Repatriation General Hospital, South Australia
Since 1920 when the first core of battle-scarred soldiers was admitted to the Australian Military Hospital in Adelaide hundreds of thousands of other brave souls have followed them through the corridors.
The suburban location has changed, so too has the name to Repatriation General Hospital, but in peacetime it remains a place where proud returned servicemen and women gather in need of care.
Affectionately known as "the Repat", this tastefully-renovated 250-bed acute care facility is renowned for its focus on services for the elderly with specialist, rehabilitation, mental health and palliative services co-located within the hospital and day-surgery unit.
It is also a teaching hospital, and has earned acknowledgement in many areas of research and practice.
The Repat's relentless pursuit of excellence became more apparent in late 2000 when in response to anecdotal evidence it noted a high incidence and prevalence rate of pressure ulcers among patients.
Understandably, the nursing division regarded the rate as undesirable, and committed resources and ethical energies to address the issue.
A working party of clinicians and managers was formed, with the Repat's Management Support Consultant Beth McErlean as project officer, and great support from Vascular Nurse Consultant Sheri Sandison. Their joint effort, and close consultation with nurses on wards saw a professional team develop a comprehensive pressure sore management framework.
The key to the framework was in the linking of individual risk identification to implementation of evidence-based pressure sore prevention strategies.
The Repat has now implemented a pressure sore prevention framework based on best practice guidelines. It has supported changes to practice decisions, and remarkably the incidence of pressure ulcers within the hospital has decreased from more than 20 percent to less than seven percent.
The reduction in incidence has been sustained over the past three years, realising total savings to the Repat of more than $A750,000. Also, the framework is now considered to be applicable across other health institutions and health sectors, and has been presented at a number of professional conferences both nationally and overseas.
The work is regarded as an important example of a sustainable quality practice project, demonstrating effective and sustained change over time. The Australian Council on Healthcare Standards (ACHS) and the State Government have recognised the framework through awards and formal recognition.
"The accolades are due to the organisation and its nursing staff having the foresight to address the issue and implement change through the principles of transferring, translating and utilising evidence-based practice," Beth said.
"The group's first task was to examine the literature and use the information from the JBI Best Practice Information Sheets, and the Australian Wound Management Association, to identify benchmark prevalence rates and best practice solutions.
"We then engaged support from our organisation - both nursing services and hospital executives - to undertake the project.
"We needed to look at how to integrate best practice information into actual practice, and we developed a number of resources and tools to support nurses. We looked at how we could integrate pressure ulcer risk assessment into our admission processes, and adopted the teachings of Brenda Ramstadius, who was then President of the NSW Wound Management Association.
"Brenda articulates the notion that it is really pressure, friction and shearing forces, which cause pressure ulcers, so we realised that we should be focusing on those issues or risk factors. We came up with that notion as well; that we could not really quantify this from a nursing perspective.
"We needed to identify the risk factor, and as nurses, implement strategies to reduce that risk factor. This is part of our responsibilities within nursing. The admission nursing assessment tool was re-vamped and the pressure ulcer primary risk factors embedded within it. A flow-chart articulating best practice care strategies was also developed linking the each individual risk factor to appropriate care strategies.
"We developed an education program and tools to assist with equipment choice, and implemented these recommendations within organisation. We are still progressing with this today.
"A reduction in the incidence and prevalence of pressure ulcers has been sustained over time, and Repat is now clearly setting the benchmark. Pressure ulcers are very, very painful, may cause delays in primary treatments, and increases length of hospital stay. Further pressure ulcers cost money, so if we can halve the rate by using evidence-based best practice then we are doing a good job."
Conducting an audit and implementing change in any hospital can be met by reluctance among nurses due to their concerns about being judged and very real issues of completing work demands, but Beth said the response from nurses at the Repat in relation to developing and implementing a new pressure prevention framework was outstanding.
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Repatriation General's Sheri Sandison (left) and Beth McClean. |
"To be honest, the best practices that are advocated aren't dramatically different to what we have been doing for the last 50 years," she said. "However, by articulating a standardised framework that nurses could apply to each patient, enhanced consistency in the nursing approach resulted. The other difference was that our nurses thought: ' ...here we have an organisation that acknowledges we have a problem and is making money available to fix it'.
"In our case it has meant spending $70,000 to date on pressure prevention equipment. We virtually had none, or it was either inappropriate according to best practice guidelines or malfunctioning.
"Once nurses see there is a real commitment from an organisation to provide the resources to support their practice then they are far more willing to work to bring about change rather than just telling them: ' ...this is the way you should be doing it'. The provision of resources to support changes in practice is very important.
"We have a robust quality structure within nursing, and a robust research focus here evident by nurses from the Repat being successful in winning Premier's Nursing Scholarships every year for the past six years and having finalists in Nursing Excellence Awards every year. It says we are all focused on innovation, continuous quality improvement and in achieving best practice in this organisation."
Walk the medical and surgical wards and the crevassed and sunburned faces of a generation of heroes can tell many tales. Their average age is 78, and whilst they may be old they live for today and remain young at heart.
The veteran factor contributes to a marvellous increase in caring and tolerance levels among staff for they respect their patients' contribution to the nation, and become warmed to constant reminders they are 'never too old to learn'.
"Our patients have always been regarded in a special way, and it has become natural for everyone here to just carry on that regard," Beth said. "We are so entrenched, and most staff have been here 15 years or more."
The strong retention rate is largely due to the Repat having the central components of nursing practice in place, like pressure prevention framework, physical restraint framework in place, and its more recent study of bowel management.
"We apply the same methodologies in that we look at current practice through auditing," Beth said. "We look at staff knowledge through questionnaires and what the literature says, then develop a best practice framework and integrate it into actual practice.
"We look at our tools and methods that we actually undertake in practice, and try to embed it keeping in mind not to create another form or method that nurses have to consider. We facilitate the development of best practice either through facilitating groups, support publication or research proposal.
"Since we first started working on the pressure prevention framework it has gone a long way. We have had interest from two hospitals in England, while three hospitals from one group in Victoria have adopted our framework.
"We feel we are never too old to learn. We do twice-yearly education programs, and we have developed self-pace learning programs for staff so they can work through a learning module. Our nurses then receive a certificate that becomes part of their life-long learning process the Nurses Board says they are required to undertake.
"We do six-monthly auditing, and feed the results back to the wards. The wards have to give an action plan back to nursing executives. We have the complete quality cycle.
"Personally, I feel nursing is coming into its own, and we are defining what is nursing practice. Technology overtook us for a long time, and as a profession we turned our attention to the medical model.
"But now, as nurses, we are back again making sure our essential nursing practice areas are evidence-based and in the best interests of the patient. That is so important."