Leading Change

Nurses and health care assistants in the Tissue Viability Link Team at Nottingham University Hospitals NHS Trust (NUH) championed best practice to improve patient care and experience in adult critical care by introducing a moisture lesion prescription sticker to address unwarranted variation seen in practice.

Where to look

NUH is one of the largest acute Trusts in England, employing 14,500 staff and providing services to over 2.5 million residents of Nottingham and its surrounding communities, and a further 3-4 million people from neighbouring counties each year.

Patients receiving critical care often go through a period of critical illness making their skin vulnerable to moisture damage, which in turn can lead to further tissue deterioration. This moisture damage is identified as moisture associated skin damage, or a moisture lesion. A moisture lesion can be extremely uncomfortable, painful and distressing for patients, with prolonged exposure to moisture adversely affecting a patient’s physical and psychological wellbeing. Within adult critical care at Nottingham University Hospitals NHS Trust, it was identified that there were variations in moisture lesion practice, at times not meeting expected standards as prescriptions were not in place, or the course of treatment did not always reflect the Trust Moisture Lesion Guideline. On identifying this, the Tissue Viability Link Team designed a standardised moisture lesion sticker for use in the Trust.

What to change

In adult critical care, moisture lesion education and training is provided by the Tissue Viability Link Team. There is also a local guideline in place. However despite these supportive measures, the team continued to see a number of moisture lesion incidents in the unit as reported via the Datix incident reporting system.

With this baseline the nursing and healthcare support workers compared their incident numbers with other, similarly sized adult critical care units. They found that other healthcare organisations were also experiencing inconsistencies in moisture lesion practice with a number of respondents describing it as an extremely challenging area of practice. With this in mind, a new approach to managing moisture lesions within the Trust was the key driver to this project, in order to improve tissue viability practice for patients.

How to change

Once the team had identified areas of improvement with prescribing within the critical care unit a moisture lesion prescription sticker was designed to support standardisation of practice. The procedure that supported the sticker was presented to the Trust’s governance committees for approval before being introduced into three adult critical care areas at NUH, using a ‘Plan, Do, Study, Act’ (PDSA) model cycle. Moisture lesion incidents from the previous year were captured to provide a baseline so that the impact of the sticker could be measured.

The sticker was designed to be quick and simple to use for the prescriber and care deliverer. The aim was that all patients who had a moisture lesion would have the sticker added in the Medicine Prescription and Administration Record, prompting the correct course of treatment to be commenced.

The Tissue Viability Link Team provided education, training and communications to help embed the change. After three months, they conducted an audit to monitor compliance and impact, leading to some revisions and re-audit. This project has been presented at various events and received an award at the Mid Trent Critical Care Network. It is being rolled out across the Trust and plans are to continue to share this work nationally to support others to achieve and maintain best practice.

Adding value

The audit of 57 patients with a moisture lesion looked at incident reporting numbers as well as the application rates of the sticker in practice, prescribing and documentation compliance as well as nursing staff feedback.

Better outcomes – In the six months following sticker implementation, there was a 43% decrease in moisture lesion incidents recorded in adult critical care.

Better experience – Reductions in moisture lesions have had a positive impact on patient experience, and staff have welcomed the change stating that it offers consistency and guidance to them which is helpful.

Better use of resources – Better patient outcomes have also demonstrated increased clinical efficiency.

Challenges and lessons learnt

• Change is achievable, but staff engagement is a key factor. The project received support from a large number of nursing teams.
• The main challenge has been embedding this change into practice. While there has been an impact, the audit results suggest that more time is needed to embed 100% compliance against all the measures.
• It is important to follow a quality improvement tool to test the innovation, allowing time to assess its impact before making a larger-scale change.
• The sticker has the capability to be applied across all healthcare settings, both primary and secondary care. The format can be simply adjusted to include products used as part of the local wound care formulary.

Find out more

For more information contact:

• Nikki Sarkar, Practice Development Matron in Adult Critical Care, Nikki.Sarkar@nuh.nhs.uk