Pressure Ulcers: Year 1 Progress

Aim:   By March 2017 we will reduce avoidable harm caused by trust attributable pressure ulcers by: Stage 2  30%, and Stage 3 & 4 by  50% from our April 2015 baseline.

We said we would measure the effectiveness of our actions by demonstrating:

Compliance with Nursing Care Indicators – these identify the standards of our care delivery At the end of Year 1 we achieved 90% compliance with all aspects of the assessment criteria

A reduction in the number of patients experiencing a harm relating to a pressure ulcer.

At the end of Year 1 we saw a slight increase in the number of patients experiencing a stage 2 pressure ulcer by 5.18%. We have reviewed this and feel it is due to a combination of factors including staff education in accurately staging a pressure ulcer and an increasing number of patients being admitted with increased risks and other illnesses that make them more susceptible to tissue damage.  We reduced the number of patients experiencing a stage 3 or 4 pressure ulcer by 18.33%

The number of root cause analysis completed following a pressure ulcer (target 100%) – this lets us learn and share lessons to make improvements. At the end of Year 1,  100% of reported pressure ulcer incidents had an RCA undertaken.

We have also made the following improvements in year 1:

Implemented a new Total Negative Pressure Wound Therapy (TNPWT) product and contract across the whole health economy – this prevents delays in patient treatment of stage 3 & 4 pressure ulcers when they are discharged home, or prevents admission to hospital. The treatment also reduces the risk of the patient getting an infection.

Negotiated and implemented a revised Wound care Formulary across the community, hospital and commissioning health care setting – This means there is consistency, safety and effectiveness with prescribing treatment and we are getting best value for money.

Integrated Tissue Viability Link Nurse Forums – we identified link nurses in all clinical areas and we meet every quarter to share best practise, learn lessons and improve education and training for staff

2 additional Tissue Viability Advisors – we were lucky to receive non-recurrent funding to support 2 additional Tissue Viability Advisors as part of our Sign Up To Safety Campaign. They have worked closely with the risk department and clinical areas to provide intensive wrap around support to drive improvements, educate staff and reduce the risk of patient harm as a result of pressure ulcers.

Worked with our Higher Education Institute colleagues to improve staff education – we have developed a bespoke Tissue Viability training course for our staff with one of our local universities, with input from expert staff employees. This has supported collaborative working and improved staff knowledge and skills

Reviewed our policies to bring them in line with the latest NICE guidance and changes in practice / equipment – This means that we are providing our care to recommended national standards

Development of a mini RCA template – This will help staff to learn lessons at the time a harm occurs so we can share these in real time and also make sure that the patient and the environment is safe

Development of an intranet resource site  – this allows staff to access resources and make referrals to the Tissue Viability Team. The site includes policies and guidance both national and local, training dates, latest news etc.

Implementation of a new pressure re-distribution mattress following trials – this will help staff in planning and providing care to prevent patients experience a harm from the development of tissue damage