Bertrand Hughes, CEO of compliant concept AG, outlines the cost-effectiveness of pressure ulcer prevention & the added value of digital mobility monitoring.
A recent report by the European Commission estimates that 4-17% of patients experience adverse events, 44-50% of which are preventable.1 In the UK, total treatment costs of pressure ulcers (PUs) are estimated to be £1.4-2.1bn (~€1.6-2.3bn) or 4% of health expenditure,2 begging the question: how can we improve the cost-effectiveness of pressure ulcer prevention?
PU incidence levels cited today vary internationally. This can be due to difficulty in training staff to categorise wounds correctly but also due to varying degrees of the present blame-free culture. The NHS Safety Thermometer for May 2018 cites a 4.51% incidence in the UK.3
An annual national census carried out in Germany by IQTIG counts only from grade/category II upwards and hence is not fully comparable. The IQTIG 20164 report for 2016 cites an incidence of 0.4% for these pressure ulcer categories, and this level is stable from 2015. Revealing, however, is the fact that the 2015 IQTIG census incidence rates (category II and upwards) in specific hospital departments can reach as high as 7-38%.
Studies affirm internationally that the costs of pressure ulcer prevention are dwarfed by the cost of failure.5,6
International expert recommendations
The guidance documents are unanimous: a structured risk assessment should be carried out on admission to identify patients at risk for developing a pressure ulcer. One of the principal factors in this risk assessment is the mobility or immobility of the patient. Individual care plans should be set according to this risk assessment.
Are we missing something?
The risk assessment is generally carried out today based on clinical observations of the care staff. They are trained to do this often according to a given risk scale such as the Norton, Braden or Waterloo. The guidance documents do not recommend which scale to use but rather stress how important it is that the assessment is carried out in a structured way and repeated regularly to record changes.
A study carried out in 2015 and published in several publications in 20167,8 and 2017 revealed startling results: some 30% of patients are subjectively judged wrongly in their risk due to immobility. In fact, these 30% are assumed to have mobility in their sleep when in fact it is the opposite: they are immobile and hence at risk for pressure injury. How is this possible? The simplest explanation, and this is borne out by repeated empirical data, is that immobility, in both nursing home but especially in hospital patients, is variable and often highly dependent on medication. To capture this correctly, nursing staff would have to observe the patient 24 hours a day, which is clearly not practical.
Digital mobility monitoring for pressure ulcer prevention
This is where digital monitoring adds great value. Digital mobility monitoring is a contact-free sensor that is placed discretely under the mattress and transmits data on the mobility of the patient 24/7. This not only enables the dynamic capture of the exact risk due to immobility, but it also enables the possibility to respond in a targeted and selective manner to the exact needs of the patient, rather than waking them up every 2-3 hours to be repositioned, no matter whether they need to be or not. This enables a managed reduction of time in bed without pressure relief-relevant movements.
A randomised control trial9 carried out in 2015 demonstrated that the quality of sleep of patients using the Mobility Monitor® system could thereby be significantly improved.
Furthermore, the data captured also enables bed exit alerts for patients at risk for falls and can thereby dramatically reduce the incidence of falls out of bed.
There are some 50 publications on digital mobility monitoring and associated with the Mobility Monitor system. Some 20 studies have been carried out, and eight years of empirical data and validation has led to a tried and tested system that in its core has an algorithm that can distinguish between pressure relief-relevant movements and non-relevant movements. Moreover, data on the impact on pressure ulcer and fall incidence level is now available. Two studies10,11 carried out in university hospitals have shown reductions from 5% and 8% PU incidence, respectively, to zero with this system. At 108 and 116 patients, respectively, these study results cannot be considered statistically significant, but they are a strong indication of what can be achieved in the real-life setting of a hospital ward and they are borne out by other studies and further empirical data. They cannot be claimed to be due to the system alone. They are only possible together with skilled nursing staff taking the right clinical decisions based on the data provided.
Implementing strategies 1, 2, and 3
Hospitals that have achieved the best results with digital mobility monitoring have three clear implementation strategy steps in common:
- Identify the right patients at risk. The expert standards and guidance documents recommend a systematic approach in order to identify at-risk patients. By using digital mobility monitoring you can identify the 30% of patients who are at risk but who would otherwise go unnoticed. This is likely the most important step and explains the biggest gain.
- Permanent mobility monitoring helps to capture patients with a variable mobility profile – one half of the night mobile with sufficient pressure-relieving movements, the other half with long periods of immobility. By providing the data 24/7 the staff are able to determine the exact time point when the risk occurs and hence respond to a specific patient in a targeted and adequate manner, aiding pressure ulcer prevention.
- Targeted intervention enables reduction of periods of immobility to a minimum. Alarms can be set individually according to the patient’s condition for two, three or four hours’ maximum immobility, and thereby the staff can intervene on an individual needs basis, allowing patients to sleep that don’t need assistance while reducing the overall burden of turns for the staff. For patients with a constant low mobility profile, the Active Mobilisation System® from the same company, compliant concept AG, provides further relief for staff by continuously repositioning the patient gently in their sleep.
Economic outcome – the value of pressure ulcer prevention
By reducing the incidence of falls and pressure injuries, hospitals can reduce the length of hospital stays, thereby reducing waiting times and improving the profitability of diagnosis-related groups. In addition, the improved quality indicators make the hospital attractive and thereby ensure future profitable revenue. Reputation is saved and litigation is avoided, but, most importantly, the patient stands to gain.
- Eurobarometer, Special Eurobarometer on Patient Safety and Quality Care, 411/2014
- European Commission, The costs of unsafe care and the cost effectiveness of patient safety programmes in healthcare systems in the EU member; report drafted by Gesundheit Österreich Foschungs- und Planungs GmbH and SOGETI, February 2016
- NHS Safety Thermometer Classic
- IQTIG Qualitätsreport 2016, IQTIG Qualitätsreport 2015
- Joint EPUAP & EWMA PU prevention & patient safety advocacy project, Sept 2017
- Demarré et al.: The cost of prevention and treatment of pressure ulcers: A systematic review, 2015 https://www.ncbi.nlm.nih.gov/pubmed/26231383
- Gattinger et al.: Mobilitätsdaten als Basis für Fallbesprechungen – Information bei Demenz und Schlafstörungen; Krankenpflege 7/2017
- Zimmermann: Unterschätzte Liegedauer; Krankenpflege 9/2015
- Gattinger et al.: Effectiveness of a mobility monitoring system included in the nursing care process in order to enhance the sleep quality of nursing home residents with cognitive impairments; Journal of Health Technology, DOI 10.1007/s12553-016-0168-9, December 2016
- Carrea-Bassin et al.: Using new technology to enable preventing pressure ulcers and falls in a university hospital in Switzerland; EPUAP poster Belfast, September 2017
- Feuchtinger et al.: Cluster Zukunft der Pflege: Pilotprojekt zur Wirksamkeit einer integrierten Bettsensorik zur evidenzbasierten Sturz- und Dekubitusprophylaxe, Deutscher Pflegetag 15-17 March 2018
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This article will appear in issue 7 of Health Europa Quarterly, which will be published in November 2018.