Reducing pressure damage: care
bundles and collaborative learning
Alison M Evans, Dwynwen Barklam, Karen Hone, Gemma Ellis, Joy Whitlock
Abstract
Reduction of hospital-acquired pressure ulcers is a patient and nursing
priority. Although evidence-based interventions to prevent such
ulcers are well known, reducing this healthcare burden has proven
consistently difficult. Via case studies, this article describes how a
bundle approach to pressure ulcer prevention may be adapted for use
within different clinical areas. It illustrates how collaborative learning
may facilitate the spread of improvement work across a health board
and build improvement skills within nursing.
Key words: Care bundles ■ Collaborative learning
pressure ulcers ■ Nurse education
■
Hospital-acquired
P
ressure ulcers are defined as a ‘localised injury to
the skin and/or underlying tissue, usually over a
bony prominence, as a result of pressure, or pressure
in combination with shear’ (European Pressure
Ulcer Advisory Panel (EPUAP) and National Pressure
Ulcer Advisory Panel (NPUAP), 2009). Pressure ulcers are
expensive to treat (Bennett et al, 2004) and the impact
on patients’ quality of life can be profound (Langemo et
al, 2000). Understanding the factors that contribute to
pressure ulcer development has improved and evidencebased guidelines for risk assessment and prevention have
been available to clinicians for over a decade (National
Institute for Health and Clinical Excellence (NICE), 2005).
Preventative measures are relatively simple and should be
straightforward to deliver. However, a European pressure
ulcer prevalence of 18.1% (n = 1078) was reported by Clark
et al (2002) and by Vanderwee et al (2007). Significantly, the
prevalence figure for the UK was 21.9% (n = 556) which
was, by a small margin, the highest reported (Vanderwee et
al, 2007). Collecting accurate and meaningful prevalence data
and understanding their significance may be difficult, e.g.
comparison of study outcomes with differing populations
and differing methods of identifying and classifying pressure
damage (Baharestani et al, 2009). In 2011, health analytics
firm Dr Foster reported variation in the rates of reported
pressure damage in England. Trusts cited some of the factors
contributing to such variation, including discrepancies in
clinical coding and attribution of the origin of the damage,
i.e. hospital vs community acquired (Clover, 2011). However,
it is reasonable to suggest, even in the absence of reliable data,
that healthcare workers have struggled to reduce pressure
damage and the harm to patients.
The imperative for healthcare providers and frontline
teams is to accelerate improvement work and reduce the
healthcare burden of pressure damage. The reduction of
pressure damage is one of the priorities in many UK patientsafety programmes (Public Health Agency, 2011; 1000 Lives
Plus, 2013a; NHS Scotland, 2013; Patient Safety First, 2013).
To enable staff members to introduce reliable and sustainable
changes, it is useful for them to have a framework to
structure improvement efforts and be skilled in improvement
methodologies. This article describes some of the work that
is being undertaken in Cardiff and Vale University Health
Board (UHB) to reduce pressure damage by adapting the
SKIN bundle (Gibbons et al, 2006) for use in maternity
and paediatrics using the Model for Improvement (MFI)
(Langley et al, 2009), a standardised method to introduce
change and a collaborative process for sharing and learning.
Aim
■■ To
introduce a bundle of care to reduce hospital-acquired
pressure damage
■■ To build a nursing workforce that has an understanding of
improvement methodologies and is able to apply them in
any healthcare setting.
Alison M Evans is Sister, Critical Care, seconded to support role-out of SKIN bundle, Cardiff and Vale University Health Board (UHB)/Lecturer
Cardiff University, Dwynwen Barklam is Staff Nurse, Peadiatrics, Cardiff and Vale UHB, Karen Hone is Senior Midwife, Cardiff and Vale UHB,
Gemma Ellis is Consultant Nurse, Critical Care, Cardiff and Vale UHB/
Senior Lecturer, Cardiff University and Joy Whitlock is Improvement
Advisor, Cardiff and Vale UHB, Patient Safety and Quality, University
Hospital of Wales, Cardiff
Accepted for publication: May 2013
S32
Care bundles are one method of improving healthcare
quality (Resar et al, 2012). The concept of care bundles has
been described as a small set of evidence-based interventions
for a defined patient population and care setting which,
when implemented together, result in significantly better
outcomes than when implemented individually.This concept
was developed by the Institute for Healthcare Improvement
(IHI) (Resar et al, 2012). Early evidence of the effectiveness
of bundles was achieved in critical care through the
reduction of ventilated-associated pneumonias and centralline infections (Resar et al, 2012).
