journal, 12(3), pp.309-312.

Duffin, C., 2014. NICE issues guidance on pressure ulcer prevention and management. Nursing Standard, 28(35), pp.10-10.

Ellis, M., 2017. Pressure ulcer prevention in care home settings. Nursing Older People, 29(3), pp.29-37.

Ghaisas, S., Pyatak, E., Blanche, E., Blanchard, J. and Clark, F., 2014. Lifestyle Changes and Pressure Ulcer Prevention in Adults With Spinal Cord Injury in the Pressure Ulcer Prevention Study Lifestyle Intervention. American Journal of Occupational Therapy, 69(1), pp.6901290020p1.

Haesler, E., Kottner, J. and Cuddigan, J., 2017. The 2014 International Pressure Ulcer Guideline: methods and development. Journal of Advanced Nursing, 73(6), pp.1515-1530..

Hampton, S., 2017. Could lateral tilt mattresses be the answer to pressure ulcer prevention and management?. British Journal of Community Nursing, 22(Sup3), pp.S6-S12.

Lachenbruch, C., Ribble, D., Emmons, K. and VanGilder, C., 2016. Pressure Ulcer Risk in the Incontinent Patient. Journal of Wound, Ostomy and Continence Nursing, 43(3), pp.235-241.

Lawrence, P., Fulbrook, P. and Miles, S., 2015. A Survey of Australian Nurses? Knowledge of Pressure Injury/Pressure Ulcer Management. Journal of Wound, Ostomy and Continence Nursing, 42(5), pp.450-460.

McBride, J. and Richardson, A., 2015. A critical care network pressure ulcer prevention quality improvement project. Nursing in Critical Care, 21(6), pp.343-350.

Neilson, J., Avital, L., Willock, J. and Broad, N., 2014. Using a national guideline to prevent and manage pressure ulcers: Julie Neilson and colleagues detail the updated National Institute for Health and Care Excellence guidance and its implications for senior nurses. Nursing Management, 21(2), pp.18-21.

Padula, W., Wald, H. and Makic, M., 2013. Pressure Ulcer Risk Assessment and Prevention. Annals of Internal Medicine, 159(10), p.718.

Pagnamenta, F., 2017. The provision of therapy mattresses for pressure ulcer prevention. British Journal of Nursing, 26(6), pp.S28-S33.

Richardson, A. and Barrow, I., 2015. Part 1: Pressure ulcer assessment – the development of Critical Care Pressure Ulcer Assessment Tool made Easy (CALCULATE). Nursing in Critical Care, 20(6), pp.308-314.

Roberts, S., Wallis, M., McInnes, E., Bucknall, T., Banks, M., Ball, L. and Chaboyer, W., 2017. Patients’ Perceptions of a Pressure Ulcer Prevention Care Bundle in Hospital: A Qualitative Descriptive Study to Guide Evidence-Based Practice. Worldviews on Evidence-Based Nursing.

Shannon, R., Brown, L. and Chakravarthy, D., 2012. Pressure Ulcer Prevention Program Study. Advances in Skin & Wound Care, 25(10), pp.450-464.

Smith, A., 2014. Pressure ulcer prevention. Nursing Standard, 28(31), pp.61-61.