A rise in pressure ulcer numbers prompted staff on a vascular ward to consider new methods of pressure ulcer prevention and inspired the development of a Stop the Clock board. Ward 22 Vascular is a 12-bedded ward at University Hospital Coventry and Warwickshire (UHCW), which specialises in providing care for patients with peripheral vascular disease. Surgeries carried out include grafts, embolectomy, fasciotomy, endarterectomy and amputation.
While anyone is potentially at risk of developing a pressure ulcer, several factors are known to increase the risk. These include limited mobility, loss of sensation due to neurological impairment, poor posture, inability to independently reposition, and conditions that cause inadequate blood flow to the skin and soft tissues, such as diabetes and peripheral vascular disease (National Institute for Health and Care Excellence, 2018). These risk factors are present in most patients in Ward 22 Vascular.
Monitoring of key performance indicators highlighted an increase in pressure ulcers on the ward. A review of data from January to December 2024 confirmed 17 patients developed hospital-acquired pressure ulcers, predominantly located on heels and buttocks. Thirteen of these were classified as category 2, and four were classified as unstageable.
Attempts made to reduce these harms throughout the year produced limited results, so increasing pressure ulcer numbers was added as an area of concern to the ward focus board, and priority was given to reduction. Several methods of investigation were employed to identify specific areas of practice that could be improved; these included observation of direct patient care and of the daily ward routine, detailed review of patient records, and the experiences of ward staff.
This investigation highlighted several aspects of care relating to pressure ulcer prevention that could be improved. These included accuracy of the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T) risk assessments, initiation of the correct pressure ulcer prevention care plan in correlation with identified level of risk, accuracy, timeliness and prioritising completion of skin assessments and a delay in registered nurses reviewing patients because of lengthy morning medication rounds.
What did we do?
UHCW utilises the UHCW Improvement System (UHCWi) methodology. This is based on Virginia Mason’s Lean management techniques (Virginia Mason Institute, 2024), which are used to identify and eliminate non-value-added waste. At UHCW, we recognise that the voice of all members of a team has equal value. Effective change often comes through ideas generated from those doing the work because they are best placed to identify what works and what does not and can suggest and test ideas for improvement. Through this process, they are empowered to create effective change and improve patient experience. Several ideas were suggested, and the four identified as most likely to have the greatest impact on reducing pressure ulcer numbers were tested using a PDSA cycle. These were: a trial of night staff completing the morning medication round to give more time for registered nurses to review patients earlier in the shift and complete skin assessments before midday. This facilitated earlier implementation of preventative measures and is now routine practice. On-the-spot education to be provided by the clinical education lead to support staff to navigate the new electronic patient record (EPR) system and to demonstrate how to complete risk assessments accurately in real time in the clinical area. Healthcare support workers and registered nurses to focus on assessing skin together, usually when meeting patients’ hygiene needs, with an aim to complete this before midday and, the development and implementation of a Stop the Clock board placed in a central position, made to be clear, simple and easily accessible.
How does Stop the Clock work?
The Stop the Clock board is a centralised visual tool used twice daily that includes the elements identified as requiring improvement while also incorporating other essential daily assessments, such as IV access, urinary catheters, fluid balance charts, nutrition charts, wound assessments and weekly tasks, such as falls assessment and Malnutrition Universal Screening Tool. Time-critical medications are also indicated on the board as a visual aid to help ensure these are given at the correct time [Figure 1].
This first Stop the Clock takes place at 9 am when all nursing staff stop what they are doing to gather round the board, which the nurse in charge uses to identify the needs of each patient and allocate tasks to individual team members [Figure 2].
The clock is then stopped again at 3 pm, and the nurse in charge systematically works through the board, one patient at a time, to confirm each task has been completed. Where it has not yet been possible to complete an action, a plan is made to help ensure it is completed during that shift.
The board is placed centrally on the ward, meaning that assessments to be carried out can be identified at a glance and quickly updated in real time during the shift.
Barriers to implementation
Initially, staff felt it was time-consuming and that their time could be better spent doing other things, so it was initially difficult to get all staff to stop at the same time due to the busy nature of the ward.
How was this overcome?
