Drivers for change

• The investigative process into a significant event highlighted inaccuracies in the nursing documentation

• Data capture for clinical governance meetings were inconsistent

• NICE pressure ulcer guidelines not fully implemented.

Aim To improve the nursing management and prevention of pressure ulcers on the in-patient unit (IPU) in accordance with best practice and evidence. To debunk the myth that pressure ulcers are unavoidable at end of life.

Method Initial audit (Hospice UK) in 2016 highlighted a required review of the hospice policy and nursing documentation on admission and discharge. A task group commenced May 2016 comprising of the clinical director, IPU manager, H@H manager and IPU nurses with expertise and special interests in tissue viability.

Action plan

• Develop and adopt a policy and guidelines for the prevention and management of pressure ulcers on the IPU

• Collaborative working with the local NHS Trust to ensure we are working cohesively and consistently

• To provide training for IPU staff to develop their knowledge of pressure ulcers, risk assessments, management and prevention

• Raise awareness of the importance of skin care with patients, families and carers

• Improve the nursing documentation and reporting procedures, data collection and root cause analysis of pressure ulcers.

Results Audit results

Pressure ulcers 2017

Pressure ulcers 2016

Conclusion Pressure ulcers are one of the most common occurring harms in healthcare. This task force has been the catalyst for the IPU nurses to challenge the myth of inevitable skin damage at end of life, underlining the importance of general nursing care interventions within a specialist palliative care unit.