Despite the risk assessment and care planning systems and processes in place on our In Patient Unit (IPU) pressure damage is the cause of approximately 53% of incidents reported each month.
National benchmarking data suggests we may admit more patients with pressure ulcers and also acquire more pressure ulcers than other hospices of a similar size, but this observation warrants further investigation. It is possible we admit more patients for end of life care than other similar sized hospices and this would make patients more susceptible to the development of pressure ulcers.
The majority of acquired pressure ulcers are categorised as unavoidable.
Ensure best practice is followed
Ensure comprehensive implementation of recommendations arising from root cause analysis investigations
Eliminate the incidence of avoidable acquired pressure ulcers on IPU.
Approach Since March 2016 we have improved oversight and reporting of pressure ulcers and recognised that this area of practice required improvement. In January 2017 we recruited a senior registered nurse to work two days a week on IPU as Tissue Viability Nurse. His priorities are to:
mentor the IPU team
develop links with tissue viability nurses in the community
undertake baseline pressure ulcer management audit using Hospice UK tool.
Evaluation Results from the baseline audit indicate good levels of compliance with the existing risk assessment and care planning processes, but scope for development in terms of the assessment of risk factors relating to nutrition, cognitive impairment and sensory loss. There is also a need for an appropriate patient information leaflet.
Conclusion Review and analysis of pressure ulcer incidents will continue on a monthly basis. The Tissue Viability Nurse will develop the risk assessment process further and design and introduce an appropriate patient leaflet.
The Hospice UK audit will be repeated in Spring 2018 in order to monitor progress.
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