Changing practice to improve outcomes and reduce spend

Introduction

Healthcare acquired pressure ulcers (PU) are a well-recognised, long standing preventable harm and historical data from the NHS Safety Thermometer suggests that in England, approximately 25,000 patients a year develop pressure ulcers.¹

Whilst there is no single definitive national figure available for the cost of treating pressure related tissue injury, the estimated daily spend on pressure ulcer management in the NHS is in excess of £3.8 million¹, with a yearly NHS spend of £1.4 – £2.1bn reported almost 20 years ago.²

The cost of pressure ulcer healing correlates to the wound severity with the more severe, full-thickness pressure ulcers incurring greater costs for the provider. In 2004, Bennet et al proposed costs for healing the various pressure ulcer categories, ranging from £1,064 for a Category I pressure ulcer to £10,551 for a Category 4 pressure ulcer.²

A more recent calculation of pressure ulcer costs, based on data from 2016/17, is available from the NHS Improvement Pressure Ulcer Productivity Calculator³ and detailed in Table 1 below.

Table 1.  The projected economic impact of pressure ulcers (costs include consideration for bed occupancy costs, nursing time costs, and treatment costs in both the hospital and community).

Clearly, pressure ulcer management and healing represent a significant cost burden at every level and finding effective ways to reduce PU incidence (and therefore spend) is a priority for governments, policymakers, managers, and practitioners alike.

The prioritisation of prevention over treatment represents an ideal opportunity for healthcare providers to invest in effective PU prevention strategies as a logical way to reduce spend on unnecessary or preventable downstream treatment costs and optimise the budgets they have available for patient care.

Quality improvement issue

During 2021, thirty one patients developed a pressure ulcer whilst in the twelve-bedded Critical Care Unit (CCU) at Great Western Hospitals NHS Foundation Trust (GWH). During this time the CCU saw many complex COVID-19 patient admissions which required prone nursing as an integral part of their management. This method of nursing the more complex COVID-19 patients also contributed to the elevated PU incidence reported on the unit.

After reviewing the PU prevention and management care-bundle the CCU identified that new admissions to the unit were routinely placed onto ‘high-specification’ foam mattresses, with alternating pressure air mattresses (APAMs) being requested for the highest risk, most dependent patients with additional pressure area care (PAC) needs.

Further Route Cause Analysis revealed that essential life-preserving patient care would take priority over support surface provision, and this could result in delays of up to 72-hours before the patient received the replacement APAM they needed to meet their pressure area care requirements.

Change in practice

To reduce PU incidence the Tissue Viability and CCU teams wanted to optimise patients’ pressure area care provision, immediately, upon admission to the unit and eliminate delays in delivering effective pressure area care.  To achieve this, the teams needed to identify a support surface that could manage the PAC requirements of CCU patients, even those classified as the most dependent, and at the highest risk of pressure ulceration i.e. those that would historically require an alternating pressure air mattress.

To deliver this change in practice the Trust invested in eleven Series6 OneSurface^TM mattress systems from OSKA (see Figure 1). These powered, true hybrid mattress systems have the option of delivering either reactive therapy in their non-powered state or optimal, active therapy when using the mattress pump.  As a result, they represent a single mattress strategy capable of managing patients’ pressure area care needs across all pressure ulcer risk categories.

Figure 1. The OSKA Series6 OneSurface^TM powered hybrid mattress.

Whilst the procurement of these eleven mattresses incurred an obvious cost to the facility, the investment ensured optimal pressure area care was available immediately upon patient admission.

The change in practice removed the need for additional use of dynamic air mattresses on the unit and simultaneously eliminated the delays in support surface provision that were evident when utilising the two mattress approach (foam + APAM) within the CCU.

Improved clinical outcomes and cost savings

In the nine months since implementing the change in practice to a single mattress strategy within the CCU, only two partial-thickness (category 2) CCU acquired pressure ulcers have been reported. Assuming these patients remained in the care of GWH NHS Foundation Trust until PU healing these two wounds would result in an additional cost of £14,000 to the Trust.

Based on the potential ‘best-case’ (scenario 1) proposed above, the projected £62,000 cost of healing 31 CCU acquired pressure ulcers from 2021 far exceeds the combined cost of purchasing eleven Series6 OneSurface^TM mattresses and the projected £14,000 treatment cost for the two CCU acquired pressure ulcers reported above.

Therefore, as a direct result of reducing pressure ulcer incidence within CCU, GWH NHS Foundation Trust have realised a saving of tens of thousands of pounds by adopting this new proactive approach to PU prevention in the CCU alone.

Discussion

This work demonstrates that prioritising and funding clinically proven interventions to support effective pressure ulcer prevention strategies and drive down PU incidence, can offer a clear cost-benefit for budget holders and healthcare providers when improved clinical outcomes eliminate significant down-stream treatment costs that would otherwise be incurred.

This specific example highlights that pressure ulcer prevention can offer obvious benefits over pressure ulcer treatment and sizeable cost savings can be realised within a very short time-frame (months) resulting in a rapid return on the initial investment required for the procurement of new clinically effective products.

Due to patient throughput and a comparatively short length of stay, the cost of healing CCU acquired PU would not necessarily be seen (or borne) by the unit’s budget holders, however these costs would be incurred during the patient journey within GWH NHS Foundation Trust. Therefore it is important for senior management not to be protective of their budgets and where possible, to think outside of budgetary silos when considering a change in practice as a way of driving quality improvement and clinical outcomes that can have benefits across the wider organisation.

Table 2. Staff views on the OSKA Series6 OneSurface^TM mattress.

Conclusion

With healthcare service managers expected to deliver improved patient outcomes often in the face of resource and/or budget cuts it can put Tissue Viability teams in the unenviable position of often having to deliver ongoing reductions in pressure ulcer incidence whilst simultaneously demonstrating cost savings within the service.

This leads Tissue Viability teams into regular cycles of reviewing alternative products, innovative technologies and reassessment of PU prevention and management care bundles. The aim of this continuous improvement cycle is to optimise pressure area care, with the goal of driving pressure ulcer incidence to its lowest practical levels, thereby improving outcomes and reducing spend.

Optimising pressure ulcer prevention is one area where shrewd investment in products and processes can offer genuine cost-benefits to healthcare providers when changes result in significant reductions in PU incidence.