Introduction
The original aim of this article was to evaluate the efficiency and effectiveness of staff utilisation within a newly implemented pilot scheme of using Recovery Nurses as transfer Nurses. Patient wait times within the Recovery setting were also evaluated.
An impact assessment was chosen as a framework, as it is the process of identifying and assessing direct and/or indirect impacts of an intervention, in relation to costs, benefits and associated risks, thereby demonstrating value. It can take place before, during or after the intervention. During this impact assessment, I found that pressure area care, i.e. pressure ulcer reduction, featured highly when looking at patient wait times on hospital trolleys.
Zwarenstein et al [Reference Zwarenstein, Goldman and Reeves2009] state that some studies indicate practice-based, interprofessional collaboration interventions can lead to positive changes in health care. It was hoped that the outcome of this assessment would demonstrate an improvement in patient experience through a reduction of wait times on hospital trolleys and collaboration through team working.
Impact assessment adapted from HM Government [2011]
Identify the issue
The objective was to evaluate the change in service, and the data assessed included: staffing, shift patterns, patient wait times and Recovery Nurses’ time out of the Unit. Burtonshaw-Gunn [Reference Burtonshaw-Gunn2010] stated that by sharing best practice and assisting in increasing organisational performance as well as being a valuable resource by using analytical and problem solving skills, while working within a framework of professional standards and ethics, adds value.
As a Senior Nurse, I assisted in the management of the daily running of the new service and from my insight as a Registered Nurse, understood that the reduction in delayed returns would reduce the length of time patients spent on hospital trolleys. Tissue viability issues, namely pressure ulcers, are a huge concern and cost to any healthcare organisation [Moore and Price, Reference Moore and Price2004; Thompson, Reference Thompson2005; NHS Institute for Innovation and Improvement, 2006–2011]; therefore, a reduction of time spent on trolleys reduced the risk to the patient and cost to the establishment, as well as improved the patient experience.
It is acknowledged that assessing patient experiences would benefit this pilot scheme, as the rationale for the new service was to reduce delays in Theatres and Recovery while enhancing patient experience. Owing to confidentiality issues and ethics, this has not been included in this piece of work. Reducing delays at any stage of the patient's journey can only increase patient satisfaction. This is highlighted by patient satisfaction surveys, which conclude that people get really frustrated and angry with wait times [Berczuk, Reference Berczuk2008].
Specify desired objectives
I developed a set of objectives to ensure the pilot scheme would run quickly, safely and as smoothly as possible. Potential bias was therefore acknowledged due to lack of input from others. The objectives documented by myself are specific, measurable, achievable, realistic and timely, i.e. SMART, as described by Cowan [Reference Cowan2010] and while not being exhaustive, link the employees to the organisational strategy of working smarter and leaner while improving the patient experience.
(a) The new service will be set up instantly using current Recovery Nurses plus an extra member of staff, who will assist in the delivery of the service.
(b) Staffing levels on the ward and in the Recovery Room to be maintained at safe levels.
(c) Patient wait times on trolleys, for return to the ward environment, will be kept to a minimum.
(d) Recovery Nurses time out of the area will be audited to ensure correct staffing levels for the needs of the service.
(e) Patient experience will be enhanced by the new service.
Identify viable options that will achieve the objectives
An Operating Department Practitioner (ODP) was moved into the Recovery area to act as transfer Nurse and assist with the service implementation. An alternative option would have been to recruit more Registered Nurses into the Recovery area. The ‘do nothing’ option would put a strain on current staff due to heavy workloads or would make the new service undeliverable due to a lack of staffing.
Clinical audit identifies and minimises risk, waste and inefficiencies as well as improves the quality of care and patient outcomes through results from those audits, and healthcare providers now have a statutory and contractual requirement to participate in national and clinical audit [Healthcare Quality Improvement Partnership (HQIP), 2009]. An exploratory approach assisted with the understanding of the data, allowing auditing for analysis of the service, [Newton and Rudestam, Reference Newton and Rudestam1999] in order to meet objectives.
Identify impacts
Utilising the ODP in the new service alleviated some work pressures on current Recovery and ward Nurses, assisted patient throughput into and out of Theatres and Recovery, thereby having a positive effect on patient experience as well as reduced delays in Theatre lists. This correlates with the Productive Operating Theatre, Recovery Module, from the NHS Institute for Innovation and Improvement [2006–2011]. It is a systematic way to deliver significant improvements in patient care, safety and efficiency and it is changing the culture within the establishment by transforming the way theatres work. It allows Recovery Nurses to manage patients’ recovery process, by focussing on activities, tasks and information flows, required to transfer the patients into recovery, out of the theatre suite and back to the ward efficiently without delay, when staff are busy.
Value the costs and benefits (direct and indirect)
Allowing ward Nurses to remain within the ward environment was beneficial to patient safety. Theatres benefitted through a reduction in delays and Recovery were able to discharge patients promptly back to the ward once ready, thus reducing wait times on trolleys and improving the patient experience. The direct cost to the Trust, for an extra Nurse in each Recovery area would be ∼£127,056.00, i.e. six newly qualified Nurses on Band 5. However, the benefit to the Trust for doing so is unquantifiable. Areas would be made safer through better staffing levels, thereby reducing the potential for errors. Delays and cancellations of theatre lists would be minimised and patient experience would be improved.
