Introduction

Pressure ulcers are a serious challenge for healthcare services. Variation in standards of care means that they are a significant cause of unnecessary patient suffering and mortality, avoidable hospital admissions and onerous costs for health services (Padula and Pronovost 2018). A growing body of evidence demonstrates the critical role of emergency departments (EDs) in preventing pressure ulcers (Denby and Rowlands 2010, Bjorklund et al 2011, Faulkner et al 2015), yet it appears that few EDs have prevention protocols in place (Gefen 2008, Gamston 2019).

Pressure ulcers are a result of damage to an area of skin and underlying tissue caused by pressure that impedes blood supply. They occur most commonly in people who are confined through illness to a bed or chair, although all patients are at risk of developing a pressure ulcer, particularly those with impaired mobility or nutrition, neurological conditions, poor posture or deformity (National Institute for Health and Care Excellence 2014). Strategies for preventing pressure ulcers include documented risk assessment using validated scales such as Braden, Waterlow or Norton, skin assessment of people at high risk, frequent repositioning, pressure-redistributing devices, for example high-specification foam mattresses, and application of barrier creams (National Pressure Ulcer Advisory Panel et al 2014).

Despite widespread implementation of these strategies, pressure ulcers remain a significant challenge for healthcare services. For example, in 2013 a Swedish national pressure ulcer prevalence survey found that despite extensive prevention efforts, 16.6% of hospital patients developed a pressure ulcer (Gunningberg et al 2013). More recently, a systematic review of studies of pressure ulcer prevalence in acute care settings published between January 2000 and December 2015 found a likely worldwide prevalence of between 6% and 18.5% (Tubaishat et al 2018).

Not only does such a high prevalence of pressure ulcers cause extensive suffering, it is also extremely costly. The US experiences more than 2.5 million pressure ulcers a year and over 60,000 associated deaths, costing the health system between $9 and $11 billion (Lyder and Ayello 2008). In England, NHS Improvement (2018) calculated that between April 2015 and March 2016, just under 25,000 patients developed a new pressure ulcer and their treatment cost more than £3.8 million a day.

This article describes a change in practice in the ED at Karolinska University Hospital (KUH) in Huddinge, Sweden, during its pressure emergency project (PEP), which aimed to reduce the incidence of pressure ulcers. The article discusses how the project team ensured that ED nurses were engaged in planning the change and that the improvements were sustained.

Role of emergency departments in pressure ulcer prevention

EDs play a crucial yet frequently overlooked role in the prevention of pressure ulcers. Fulbrook et al (2019) investigated the incidence of pressure ulcers in adults in the EDs of two Australian tertiary hospitals. The researchers conducted full skin inspection and pressure injury risk assessment using Braden and Waterlow scores within one hour of the patient being triaged (n=212) and found that 11 patients (5.2%) had pre-existing pressure ulcers and that these patients tended to be those who had a longer ambulance journey or spent longer on an ambulance stretcher. In a French study, Dugaret et al (2014) observed that of the 602 patients admitted to an ED over 15 days, 77 (12.7%) had pressure ulcers on admission and 115 (19.1%) had pressure ulcers on discharge, showing that 38 (6.3%) patients had developed new pressure ulcers during their time in the ED.

Despite the findings of these studies, and research demonstrating that malnourished patients can develop pressure ulcers within a few hours of entering an ED (Cereda et al 2017), evidence suggests that few EDs and even fewer ambulance services have pressure ulcer prevention protocols and that this is a global issue (Gefen 2008, Gamston 2019). Too often, patients who wait in an ED for several hours may not receive a pressure ulcer prevention protocol until admission to an inpatient unit, by which time a pressure injury may have already occurred (Denby and Rowlands 2010). In many US hospitals, failure to assess and document pressure risk and ulcers effectively at the time of admission, combined with a strong desire to avoid payment penalties from medical insurance companies, has resulted in long-term care facilities and other community care settings being unfairly blamed for pressure ulcers that are highly likely to have developed in an ED (Squitieri et al 2018).

Prevention emergency project

KUH delivers care across two sites, Solna and Huddinge, in Stockholm County, Sweden. As in most hospitals, the ED at Huddinge, which is one of the largest in Europe, is the gateway through which almost all non-elective patients are admitted to the hospital, many of whom are at risk of pressure ulcers.