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 12
© 2013 MA Healthcare Ltd
Methodology
Care bundles to reduce pressure ulcer acquisition
120
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% Compliance
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u
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60
40
20
0
1
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9 10 11 12 13 14 15 16 17 18 19 20
Months
Figure 1. Compliance with the SKIN bundle in a nine-bedded critical care unit
200
172
days
180
127
days
140
l
l
l
Values
Median (51.0)
Lower (0.0)
Figure 2. Days between hospital-acquired pressure damage: critical care
S34
07 Aug 12
01 Feb 12
29 Mar 12
13 Jun 11
25 Oct 11
28 Jun 10
30 Apr 10
03 Nov 09
04 Oct 09
14 Jul 09
l
l
l
l
10 Jul 09
18 May 09
10 May 09
l
l
13 Sep 09
l
28 Aug 09
l
20
0
l
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24 Dec 09
14
days
60
40
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80
23 Dec 10
100
131
days
l
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Introduction
of the SKIN
bundle
15 Sep 10
120
01 Jun 09
Days between events
160
Upper (153.1)
Welsh, 1000 Lives Plus programme to improve patient safety
(1000 Lives Plus, 2013a). The bundle is a checklist of good
practices for managing vulnerable patients, focusing on:
■■ Identifying patients at risk
■■ Surface selection
■■ Keeping patients turning and moving
■■ Increased moisture and incontinence management
■■ Nutrition and fluid intake.
Compliance is dependent on all elements of the bundle
being achieved every time. If any element of the bundle
is not completed, the bundle has not been provided. This
approach may help nursing staff negotiate complex protocols
and care algorithms and assist them to decide on priorities in
complex clinical situations. Using the acronym SKIN above,
may act as an aide mémoir and communication tool for ward
teams. In summary, the SKIN bundle is a simple concept,
which is a format that can be understood by carers and
patients through appropriate education and can be adapted
to any clinical area and patient demographic.
Collaboration to introduce change
across an integrated health service
Following implementation of the SKIN bundle in critical
care (Figures 1 and 2) and a successful application to become
a mentor site through the Health Foundation’s Safer Patient
Network (The Health Foundation, 2012), Cardiff and Vale
UHB was in the unique position of being mentored by the
IHI and supported by the Health Foundation to guide six
other sites across the UK during introduction of the bundle
within their organisations. As a consequence of learning from
IHI mentors, Cardiff and Vale UHB has taken a collaborative
approach to introducing the SKIN care bundle. The aim
was to reduce pressure damage and embed a standardised
approach to improvement within nursing teams.
Collaborative learning is an interactive process, which
recognises the social aspect of learning. Teams that work
together, learn and improve together. This is fundamental to
the IHI philosophy of ‘all teach, all learn’. Learning sets are,
therefore, constructed to enable the sharing of good practice
within the organisation (IHI, 2003).
Healthcare improvement is an aspect of everyone’s role. To
maintain the philosophy of collaborative learning, all grades
of nursing staff are encouraged to attend the three learning
sets of the collaborative. Collaboratives bring together teams
from across different clinical areas to focus exclusively on one
area of improvement (IHI, 2003) Learning sets (study days)
are facilitated by clinical and improvement experts. Each
learning set is followed by an action period in which teams
are tasked to implement changes in their local area and then
report back on successes and barriers to change (IHI, 2003)
The first learning set introduces the content of the bundle
and the Model for Improvement, including how and what
to measure to demonstrate improvement. Following the
learning set, teams return to their clinical area and introduce
the bundle. In subsequent learning sets, teams present their
results using storyboards, swap shops and group work. This
has proven to be an invaluable opportunity for networking,
sharing ideas and supporting each other. It is the antithesis of
working in silos (in isolation).
