Background There was recognition at leadership level of an increased number of new pressure ulcers across Jersey Hospice Care. In line with the island-wide pressure ulcer prevention policy, the organisation developed a standardised holistic approach around assessment including risk to palliative care patients admitted to the in-patient unit.

Aims and purpose

• To reduce the number of new pressure ulcers and avoidable harm to palliative care patients on the in-patient unit.

• To educate all front-line clinical teams on how to undertake a baseline assessment and understand different categories of pressure damage.

• To develop person-centred information for patients and their families on pressure ulcer prevention.

Methods On commencement of the project a baseline assessment on the current pressure ulcer management approach was undertaken against the Quality Improvement Scotland Health (2009) - now Healthcare Improvement Scotland (2020) - standards to assess the gaps related to pressure ulcer prevention, assessment and management of new pressure ulcers across the patient pathway.

Results The outcomes have reduced the level of harm for all patients admitted to the in-patient unit:

• 30% reduction of new pressure ulcers from Year 1 to Year 2 and a further 7% reduction from Year 2 to Year 3.

• 35% reduction of new pressure ulcers compared to 2019.

• New pressure ulcer incidences are below Hospice UK average for medium hospices.

Highlighting the risk of developing pressure ulcers at structured shift handovers and safety huddles facilitated patient-centred discussions amongst clinical teams on the frequency of repositioning and reassessment of risk.

Conclusion There is recognition that a standardised approach to educating and maintaining competencies of all front-line clinical teams including new joiners is imperative to maintaining the downward trend. Learning from incidents and shared learning at team meetings motivates teams on reducing harm to patients.