Consider enforcement and implementation issues
Ward, Theatre and Recovery Managers were responsible for the enforcement of the new service. Regulation is through the Nursing and Midwifery Council (NMC) and Health Professional Council (HPC). Staff should act within their code of professional conduct [NMC, 2004; HPC, 2008] at all times, while providing the new service. This involved treating people as individuals, collaboration, maintaining clear professional boundaries, working effectively as a team, acting with integrity, dealing with problems and assessing risk. Risk assessment was done daily on an individual basis.
Plan for evaluation and evaluate implemented projects
Evaluation is fundamental in the assessment of any success arising from change, and was an ongoing process through periodic auditing and continuous monitoring. The service aim was to improve throughput of patients to Theatres and return patients promptly to the ward from Recovery; however, while assessing the new scheme, it was found that reducing patient wait times on hospital trolleys correlated with Government White Papers for reducing the risks of pressure ulcers.
Results from a literature review
Patient wait times on hospital trolleys raised concerns for tissue viability, which had implications for increased in-patient length of stay and costs [Moore and Price, Reference Moore and Price2004; Thompson, Reference Thompson2005; NHS Institute for Innovation and Improvement, 2006–2011]. While it was acknowledged that tissue viability, mainly pressure ulcers, was not part of the original project, a literature review of the previous 20 years’ Government White Papers highlighted that improving patient experience and pressure ulcer reduction featured high on their agenda [Department of Health (DoH), 1992, 1998, 2000, 2001a, 2008, 2010a, 2010b; National Institute for Clinical Excellence (NICE), 2001; National Patient Safety Agency (NPSA), 2004]. I used this information to underpin the new service of a reduction in patient wait times for transfer back to the ward. This would mean less time on a hospital trolley, and therefore pressure ulcer prevention.
Pressure ulcers (also known as pressure sores, decubitus ulcers and bedsores) are defined as 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), 1998; National Pressure Ulcer Advisory Panel (NPUAP), 2009]. The EPUAP [1998] supported the fact that the population was aging, were at risk of developing multiple co-morbidities and envisaged that the numbers of patients with pressure ulcers would increase.
I contacted National tissue viability groups, namely the Tissue Viability Society (TVS), the Tissue Viability Nurses Association (TVNA) and Tissue Viability (Health Improvement Scotland) in order to access published literature around pressure ulcer reduction on hospital trolleys. Tissue viability link Nurses within the organisation and external websites were also liaised with, due to the lack of specific research. Without exception, all of the specialists stated that they understood there to be no research conducted specifically on pressure ulcers and tissue viability with regard to time spent on hospital trolleys.
Following the contact with the Tissue Viability Nurses, I undertook a systematic literature review with regard to tissue viability issues for post-operative, surgical patients on hospital trolleys (see Appendix I). Pressure ulcers were deemed to be the pertinent area of tissue viability and were therefore researched.
Secondary quantitative research and randomised control trials were utilised due to the limited availability of specific research. According to Morton-Cooper [Reference Morton-Cooper2000], literature reviews should be both practical and feasible, within a given time frame. I identified limitations of this literature review as time constraints, searching only electronic data and bias from lack of validation from another professional around the inclusion and exclusion criterion.
When the search term ‘post operative’ was included with criterion used, no hits were obtained at each stage. This has not been included within the table. A total of 31 articles were retrieved via the literature search. Further screening highlighted a possible nine relevant research articles, although not directly linked to pressure ulcer reduction for post-operative patients on hospital trolleys, pertinent information was extrapolated.
Surprisingly, there was little published evidence around overlays and mattress types for hospital trolleys as preventative measures for pressure ulcers, yet pressure area care can be traced back to Norton et al [Reference Norton, McLaren and Exton-Smith1962]. Nixon et al [Reference Nixon, Brown, McElvenny, Mason and Bond2000] found that while there was considerable literature surrounding pressure sores, few prospective studies had been conducted to determine key prognostic factors. They ascertained that the type of mattress was found to significantly affect pressure sore development, concluding that grade 2a pressure sores were directly related to the peri-operative period. Reddy et al [Reference Reddy, Gill and Rochon2006] stated that pressure sores, which occur in the operating theatre, are different from those developed during hospitalisation. They further highlight that pressure sore incidence was high when patients sat up at 90 degrees, yet no significant difference was found at 0, 30 and 60 degrees.
A recent systematic review of literature from 53 randomised controlled trials (n = 16,285) surrounding pressure ulcer prevention through pressure redistributing support surfaces by McInnes et al [Reference McInnes, Jammali-Blasi, Bell-Syer, Dumville and Cullum2011] found a high risk of bias; however, it concluded that higher-specification foam mattresses, sheepskins and some overlays within the operative setting were effective in preventing pressure ulcers. Pham et al [Reference Pham, Teague and Mahoney2011] found dry, viscoelastic and polymer overlays were preventative measures.
