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Clinical IT in Aged Care Product Trial - Trial of a System for Prevention and Management of Pressure Ulcers - Report

Report of the product trial of a System for Prevention and Management of Pressure Ulcers

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The incidence of pressure ulcers in residents of Australian aged care facilities has been reported to range from 13% to 37% in any one year. This incidence is unacceptably high and has been attributed to inadequate risk assessment, monitoring, management and evaluation by clinicians.

This trial explored how clinical IT combined with the introduction of clinical guidelines can improve the quality of care for residents in aged care homes.

This trial was the first attempt in Australia to measure the effect of the introduction of evidence-based methodologies to reduce the incidence and duration of pressure ulcers.

Situation

Pressure ulcers in older people can increase both morbidity and mortality. Residents develop infections that may progress to overwhelming sepsis and death. Pressure ulcers take a long time to heal and are resource intensive and expensive to treat.

There is an increasing need to provide quality care for the growing number of persons aged over 65, especially as it is in this population that most enduring wounds occur. Recent Australian research indicates that the prevalence of pressure ulcers in high-care nursing homes is 26% and that perhaps 25% of all people living in aged care homes have a wound at any one time. Based on 2004 estimates (Australian Health and Ageing System – The Concise Factbook 2005), this would equate to 44,000 older Australians in aged care homes who have a wound. Using current population predictions this figure rises to more than 80,000 by 2041 (ABS Austats: Population Projections: Projections of the aged population).

The Clinical IT in Aged Care project provided $275,000 to Bayside Health for a trial of a Pressure ulcer Research, Intervention, Management and Evaluation (PRIME) system. Additional funds (cash and in kind) for the project were provided by consortium members.

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Aim of the Trial

The trial aimed to evaluate the effect of the introduction of an integrated clinical IT system designed to decrease the prevalence, incidence and cost of pressure ulcers over a 15 month period (November 2004 to February 2006).

Specific objectives included:

1. A decrease in the prevalence and incidence of pressure ulcers.
2. A decrease in the duration of existing pressure ulcers.
3. Improvement in pressure ulcer risk assessment procedures.
4. Improved knowledge levels of clinical staff at aged care facilities in the prevention and management of pressure ulcers.
5. Improvement in the documentation and monitoring of pressure ulcers.
6. A decrease in the cost of pressure ulcer care (through the reduction of incidents).
7. Identification of the cost benefit of introducing the PRIME system into aged care facilities.
8. Documentation of the organisational changes that occur with the introduction of the PRIME solution.

Consortium Members

Bayside Health, The Alfred Hospital and the University of Melbourne provided project management services for the project as well as provision of the Alfred Medseed/Wound Imaging System (AMWIS), research design and data analysis. Medseed Pty Ltd provided technical and programming support for users of AMWIS.

The Silver Chain Nursing Association and Curtin University provided the Pressure Ulcer Risk Assessment instrument and related education resources. They also provided educational support for the trial and research services.

The Combined Universities Centre for Rural Health in Western Australia provided organisational change analytical methodology and evaluation of the introduction of IT into aged care facilities.

The University of South Australia provided research design and wound care consultation. A specialist Wound Care Consultant was also commissioned for the project.

Access to clinical facilities and allocation of nursing staff time was provided by the Hardi Group of Aged Care Facilities. Hall and Prior Aged Care, South Port Community Nursing Home and Cumberland View Nursing Home.

The Trial Setting

A total of 3,526 aged care home residents were enrolled in the trial from 23 homes located in Victoria, NSW, SA and WA belonging to the Hall and Prior Aged Care Organisation, Hardi Nursing Home Group, South Port Community Residential Home and Cumberland View Nursing Home. They included single and multi-facility organisations, public companies and not for profit. All were highcare facilities.

All sites had existing IT facilities and each committed key clinical resources to the trial.

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The Solution

The Pressure ulcer Research, Intervention, Management and Evaluation (PRIME) system is an integrated set of tools and processes to both improve wound management and measure the outcomes of the process. This trial involved a significant research component to qualify and quantify the potential benefits from the IT applications and tools. PRIME comprises the following components:

1. Pressure Ulcer Prevalence Survey (PUPS) instrument;
2. Pressure Ulcer Risk Assessment and Management System (PURAMS) instrument;
3. Alfred/Medseed Wound Imaging System (AMWIS);
4. Australian Wound Management Association (AWMA) Clinical Guidelines for the Prediction, Prevention and Management of Pressure Ulcers;
5. Pressure Ulcer Incidence Database; and
6. In addition, the project involved a specific set of educational programs and a survey to assess the organisational change which implementation of PRIME would create.

During the trial, clinicians in aged care homes recorded information electronically in the AMWIS system, assisted by digital camera technology. Wounds were treated in accordance with the AMWA Clinical Guidelines and tracked through use of the AMWIS system.
Encrypted patient files could be sent to external wound consultants for remote consultation via the AMWIS telemedicine facility.

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Involvement of Clinical Staff

Extensive planning and collaboration was undertaken with the administrative, IT and clinical management personnel at each participating facility to ensure a shared understanding of the aims and objectives of the trial. These staff were involved in refining the project methodology to ensure its appropriateness for their environments. In addition, they were trained in the disciplines of project implementation to ensure that the project was undertaken with them rather than to them.

Key clinical staff were appointed within each aged care home and staff education sessions were conducted in August and September 2004 and July 2005 with Registered Nurses and Enrolled Nurses.

