Background Pressure ulcers are wounds that occur due to an inability to change your position to relieve pressure and are graded from 1 to 4 depending on the damage to the skin and underlying tissues (National Pressue Ulcer Advisory Panel and European Pressure Ulcers Advisory Panel 2009). Pressure ulcers have a number of adverse impacts. The most important one is on patients in terms of increased morbidity, pain and reduced quality of life but they can also cause distress to their relatives and carers. Pressure ulcers can affect clinical staff in terms of their workload linked to documentation, assessment, treatment, prevention and data collection. In addition, pressure ulcers impact on health care providers as they are associated with increased costs and resource use linked to staff time, wound dressings and specialist mattress provision.
At risk patients can be identified through clinical judgement and the use of assessment scales. Prevention and treatment are focussed on reducing tissue damage through regular turning and the use of specialist pressure relieving beds and mattresses (Jones 2009). These specialist mattresses come in a number of different types including dynamic, where there are air cells that inflate and deflate, and fixed low air-loss which do not inflate and deflate. These can vary in terms of their costs and availability (Defloor et al. 2005)
There may be a potential for the number of the mattresses available within the acute setting to be less than ideal (Vanderwee et al. 2008). This can be a result of them requiring time to clean and sterilise in order for them to be available for subsequent patients. One consequence of this may be that patients are waiting to be placed on a mattress. The waiting time for the mattress may be due to the lack of mattresses in circulation or their inappropriate use on patients who may not require such mattresses or whose condition has improved so that the mattress is no longer required. The increased waiting time may also mean that the patient may be at a greater risk of developing a pressure ulcer whilst awaiting the mattress. However, there is no current data regarding the number of occasions that this may happen and whether patients develop pressure ulcers irrespective of if they are on a mattress or not. There may also be the potential for the patient to experience problems when they are discharged home, or to another care setting, where they may be using traditional foam mattresses rather than a pressure relieving mattress. A consequence could be that carers or the patients do not realise the importance of regular changes in position and so there is an increased risk of acquiring a pressure ulcer
Project Aim To evaluate the impact of using a triage nurse (a nurse who makes decisions regarding priority and need) to promote the timely and effective use of pressure relieving mattresses on patient outcomes and staff behaviour.
1. Evaluate whether a mattress management system would increase the efficiency of the use of pressure relieving mattress. 2. To gather data regarding patient risk factors and the provision of mattresses. 3. Produce a simple model of the mattress usage to provide information regarding the efficient use of mattresses including the optimum number of mattresses needed.
Methods The project will collect data regarding whether having a mattress management system i.e. using a mattress triage nurse will result in a reduced waiting time and efficiency in mattress provision in an acute hospital. A system will be piloted in clinical areas which have been identified as having a higher than average mattress usage or pressure ulcer prevalence. Patients will be screened by the mattress triage nurse regarding suitability for a dynamic mattress. Detailed information will be collected regarding pressure ulcer risk, co-morbidities, the presence/ absence of pressure ulcer prior to a mattress being allocated. In addition, patients currently on a mattress will be screened to evaluate whether they continue to need a dynamic mattress. Finally, the data will be used to inform a model of pressure ulcer mattress provision which will seek to identify the most efficient use of dynamic mattresses within the local Trust.
There currently seems to be a lack of detailed data regarding mattress utilisation. Data will be collected regarding the total number of mattress in circulation, waiting times, assessment criteria, types of patients and their co-morbidities using the mattresses, duration of mattress use, and proportion of patients using mattresses. Some of these data such as waiting time, duration of mattress use and number of mattresses in circulation, will be available on a retrospective basis. However, data regarding types of patients will need to be collected prospectively for a period of three months.
In order to obtain data on how clinicians make decisions regarding mattress use and how patients on the waiting list are managed, a period of observation within the clinical area will be undertaken. An observer will use a pro forma to collect data regarding pressure area care. Data will include frequency of interventions, numbers and range of clinical staff and resources used. Based on a previous CLAHRC SY project that collected data on nutritional interventions (see the EQONS project at http://clahrc-sy.nihr.ac.uk/theme-knowledge-projects-eqons.html) it is anticipated that there would need to be a total of five data collection points lasting four hours each.
The main intervention will be the screening and assessment of patients who have been identified as needing a dynamic mattress. The aim will be to assess the suitability and need of patients for a dynamic mattress and also to check on whether patients have a continued need for a pressure relieving mattress. It is proposed that a mattress triage nurse will be appointed for ten months until December 2013, in order to screen and evaluate dynamic mattress provision. The triage nurse will collect data to inform provision and also assess the patients allocated a mattresses about whether their need has changed.
It is anticipated that the triage nurse would have an impact on the total number of dynamic mattresses allocated. The potential for mattresses to be released would result in a reduction in the waiting time for mattresses. Also, that the triage nurse would help to influence the behaviour of clinical staff in regard to mattress selection and the assessment of the need of the patients for the continued use of pressure relieving mattress.
The impact of the mattress triage nurse will be evaluated by comparing the following outcomes, before and after the intervention:
Total waiting time for dynamic mattresses
Number of mattress referrals and the ratio of appropriate to inappropriate referrals
Number of inappropriate patients using dynamic mattresses
Pressure ulcer prevalence and the at risk population who develop a pressure ulcer
A survey of staff regarding their perceptions of mattress waiting times, effectiveness and patient assessment.
Modelling A computer model based on queuing theory will be created. Queuing theory uses a mathematical model to look at waiting lines, or queues, so that queue lengths and waiting times can be predicted. Discrete event simulation will be used to model individual patients through time as they pass through the system. Data collected during the project will be used to inform the model and where no data is available, expert opinion may be used supplement the model. Outputs from the model will include graphical, tabular and report forms of the model parameters. In addition, “what-if scenarios” can be tested in the simulation model to provide information regarding the optimum number of mattress needed to achieve different scenarios, including specified waiting times.