Improving patient safety
Aneurin Bevan UHB - #ShareforcareWales: Reducing Health Acquired Pressure Ulcers across Aneurin Bevan University Health Board
507 Health Acquired Pressure Ulcers (HAPUs) were reported for the two major acute hospitals in Aneurin Bevan University Health Board (ABUHB) between January and August 2017. Whilst the health and wellbeing cost to patients and their families is substantial, the financial cost to ABUHB was more than £500K per year in redress compensation; not counting treatment cost, additional nurse time and the cost of 5-8 additional inpatient days.
The ABUHB Pressure Ulcer Prevention Collaborative programme was launched in September 2017 with 6 wards at Royal Gwent Hospital (RGH). The programme’s aim was to reduce the incidence of HAPUs by 50% (regardless of grade) and to eradicate all avoidable grade 3 and 4 HAPUs, within 10 months.
More than 30 sets of Plan, Do, Study, Action (PDSA) cycles were carried out. Alongside other learning opportunities, these cycles allowed the programme team to learn how to reliably collect and feedback data to frontline staff to highlight the relationship between compliance and HAPU incidence, and how to enable staff to “do” – and not to wait for ideas and permission to initiate small-scale changes. The cycles also supported the programme to learn how to communicate information, and how to remove barriers for communication between shifts, teams and wards.
An important set of PDSAs around the development of visual triggers for timely care involved the “Pressure Ulcer sticker”. The sticker was trialled and tweaked in clinical practice until data showed significant improvement of compliance and management of pressure ulcers.
These changes have led to a HAPU-free period on the ward of more than a year (still counting), and the programme has been adapted and adopted across other collaborative wards. As at April 2019, 12 wards have participated on the programme for between 9-18 months.