Separate educational sessions were conducted for carers. Staff that were directly involved in data collection also undertook a specific education program to ensure that reliable data was collected throughout the trial.

All clinical staff who were responsible for documenting ulcers using AMWIS and the pressure ulcer incidence database were also individually trained on-site on how to use the software, digital photography techniques and how to transfer these images and data to the chief investigator of the trial.

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The Technology

AMWIS is designed to be used in two ways:
1. As a standalone system for accurately recording details of patient wound care within a single institution, or
2. To record details of patient wound care, and send them electronically to an external consultant for advice.
Minimum system requirements:

• Pentium processor or equivalent
• 64MB RAM
• 20MB hard disk space
• CD ROM drive

To use AMWIS as a telemedicine program:

• Modem or network internet connection
• Account with an Internet Service Provider
• Digital still camera with a minimum resolution of 640 x 480

Barriers

Clinical staff must have access to the technology at the point of care if the new processes are to become imbedded within clinical routines. The physical location of computers played a role in staff perceptions about the efficiency of the system. Where AMWIS was installed on a computer that was physically located away from the clinical area and where the digital camera was difficult to access, staff were more likely to view the use of the system as time consuming.

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Outcomes

Overall the trial was effective in reducing the prevalence of pressure ulcers in aged care. The trial demonstrated that through the use of clinical IT, it is possible to protect the fragile aged individual from the development of pressure ulcers and improve the quality of life of these individuals and their families.

Better wound care documentation and improved communication within and between aged care homes, GPs and residents' families were all reported as part of the trial with the majority of participating facilities choosing to continue use of AMWIS after the trial.

The trial demonstrated the applicability of the system and methodology across a range of aged care homes in reducing the prevalence and incidence of pressure wounds. During the trial, pressure ulcer prevalence was reduced by 42% resulting in a cost saving of almost $200,000 across the 23 participating aged care homes. The incidence of pressure ulcers was lower than reported in the literature following the introduction of the PRIME system.

The reasons for reduced pressure ulcer incidence during the trial were believed to be multifactorial and included factors such as improved staff knowledge and risk assessment methods, and the availability of appropriate equipment. The cost saving demonstrated that significant savings can be realised through the use of an integrated clinical IT system.

The trial provided ground-breaking understanding about the prevalence and incidence of pressure ulcers in aged care homes. It identified a wide variance in prevalence across aged care homes. It also demonstrated that the variance can be decreased through standardised approaches to assessment and management and to provide benchmarks against which future programs can be measured. It increased the understanding of the risk assessment process by identifying co-contributing factors to the incidence of pressure ulcers in residents.

Telecommunications assisted wound consultation benefited the patient and provided clinical staff with significant on-going learning opportunities in wound management. The consistent wound documentation process provided assurance to carers, GPs and family members that the treatment was delivering results.

The trial demonstrated that pressure ulcer risk assessment instruments were reliable predictors of risk. As a result of emerging evidence and data obtained from the trial, the elderly are at greater risk of developing a pressure ulcer in an acute hospital than an aged care home, and that if they do, they are more likely to develop more than one ulcer and ulcers of greater severity.

Feedback from clinical staff regarding the use of AMWIS was positive, with the mostly commonly reported response being that using the system resulted in an organisation-wide standardisation of wound documentation. Other comments included the benefits of having a visual record of the progress of the wound over time as a function of the treatment, and the ability to communicate more effectively with GPs, temporary staff and family members about the progress of the wound. Residents' families often commented on the reassurance felt by being able to see the improvement in a relative's wound through digital images.

Initially, staff found the use of the clinical IT components of the trial challenging, however the IT quickly became an integral part of daily clinical practice. The wound imaging system was almost universally utilised to document all wounds. An unexpected outcome was that staff in one aged care home were using the AMWIS measurements to document their successes.

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Key Success Factors

The trial demonstrated that clinical IT systems can be successfully introduced into aged care if adequate emphasis is placed on organisational factors involved in the introduction process. Effective organisational leadership and clinical and IT support are crucial to this. Staff education and staff development plans as well as organisational communication strategies are also crucial factors for the successful introduction of clinical IT.

The project implementation strategy involved wide consultation with all clinical stakeholders (aged care home management and clinicians). The three major goals of the consultation process were to:

1. Strengthen the partnership between the project team and the clinical site.
2. Clarify goals and methodologies.
3. Develop and implement an appropriate action plan.

Detailed project planning engaging all participants in the trial to establish collaboration and buy-in to the aims and objectives ensures team resiliency to deal with the unforeseeable. Of note was that the participating agencies allocated more staff to the trial than was originally requested by the research team.
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Lessons Learned

There is significant room for improvement in the quality of life for aged care residents through the reduction of pressure ulcers, and opportunities for cost reduction in the management and treatment of wounds using IT and evidence-based procedures. By integrating clinical IT with clinical practice guidelines, variations in clinical practice can be reduced and care improved.

Facilities with existing training and staff development programs were better able to utilise evidence-based procedures than those with less structured communications. However, with effective implementation education and support, the PRIME solution can achieve significant improvement in wound prevalence across a wide range of aged care facilities. To do this, a specifically designed educational program is necessary. The program must be tailored to the needs of the different levels of clinical staff.

This product trial summary was prepared as part of the Australian Government Department of Health and Ageing's Clinical IT in Aged Care Project. The product trials aimed to assess improvements to the care provided to residents in aged care homes as a result of the implementation of technology. The use of the IT product in this trial should not be taken as an endorsement of the product.
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