Maintaining and/or improvement of skin integrity remain the benchmark for the prevention and treatment of pressure ulcers and teamwork is vital to promote individualised care [Morris, Reference Morris2002]; however, predominantly only nursing strategy is represented within The Essence of Care document [DoH, 2001a]. NICE guidelines [2005] state that patients at risk of developing pressure ulcers should be placed on pressure-relieving surfaces, before, during and after surgery. Berlowitz and Wilking [Reference Berlowitz and Wilking1990] highlight that patients with existing pressure sores and morbidity rather than age had an increased risk of developing pressure sores. Diabetes Mellitus, cardiac diseases, vascular failure [Bulfone et al, Reference Bulfone, Marzoli, Quattrin, Fabbro and Palese2012], respiratory diseases, renal failure and cancer [Shewchuk et al, Reference Shewchuk, Padula and Osborne2006] were statistically and significantly associated with pressure sore occurrence. Hartley [Reference Hartley2003] confirmed that identification of surgical patients at risk of developing pressure sores and activating effective risk management strategies are internationally well-established practices of prevention.
Maylor and Torrance [Reference Maylor and Torrance1999] concluded that increasing the value placed upon pressure ulcer prevention can lead to an increase in preventative strategies being carried out. Thompson [Reference Thompson2005] found that Nurses’ clinical judgement on tissue viability issues were more reliable and had concurrent validity than current risk assessment tools. The Royal College of Nursing [2001] document that the frequency of repositioning should not be ritualistic, rather determined by skin inspection results and individual needs.
Team working with all areas involved would allow findings to be shared and affect improvements in both practice and monitoring, thereby providing evidence for the Commission for Health Improvements by setting the foundations for regional benchmarking and potentially the development of nationally agreed standards [Morris, Reference Morris2002]. Bulfone et al [Reference Bulfone, Marzoli, Quattrin, Fabbro and Palese2012] concur with this highlighting monitoring of outcomes for effectiveness of prevention strategies adopted, as being extremely important for all involved in the care of the patient. O'Mahoney [Reference O'Mahoney2010] states that change will only come from new ideas and critique of existing service provision.
Following the literature review, I undertook informal interviews with staff involved, gaining qualitative research, as it explores meanings and phenomena within the natural setting [Aveyard, Reference Aveyard2007].
Evidence-based practice was promoted via the collecting and collating of information for this pilot scheme. This enhanced accountability for the decision-making process as well as fulfilling the requirement to become lifelong learners by the Government from their publication, ‘A framework for Lifelong Learning in the NHS’ [DoH, 2001b].
Conclusion
The newly implemented service of using Recovery Nurses as transfer Nurses worked well from the outset and having the extra member of staff assisted with the delivery of it. Patient wait times on trolleys were dramatically reduced and ward Nurses could remain on the wards. This ensured that patient care was at the heart of the pilot scheme.
Reducing time spent on hospital trolleys, correlates with current and previous Government White Papers [DoH, 1992, 1998, 2000, 2001a, 2008, 2010a, 2010b; NICE, 2001; NPSA, 2004], which highlight the need to improve patient experience and reduce pressure ulcer incidence. Research papers found via the literature review confirm that a difference in pressure sore definition, patient samples, assessment schedules and exclusion criteria account for wide variations in incidence [Nixon et al, Reference Nixon, Brown, McElvenny, Mason and Bond2000]. Not one type of overlay or mattress was highlighted as superior, with selection bias remaining high. However, higher-specification foam mattresses, sheepskins [McInnes et al, Reference McInnes, Jammali-Blasi, Bell-Syer, Dumville and Cullum2011] and some dry, viscoelastic and polymer overlays [Pham et al, Reference Pham, Teague and Mahoney2011] within the operative setting appear effective in preventing pressure ulcers. Wallace [Reference Wallace2009] confirmed that alternative foam mattresses reduced pressure ulcers more than standard hospital mattresses; however, the research was not able to provide clear, discrete answers to clinicians to aid decision making [Australian Wound Management Association, 2001].
A specific tool for Peri-operative Nurses to standardise evaluations of the effectiveness of preventative strategies for patients at risk needs to be developed [Bulfone et al, Reference Bulfone, Marzoli, Quattrin, Fabbro and Palese2012]. Nurses’ clinical judgements were found to be superior to any current risk assessment tool [Thompson, Reference Thompson2005], and team working was found to improve both practice and monitoring [Morris, Reference Morris2002].
According to Moore and Price [Reference Moore and Price2004], management have a responsibility to ensure that the resources necessary to provide effective pressure ulcer prevention are available. Tarpey et al [Reference Tarpey, Gould, Fox and Cockling2000] highlight the lack of nationally agreed guidelines to assess the suitability of the standard hospital trolley, and I believe that is still the case due to the lack of research available. Hospital trolley mattresses need to have the same value placed upon them as bed mattresses and pressure-relieving devices, and more risk management strategies need to be utilised for pressure sore prevention, where trolleys are concerned. This requires further research.
I would have liked to prove a link between reduced time on hospital trolleys with a reduction in tissue viability issues, however, further research needs to be undertaken to confirm this hypothesis.
Appendix I – Literature review results
Initial search of research papers