The implementation of the Stop the Clock board was supported by the clinical education lead and modern matron, who attended twice daily to guide staff in its use and to help keep conversations on track. This strict adherence to the stop the clock format helps limit time gathered at the board and increase time spent at the bedside. Staff also complete sections of the board in real time, as tasks and assessments are completed, which means the 3 pm Stop the Clock is more efficient and outstanding tasks are easily identifiable. Early in the implementation stage, documentation was checked during the Stop the Clock process to confirm completion while staff were getting used to the changes. Now that staff are familiar with the process, monitoring only occurs during ward audits, again keeping time spent at the board to a minimum. Furthermore, the enthusiasm to embrace this change in practice to improve patient care, demonstrated by the ward manager and band 6 clinical sisters and championed by some key team influencers, has been crucial in embedding this positive change on Ward 22 Vascular.
How has the Stop the Clock board helped reduce pressure ulcer numbers?
The central position of the Stop the Clock board and its clear, uncomplicated design mean that nursing staff can see, at a glance, which assessments and tasks are due each day. This allows them to plan and deliver care more efficiently adding value to their day. Time spent searching through the new EPR system has been eliminated, freeing up more time for nursing staff to be at the bedside, identify pressure ulcer risk promptly, and implement preventative measures to reduce that risk. This renewed focus on pressure ulcer prevention utilising a team approach and the Stop the Clock board has likely contributed to a significant reduction in pressure ulcers on ward 22 vascular. This has been reiterated by the ward manager, Rosie Wheatley, who said: “Before the implementation of Stop the Clock, we had worryingly high numbers of hospital-acquired pressure ulcers. The client group on Ward 22 Vascular is at very high risk of developing pressure ulcers, which means accurate risk assessments, skin assessments and preventative nursing measures are vital in reducing that risk. During 2024, we were struggling as a ward team to implement the correct measures consistently, and patients were coming to harm. The Stop the Clock board has enabled the team to be more focused and easily see what is required for each patient each day. As a ward manager, I attend Stop the Clock, and now have assurance that standards are maintained and patients are receiving high-quality care whilst on Ward 22 Vascular. It is a simple yet highly effective tool that the team has embraced. I am grateful to our clinical education lead for developing the board and senior nursing team for their support in its implementation, and am very proud of my team for their achievements and commitment to providing safe and effective care for patients.”
Clinical sister Leeann Tyrrell said: “I get to see my patients earlier in the shift and can work with our healthcare support workers to provide direct patient care where I can look for the first signs of pressure damage and quickly implement preventative measures.”
Healthcare support worker Sarah Shakespear said: “Teamwork has improved since we started using the Stop the Clock board as registered nurses now have more time, so we now work together with them to provide care to our patients.”
Comments from other members of the team include:
“When I update the board during the shift, my contribution to the patients’ care is recognised, which makes me feel valued.”
“Because of where the board has been placed, I can simply look up and see what I need to do for my patient that day. This means that I don’t have to spend too much time on a device and can spend more time with my patients, making sure they have an up-to-date risk assessment and everything in place for pressure ulcer prevention.”
“Updating the board when I have completed tasks throughout the day helps me to feel in control, use my time well, and prioritise my tasks.”
“The design of the board is really easy to use and understand.”
“I definitely find it easier to organise my day.”
What has happened since the implementation of the changes?
PURPOSE T risk assessments are completed accurately, patients are reviewed by a registered nurse early in the shift, prevention interventions are implemented promptly, and the team works together to complete skin assessments.
The Stop the Clock board has now been implemented on several wards at UHCW as its simple design means it can be easily adapted to suit different wards and departments. It is hoped that its use will help reduce pressure ulcer numbers wherever it is implemented.
And most importantly the team on Ward 22 Vascular are delighted to have now achieved 12 months free of hospital-acquired pressure ulcers. This commitment to high-quality patient care has been recognised by the chief nursing officer at UHCW, who presented them with a special award recognising their efforts to prevent harm, and emphasised that it is the little things done collectively that can really make a difference.
While we recognise it is inevitable that patients on our ward will develop pressure ulcers in the future, we feel confident that the process we have developed can be applied and further developed to help us continue to reduce hospital-acquired pressure ulcers.