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 12
© 2013 MA Healthcare Ltd
Using a care-bundle approach, significant improvements
have also been reported in the prevention of pressure ulcers
(1000 Lives Plus, 2013b). In 2002, Ascension Health (a
non-profit healthcare organisation operating a network of
hospitals in the USA) set a goal promising ‘healthcare that
works, healthcare that is safe and healthcare that leaves no
one behind for life’. One of their priorities was to prevent
pressure damage. St Vincent’s Medical Centre, an alpha site (a
site selected to develop and test prototype care improvement
strategies) in their pressure ulcer prevention initiative,
developed the SKIN bundle, which was adopted with great
success across Ascension Health’s 67 acute-care facilities.
They have since trademarked the term SKIN bundle
(Gibbons et al, 2006). The SKIN bundle was introduced
to Wales by Annette Bartley (an IHI Fellow) as part of the
RESEARCH
The Model for Improvement
Frontline teams are increasingly being asked to lead
improvement work. A framework to structure such efforts
that is taught in the collaborative is the Model for
Improvement (MFI) (Langley et al, 2009). The MFI is
based on three questions (Figure 3) which, when used in
conjunction with cycles of small tests of change, Plan, Do,
Study, Act (PDSA), will help guide improvement efforts.
Teams set their own aims based on their knowledge of the
clinical area, decide how and what to measure and test and
which interventions will improve outcomes for patients. At
the beginning, the faculty team had concerns about how this
would be received by nurses more used to didactic study
days, but evaluations have been resoundingly positive, for
example:
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
ACT
PLAN
STUDY
DO
‘...We come out of the study days saying “alright,
we have got to do this!”.’
Two case studies will be presented to demonstrate how
a bundle approach may be adapted for use within very
different clinical areas.
Figure 3. Model for Improvement. Sources: Associates in Process
Improvement (2012) and Langley et al, (2009)
Introducing the SKIN bundle to paediatrics
Once the work begins all teams start to examine their care
more closely and aims develop:
Patients most at risk of pressure ulceration are often thought
to be those who are acutely ill, immobile, or in an altered
level of consciousness. However, neonates and children under
5 years are also at risk (Royal College of Nursing, 2001). The
site and nature of pressure injury may be different to adults
and, consequently, tools to aid prevention must be adapted to
reflect the difference.
Nurses on a paediatric medical ward caring for children
age 0–3 years demonstrated how the SKIN bundle may
be adapted. The ward cares for several specialties including
neurology, gastroenterology and respiratory medicine, all
bringing different challenges. Staff nurse Dwynwen Barklam,
the ward champion who led the introduction, initially had
mixed thoughts and wondered how the SKIN bundle might
be adapted to make it relevant for the ward and whether it
could be implemented. Using the MFI questions, Dwynwen
was interviewed for this article and her reflections on the
introduction process help demonstrate how the bundle was
made to work effectively in paediatrics.
What are we trying to accomplish?
© 2013 MA Healthcare Ltd
One of the most important stages in the MFI is the setting of
an aim. This is the point at which the conversation regarding
improvement begins. As Dwynwen stated:
‘There had been a few incidences where babies
and toddlers had...pressure damage underneath
cannula. Following discussions with the ward sister, we thought this was one area we could target,
to try and reduce those incidences. Compared to
adult wards, I am sure most of those nurses would
think that our incidences were nothing, but this
is the damage we have on the ward and we must
attempt to minimise the harm to babies.’
‘We then broadened it to any device we used,
from cannulae to nasogastric tubes, nasal specs
for oxygen and also when babies are admitted
with diarrhoea, or are on antibiotics and are
likely to develop nappy rash. They were the key
areas that we thought we would look at.’
An overarching aim for the team was to change the
perceptions of pressure damage on the ward, to move from a
reactive culture towards proactive investment in continuous
safety improvement.
