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Team work to reduce the incidence of pressure ulcers Hot

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Area Classification

Acute / Hospital Care

Briefly describe what it is

The Trust appointed 2 tissue viability support nurses and a clerical officer to assist the Tissue Viability Nurses to reduce the incidence of hospital acquired pressure ulcers. A strategy was developed to introduce a rigorous system to monitor the incidence and provide education to clinical teams and patients. All tissue viability link nurses attend a study day every quarter and outreach visits were made to wards where the incidence rate was over 2%. A root cause analysis was conducted for any patient who developed a grade 3 or 4 pressure ulcer.

Were there any key things that you had to do to make it happen?

Establish a data base and robust weekly incident monitoring system.
Design a root cause analysis form and establish regular meetings with the Director of Nursing to review the patients with clinical staff involved in their care.
Education package and quiz on the Trust Intranet.
Establish outreach visits to wards.

Describe (and provide evidence) of the impact on quality of care

The pressure ulcer incidence rate has decreased from 3.3% to 1.73%
The pressure ulcer prevalence rate has demonstrated a reduction of 3.4% in the number of patients developing a hospital acquired pressure ulcer.

Describe (and provide evidence) of the impact on patient (or staff) experience

The strategy has reduced the harm and suffering caused to patients and made them more aware of their role in prevention.
Over 635 registered nurses have completed the education programme on pressure ulcer prevention.

Describe (and provide evidence) of the impact on reducing cost

The financial cost of treating a pressure ulcer has been estimated from £1,064 for a grade 1 to £10,551 for a grade 4. It is difficult to estimate the costs when complications develop as a result of the pressure ulcer but they include antibiotics, septicaemis and litigation costs.

Keywords / Tags

Pressure Ulcers Root Cause Analysis

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