SPECIAL SESSION: Developing and Testing a Patient Centred Pressure Ulcer Prevention Care Bundle

Description/Overview: A pressure injury (PI), also known as a pressure ulcer, is an area of localized damage to the skin and underlying tissue caused by pressure or shear and/or a combination of these (DeFloor et al., 2005). PI incidence rates are an indicator of quality of nursing care, thus PI Prevention (PIP) is an international priority. Yet, implementation of PIP strategies remains suboptimal in many settings. A care bundle is a structured group of interventions, based on research evidence and/or clinical practice guidelines (CPG), which have been shown to improve patient outcomes. They improve processes of care and encourage CPG compliance. In relation to PI, a US group developed an 8-item PIP care bundle that included skin care, turning, and nutritional assessment, directed at nursing staff and although their annual PI prevalence data showed trends towards improvements in PI prevalence (Baldelli & Paciella, 2008). To date, care bundles have focused on guiding clinicians in their practice, yet the literature on patient participation suggests involvement of patients and their families working alongside clinicians could be a major driver in the use of care bundles (Coulter, 2006). Our team developed a patient centred PIP care bundle (PIPCB) to be used by patients, in partnership with nurses. A care bundle is an example of a complex healthcare intervention. This care bundle was based on the literature on patient participation in care, care bundles and current PIP CPGs. The training resources included a 5-minute DVD, a brochure and a poster. Modifications to the content of the PIPCB were based on feedback from health professionals and consumers (Gillespie, Chaboyer et al., 2014). Our pilot trial investigated the feasibility of the PIPCB. Over half of the 102 medical and surgical patients approached, were willing to participate in the pilot. Interviews with 11 patients and 20 nurses showed the PIPCB was well received, informative and could likely be integrated into current clinical practice (Chaboyer & Gillespie, 2014). With funding awarded by the Australian National Health and Medical Research Council, a cluster randomised trial (c-RT) was undertaken in 8 hospitals in 3 states in Australia. The research team was comprised of 8 nurses, a statistician and a health economist. To be eligible for the study, hospitals had to be metropolitan referral hospitals that cater to diverse patient adult populations and case mix groups, offering acute medical and surgical and rehabilitative services. They had to have 200 or more beds. All adult patients who had restricted mobility from wards except day-surgery, critical care, mental health, and dialysis units were eligible to participate. The primary outcome of for the trial was the development of a new PI, with secondary outcomes PI stage, hospital length of stay, and patient participation in care (self report 7-item patient participation scale adapted to PIP). The PIPCB was delivered by dedicated intervention research assistants (RAs) to both the patient and nurses (patient and cluster level) and was comprised of three main messages; 1) keep moving, 2) eat a healthy diet and 3) look after your skin. Patients reached the study endpoint if they developed a PI, if they were discharged, after study day 28, if they died or if they were transferred to another hospital or to the ICU and were mechanically ventilated. An economic sub-study was undertaken to identify the cost effectiveness of the PIPCB. In total, 1,600 patients with restricted mobility were recruited (200/site) with the sub-study recruiting 320 patients (40/site). Separate recruiters, outcome assessors and intervention research assistants were employed in addition to dedicated RAs for the health economic sub-study. This presentation will provide an overview of the program of research that led to this large, multi-site c-RT as well as the findings to date. It will also briefly introduce the process evaluation, that was undertaken alongside this c-RT to better understand and explain who the PIPCB worked for and under what conditions.