Safety calendar
Month:
Date of last pressure ulcer
1
2
Ward acquired: 18 May
3
4
Admitted with: 21 May
5
6
May
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
No new case
identfied
Admitted with
New case
identified
29
30
31
Figure 4. The Safety Cross
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 12 S35
As an organisation, monthly point prevalence data on pressure
ulcers are collected. Prevalence is the ‘number of events’.
In this context, prevalence is the number of pressure ulcers in
a given population at a designated point in time. However, this
information does not always translate to knowledge within
frontline teams. Teams often have little understanding of what
prevalence means. Using a monthly figure, which is a ‘snapshot’
of pressure ulcers on a ward, is not helpful in understanding
whether care is improving. Incidence, generally described as
the number of new events within a defined population over
a given period, can be easier for busy clinicians to understand
and enables teams to examine data on a daily basis to see if
their interventions are resulting in improved patient outcomes.
Within the collaborative, teams were encouraged to measure
days between the occurrence of hospital-acquired pressure
ulcers using the Safety Cross (1000 Lives Plus, 2012) (Figure 4).
The Safety Cross is a calendar in the shape of a cross on which
each hospital-acquired pressure ulcer is recorded:
‘I have put information and guidelines in the staff
room and on the desk so that the night staff can
fill in the Safety Cross. I added a section onto the
safety briefing for pressure areas, so that all the
staff are aware of which patients have pressure
areas and why.’
The Safety Cross, used first in industry as part of ‘lean
thinking’, was introduced to healthcare teams in Wales as
part of Transforming Care (a programme that empowers
teams to improve the quality and efficiency of the services
it provides) (1000 Lives Plus, 2012). Measurement for
improvement is an integral aspect of the programme so teams
use data collected to understand which interventions are
working and why:
‘I refer back to the safety briefing to see where
the pressure areas were...that information is
valuable to reflect upon. None of us want to
cause harm to a baby, but we now recognise we
are and there are things you can do to prevent
pressure damage from happening.’
In paediatrics the Safety Cross has only been in use for a
few weeks and limited data have been collected. However,
in critical care, the early adopter of the SKIN bundle and
the Safety Cross, incidence data have now been collected
for over 2 years. This has enabled the critical care team to
measure how effective it has been in reducing pressure ulcer
acquisition and has been a great motivator (See Figures 1
and 2). One of the disadvantages of using this methodology
for rare events like pressure ulcers is the very real feeling of
distress that may occur when a patient does develop an ulcer.
The acquisition of a pressure ulcer may be a demotivating
event if it is not seen as an opportunity to learn and improve.
Teams should also be prepared for an increase in reporting of
pressure damage as a result of increased awareness and focus
when they introduce the SKIN bundle. This was clearly
demonstrated when the SKIN bundle was introduced to the
33-bedded critical care unit. An increase in reporting of grade
S36
1 and 2 pressure damage initially caused concern. However,
subsequent reduction in grade 3 and 4 damage (49 in 2011
to 29 in 2012) has been motivating.
What change can we make that
will result in improvement?
The interventions the team wished to test were straightforward,
including reliable application of an appropriate barrier cream
to prevent moisture lesions:
‘...sometimes we use preventative creams but
nappy rash still occurs. However, if we put measures in place to minimise the risk as much as
possible then we have tried our best to prevent
it. We should not be accepting that it’s inevitable
that babies will develop nappy rash.’
Following the advice of tissue viability nurses, the team
introduced one barrier cream. Negotiating a product change
with the pharmacy and testing how best to demonstrate
how and when to use the barrier cream formed part of the
Plan Do Study Act (PDSA) (see Figure 3) process for testing
interventions (Langley et al, 2009; Associates in Process
Improvement, 2012). Dwynwen also wanted to test if a simple
and sustainable approach to reducing device-related injuries
would be to stock a trolley with a dressing and barrier cream
that could help prevent damage. Making only one product
choice available has reduced variation in care. Everybody now
knows how much barrier cream to use and how frequently, so
the reliability of care is guaranteed:
‘The trolley is always kept stocked up with the
chosen products. We have educated the doctors
why they need to use this IV [intravenous] dressing and not just their favourite.’