In 2014, the Swedish Association of Local Authorities and Regions launched a national patient safety initiative that aimed to raise awareness of pressure ulcer prevention practice among nurses (Ridelberg et al 2016). This initiative resulted in an increase in the number of documented prevention activities taking place at Huddinge, measured through local audit. However, in 2017, a hospital-wide audit revealed that pressure ulcer incidence was 10.1%, which was concerning. Despite many patients having to stay for up to 24 hours in the hospital’s ED before admission due to a lack of inpatient beds, the ED did not have a strategy for identifying those at risk of pressure ulcers and consequently was not implementing preventive measures routinely. Because it was not uncommon for patients to remain in the Huddinge ED following a decision to admit them, senior emergency nurses believed there was a need for more progressive nursing practice in the ED. This led to the launch of the prevention emergency project (PEP).

Engaging staff and sustaining improvement

Many innovations that are tested during healthcare improvement projects fail to gain the user acceptance necessary to become embedded and sustained in clinical practice, even if they deliver measurably improved patient outcomes (Robert et al 2020). The PEP team, therefore, was mindful of the need to engage with ED nurses in such a way that two important outcomes were achieved. First, the team wanted to develop a deeper understanding of the daily challenges and frustrations faced by ED nurses as well as their current practice and behaviours. To achieve this, an extensive programme of interviews and workshops was conducted before the changes in practice were designed. These revealed that for PEP to become permanent, the best practice on which it was based would have to be integrated into nurses’ workflow as smoothly and seamlessly as possible (Figure 1).

Figure 1.

Integrating best practice for pressure ulcer prevention into the emergency department workflow

One of the actions taken to accomplish this was to work with the supplier of Huddinge’s EMR to integrate a PEP checklist into the software to trigger alarms and reminders for staff to carry out activities such as intentional rounding.

Second, the team wanted the project to resolve some of the ED nurses’ recurring issues, for example back pain and injuries commonly associated with repositioning patients without the assistance of colleagues during busy shifts. Introducing ergonomic systems for repositioning patients improved nurses’ occupational health, which enabled the PEP team to address staff satisfaction and in turn minimise resistance to change and make it easier for nurses to re-engage with their role as compassionate, person-centred caregivers.

Other techniques used by the PEP team to embed and sustain practice improvements are shown in Box 2.

Effect of prevention emergency project on nursing practice

Huddinge’s data analytics team undertakes annual audits of pressure ulcer care by reviewing a random sample of 600 inpatient medical records from across the hospital and checking for documented evidence of prevention activities. As Figure 2 shows, baseline data for audits performed before introduction of the PEP found that pressure ulcer prevention activities were undertaken in only 30% of patients in 2013 and 2014.

Figure 2.

Percentage of patients at Huddinge hospital with documented evidence of pressure ulcer prevention activities

A national awareness campaign in 2014 increased pressure ulcer prevention activities to around 46% of patients by 2015, which was sustained for another two years. The PEP delivered further measurable improvements in documented pressure ulcer prevention activities. In 2018, audit data showed there was documented evidence of pressure ulcer prevention activities performed for 61% of patients and by 2019 this had increased to 66% of patients across the hospital.

Responses from 60 ED nurses to a work environment survey conducted before and after implementation of the PEP found that pre-implementation only 12% (n=7) agreed they were ‘always’ or ‘often’ able to provide appropriate pressure ulcer prevention care, while after implementation 58% (n=35) believed they ‘always’ or ‘often’ provided appropriate preventive care.

Conclusion

EDs are at the frontline of care delivery for patients who require unscheduled hospital care. Despite the daily pressures they face, staff in EDs must also be at the frontline of pressure injury prevention. The PEP at KUH demonstrated that emergency nurses can improve pressure ulcer care through practices such as providing early patient risk assessments, protective bed surfaces and pressure-relieving equipment, intentional rounding, prophylactic dressings, and incontinence pads.

Involving ED nurses in the design of changes in practice, and ensuring that any changes were responsive to the nurse’s needs as well as to those of their patients, substantially improved the culture and working environment of the ED. It also ensured that pressure injury risk was documented more accurately and consistently, and that care was person-centred and responsive. A firm foundation has been laid on which future changes that improve the quality of nursing care in the Huddinge ED can be tested and, if successful, embedded in the flow of care.