Journey from ‘inevitable’ to ‘zero’

International and UK epidemiological research demonstrates that 10% to 12% of all patients suffer from pressure ulcers (7% for category 2-4 pressure ulcers), a substantial proportion of which can be avoided.1 Some reports point to the figure being even higher – Vanderwee et al (2007)2 suggested that, across Europe, 20% of patients in acute care settings go on to develop a pressure ulcer. They can occur in any patient but high risk groups include: the elderly, obese or malnourished; people with spinal injury, orthopaedic or neurological conditions; acutely ill patients; individuals with reduced consciousness; as well as those with certain underlying conditions such as diabetes or peripheral vascular disease. The presence of pressure ulcers has been associated with an increased risk of secondary infection and a two to four fold increase of risk of death in older people in intensive care units.3 In recent years, progress has been reported in reducing rates of pressure ulcers, at a number of healthcare providers across the UK, while there is now an increased focus on the issue at a political and health leadership level. With the introduction of the NHS Safety Thermometer, this is set to intensify as healthcare providers are incentivised to monitor and measure the scale of the problem.

Understanding the scale of the problem

Speaking at University College London Hospitals, London, the Secretary of State, Jeremy Hunt, commented: “I want our NHS to be the first healthcare system in the world to publish the relative likelihood of a harm-free patient experience across every hospital in the country. In doing so, we will be embracing a transparency revolution more ambitious than anywhere else in the world.”4 The NHS Safety Thermometer is a step towards delivering this transparency and has been developed to monitor the occurrence of pressure ulcers, as well as other preventable incidents such as urinary tract infections, venous thromboembolism (VTE) and falls. The Department of Health (DH) originally calculated the annual financial costs associated with these harms as: £155 million to treat pressure ulcers (grade 3 and 4); £13.5 m to care for moderate-to-severe harm from falls; £80 m to treat urinary infections (in patients with a catheter). This equates to £249 m without including statistics/costs from preventable VTE. (The incidence and associated costs of VTE were not calculated at the time [March 2011]). However, initial data from the NHS Safety Thermometer has suggested that these calculations on the cost savings may be an underestimate – the revised figures stand at £430 m or £826,000 per 100,000 population.5 The aim of the initiative is to enable frontline staff to check basic levels of care, identify where things are going wrong and take action. The national CQUIN scheme will also be rewarding organisations that deliver improvements such as reductions in pressure ulcers – as measured by the NHS Safety Thermometer. The data was published in June this year and, while these early figures should be interpreted with caution, there have been some overall improvements in terms of pressure ulcer reduction: in May 2013, 5.4% of reported patients had pressure ulcers, compared with 6.8% in May 2012.6 The DH emphasises that the tool is designed to measure local improvement over time and should not be used to compare organisations, as there are differences in data collection methods and patient mix, which can invalidate comparisons across organisations. It points out that Trusts that have a high percentage of older patients or specialist services are likely to present with more harms on this measure. The DH acknowledges that there is a significant gap between the best and worst performers in terms of the number of patients who experience pressure ulcers.7 However, among the best performers there are examples of wards that have not had a pressure ulcer in years. These beacons of excellence demonstrate what can be achieved through a combination of the bundle approach, raised awareness and education, proper assessment of risk, frequent rounding, optimisation of nutrition, appropriate patient positioning/mobilisation, effective management of pressure prevention equipment, as well as monitoring and reporting of prevalence. There are lessons to be learned from organisations that are demonstrating best practice, across the whole of the UK.