The MFI process is a quick and effective way of transferring
evidence into practice and adds structure to change. When
it can be demonstrated that an intervention works for a
particular patient on a particular day, powerful evidence may
be gathered to aid understanding of the process of care before
spreading the knowledge to an entire ward. This process
helps convince the rest of the team that making the change
is worthwhile:
‘I wanted to keep it simple, I did not want staff
to think it was extra work and to have a negative
approach. Should we be accepting these babies
are getting nappy rash? Just talking and discussing
on the ward, our perception is changing, staff are
saying we should...prevent this from happening.’
To assist in the documentation of care and measure
compliance a SKIN bundle communication tool was
introduced. Through the collaborative process, templates of
tools have evolved and been shared. They are freely available
on the UHB intranet site. Through the PDSA process, staff
are supported to adapt these tools to make them suitable for
practice in their clinical area:
‘I used the template as a starting point and made
it more relevant, useful, easy and quick to fill in,
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 12
© 2013 MA Healthcare Ltd
How will we know when a
change is an improvement?
but with enough detail for staff to check they
have completed all tasks and provide information
for the next carer. We introduced a comment box
where exceptions to normal practice are able to
be recorded. Checking is not a change in practice, but it’s now being documented and is being
done reliably and consistently. If we have a child
that isn’t able to move, we should care for them
like any adult who doesn’t move. The difference
now is that we have a process for choosing the
correct mattress. First on the check list is “is the
mattress appropriate?” and it makes staff think
whether the patient has the right mattress rather
than assuming that our age group don’t need
pressure-relieving equipment.’
Work on reducing pressure damage within paediatrics is
ongoing and the bundle has been adapted for use in caring
for premature babies, teenager cancer, orthopaedics and
intensive care.
Introducing the SKIN bundle to maternity
Specialties in which the patient population has a low
incidence of pressure damage and where prevention is not
considered a clinical priority are presented with a different
challenge. Maternity services is one such area. Incidence and
prevalence figures for this population are hard to find but
the National Patient Safety Agency (NPSA) stated that since
2005, out of the 75 000 pressure ulcers reported, there have
been 100 incidents of women developing pressure damage
on maternity wards (NPSA, 2010). Not surprisingly, the team
of midwives attending the collaborative, initially struggled
to see the relevance of the SKIN bundle to their practice.
However, their experience of adapting the bundle for use in
midwifery illustrates some of the key factors that will make
improvement work successful.
Determining if you have a problem and what may be the
root cause is a crucial first step in any improvement work.
Therefore, in the first learning set, teams are asked to examine
the available data on pressure ulcers in their clinical area. The
use of incident data and clinical experience helped focus the
work in midwifery on women known to be at high risk, e.g.
following long periods in theatre, or with an epidural in place
resulting in a loss of sensation. The key learning point for the
team was that the emphasis placed on understanding local
data and setting local aims was crucial in galvanising ward
teams to want to improve care.
However, important as engagement of the frontline team
may be, it is also vital that the senior team views the
improvements as a clinical priority. Senior support is necessary
to commit resources and time to education, for investment in
equipment and in holding teams to account for the care they
deliver and patient outcomes. When considering where to
start improvement work it is essential that the focus be on
priorities in the patient safety and healthcare quality agenda.
As the first midwifery team to attend the collaborative, Karen
Hone, Senior Midwife leading the improvement work, had
no model to follow to adapt the SKIN bundle. The first aim
was to introduce a reliable process to identify women at risk
British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 12 of developing pressure damage. Introducing a risk-assessment
tool to the clinical area proved a challenge as no validated
tool, specifically adapted for midwifery, could be identified.
Bick et al (2011) identified that 41% (n = 28) of midwives
found the Waterlow assessment tool to be helpful in practice.
