Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

RCSI's Prof Zena Moore chairs healthcare initiative which aims to prevent Pressure Ulcers

01 October 2014
Pressure Ulcers to Zero, an innovative healthcare initiative aimed at reducing and ultimately preventing pressure ulcers in patients was launched in the HSE Dublin North East (DNE) region earlier this year. The initiatives steering group is chaired by Professor Zena Moore, Head of the School of Nursing and Midwifery, RCSI (Royal College of Surgeons in Ireland). It is part of the National Quality Improvement Programme, a joint programme between the HSE and the RCPI and brings together 21 teams from different healthcare settings in the DNE Region including acute hospitals, primary care teams, public and private nursing and residential units, maternity services and disability services. The teams include tissue viability nurses, healthcare assistants, household staff, nursing staff, midwives, physiotherapists, occupational therapists and dieticians. 

Pictured (l-r) is Gillian Whyte Practice Development Coordinator, Maeve Hyland Tissue Viability Nurse Cavan Monaghan Hospitals, Caralyn Horne, Quality Improvement Manager PCCC Cavan Monaghan, Cornelia Stuart, HSE Lead, Quality Improvement, Quality and Patient Safety Division, Prof. Zena Moore Head of School of Nursing and Midwifery RCSI, Geraldine Craig Tissue Viability Nurse Louth Meath Hospitald Group, Julie Jordan O Brien RCSI /Beaumont Hospital
The initial target for the six month initiative was to reduce the number of avoidable pressure ulcers by 50% by the end of September. The data provided by the teams to date shows that the actual reduction has been a very successful 73%.
Sometimes known as bedsores or pressure sores, pressure ulcers are a type of injury that affects areas of the skin and underlying tissue. Prof Moore, explains; "Pressure ulcers are an increasing problem that affect thousands of people unnecessarily every year. They are painful, debilitating and can be life threatening. Around one in 20 people who are admitted to hospital with an acute (sudden) illness will develop a pressure ulcer; with people over 70 being particularly vulnerable. It is estimated that it could cost €250 million per annum to manage pressure ulcers across all care settings in Ireland (Gethin et al, 2005)".
Pressure Ulcers to Zero follows the collaborative learning model developed by the Institute for Health Improvement (IHI), Boston, USA and is designed to bring together groups of individuals from different organisations to focus on a specific topic. Learning sessions are arranged where the teams can come and work together, and consider a particular problem in their own organisation and how they can implement a model of care to address the problem and bring about an improvement in patient care. While the subject for this collaborative is pressure ulcers, the methodology can and hopefully will be used in the future to implement change in other areas.
Since February 2014, the teams in the Pressure Ulcer collaborative have been focusing on the SSKIN Bundle of care to target pressure ulcers. SSKIN is an acronym used to identify the five key steps for protecting patients at risk of pressure ulcer development; 1-Skin Inspection 2-Surface 3-Keep Moving 4-Incontinence Management 5-Nutrition. Tissue Viability Nurse Geraldine Craig from the Louth Meath Hospital Group team explains; "The first step is to inspect the patients' skin regularly to check areas most at risk. Secondly we make sure the patient is seated or lying on the correct surface. In so far as possible, we keep the patient moving to prevent pressure on same areas all of the time. Incontinence management is also very important to ensure the patient is not lying on a wet surface and that their skin is properly moisturised. It is also crucial to make sure the patient has the right diet and is properly hydrated with correct fluid intake".
According to Professor Conor O'Keane, Co-Chair, National Quality Improvement Programme; "The impact of a multidisciplinary team in driving quality and improvements from the front line cannot be underestimated. Through using IHI system wide improvement methodology in this collaborative we have increased team communication and engagement across multiple institutions and teams, which has led to positive outcomes on our patients' safety".
In order to track progress, the teams have been recording on a daily basis the number of patients in their respective units and wards who have pressure ulcers. This information is recorded in a simple chart known as a ‘safety cross‘. The safety cross allows the teams to differentiate between those patients who have been admitted with a pressure ulcer and those patients who have developed a pressure ulcer since admission. Teams can therefore not only track their progress but can also track emerging trends and patterns that help to identify potential areas or actions that could bring about benefits and improvements.

One such action that has already been noted is the potential benefit of introducing a system that identifies a patient who has a pressure ulcer or is at risk of developing a pressure ulcer as they move through the healthcare system such as from a residential unit to acute care or community care. This is demonstrated by the recent actions of the Howth Sutton Primary Care Team when they requested a client to display a ‘pressure alert' sticker when presenting for a hospital appointment. The hospital staff recognised the pressure ulcer alert and took the necessary action to support the patients' pressure ulcer prevention care.
The benefits of such an approach are echoed by Professor Moore as she explains; "Many of the interventions we use for pressure ulcers are intrusive and have significant costs. Not only by implementing the SSKIN care bundle are we preventing pressure ulcers; but also by taking this more proactive approach we know who really is at risk and who is not, therefore we can target interventions in the most appropriate way which can be a very clinically effective and cost effective way of providing patient care".
Dr. Philip Crowley National Director, Quality and Patient Safety Division, explains how the approach of the collaborative has been different in that it is not about implementing change in one small setting, but instead working and learning together across a range of settings to implement change on a much larger scale. He explains the next steps are to complete the collaborative in the DNE Region, evaluate it and use the learning to inform future use of the collaborative methodology. He says " Evidence to date has shown that when health professionals, managers, patients, families and carers work in partnership the quality and safety of care increase, costs decrease and patient's experience of care improves. We believe Pressure Ulcers to Zero is proving this to be the case."
For further information visit