As it is used throughout the UHB, it seemed appropriate to
test if this tool would be suitable. Part of this process involved
drop-in information sessions to talk the team through the tool
and demonstrate how it should be used as a trigger to escalate
interventions as a woman’s risk of pressure damage increased.
One of the benefits of a collaborative approach is the
bringing together of clinical teams that would not normally meet, adding new perspectives and different approaches to
implementing prevention strategies. In maternity, a partogram
is used to monitor and record the progress of labour. Key
data are entered on the partogram. The midwifery team
felt it appropriate to include the SKIN bundle within this
document to give fundamental care prominence. As the care
needs of women in labour care can quickly change, assessing
and recording altering risk was identified as a priority within
the tool. Combining risk assessment with a SKIN bundle
chart is an idea that can be translated into various clinical
areas as an added trigger or prompt to nursing staff to make
a change. It is essential to include sufficient time within
learning sessions to be able to discuss how different teams
are executing change and learn from each other. Shared
discussion time is always rated by the attendees as the most
valuable aspect of the collaborative. One attendee described
the discussion time thus:
‘I had that problem. Let me show you how I
solved it.’
When improvement work involves a whole organisation
it is crucial not to assume that universal common language
and aims exist. By way of an example, facilitators had not
considered it would be necessary to adapt the training to
reflect the needs of midwives who had never seen a pressure
ulcer. This illustrates the importance of teams being able
to access help during action periods, which may involve
supplementary teaching sessions, as in the case of the
midwives, or help in data interpretation and presentation.
The work in midwifery is at an early stage, with the
emphasis on raising awareness and education. Karen has now
developed a flow diagram to help midwives assess and manage
the risk.This is being tested, along with the partogram, as part
of their PDSA cycles.
Critical success factors include:
■■ Strong leadership to promote the importance of the
improvement work, ensure appropriate resources are
available and remove barriers to improvement
■■ Multidisciplinary support, particularly from practice
educators, tissue viability nurse specialists and dietitians
■■ A faculty which has expertise in implementing the SKIN
bundle and improvement methodology to manage the
spread of the bundle.
Conclusion
Collaboratives focus on one topic that requires improvement.
They enable teams to achieve successful and measured
S37
KEY POINTS
n Reduction of hospital-acquired pressure ulcers is a patient and nursing priority
n Care bundles are one method of improving healthcare quality
n Cardiff and Vale University Health Board has used a collaborative learning
approach to introducing the SKIN care bundle within its own organisation
improvements by sharing and learning together.Three learning
sessions are delivered over 6 months, with teams tasked during
‘action periods’ to deliver aims they set themselves. The
emphasis is on using the Model for Improvement to deliver
results. Although both teams highlighted in this article are at
the beginning of their improvement journey, their experience
demonstrates how the SKIN bundle can be adapted to make
it relevant to a diverse patient population.
Collaborative learning is interactive, mobilises teams and
maintains motivation. It is the authors’ experience that, with
the right knowledge and skills, coaching and support,
healthcare workers are able to deliver improved outcomes.
This approach is building a network of staff with reusable
healthcare improvement skills to support the continuous
drive towards safe, reliable care. Currently, 14 SKIN bundle
collaboratives have been undertaken with 270 staff members
introduced to the Model for Improvement methodology.This
approach is being considered with regard to the introduction
of other improvement initiatives, such as oral-care pathways
and the catheter-associated urinary tract infection care
bundle, thus building on the skills already developed within
BJN
nursing teams. Conflict of interest: none
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ulcer prevalence in Europe: a pilot study. J Eval Clinical Pract 13(2): 227–35
A-Z Dictionary of Wound Care
Fiona Collins, Sylvie Hampton, Richard White
 Essential dictionary defining words and terms that are used in the
field of tissue viability
 Essential guide for students or those aspiring to become specialists
 Includes more rarely used terms
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S38
© 2013 MA Healthcare Ltd
ISBN-13: 978-1-85642-225-3; 216 x 138 mm; paperback; 112 pages; publication 2002; £19.99
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British Journal of Nursing, 2013 (Tissue Viability Supplement), Vol 22, No 12
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