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Southern Health NHS Foundation Trust Southern Health Covid-19 Service Changes

Pressure ulcers - reducing the number that patients develop

Pressure ulcers - reducing the number that patients develop

Transformation Pressure Ulcer BW roadshow pic - Dec 2018.jpg

To improve the number of pressure ulcers patients are developing under our care.

"We are aiming to reduce the number of pressure ulcers that patients under our care are developing. Our aim is to understand what the contributory factors are and root causes of patients developing pressure ulcers."

During the initial data collection period the team observed a number of visits to patients homes and pressure ulcer panel meetings, as well as holding focus groups with patients and carers, and examining data from different areas within the trust and nationally. 

Incidents of pressure ulcers were found to be most prevalent within the community, in people's homes, and our community teams will all be affected by changes and improvements.

The examination of all the information collected during the week-long Rapid Process Improvement Workshop in September 2018 highlighted a number of opportunities for improvement within some key areas; training, reporting, documentation and the availability of equipment for patients.

Since then the team embarked on a roadshow in December, visiting every community team in Southern Health with their plans for change, bringing the whole county along on their transformation journey! Already the planned changes to how pressure ulcers are reported are in place, and staff have been enabled to work more remotely so that care plans and treatment plans can be completed in patient's homes while on the visit. This is a simple change with huge effects.

The next steps for early 2019 are to record the e-learning package and roll this out to teams, which has been rewritten to reflect the improvements, and to continue working with partners in the local authority and CCGs in Hampshire to reduce waiting times for equipment being delivered to patients at home.

This project review has found that there has been an overall improvement in the quality and delivery of pressure ulcer prevention care.  The levels of harm have reduced and teams are starting to identify acts or omissions in care through their reflections.

6.2 The incidences of pressure ulcers have increased overall in 2018/2019, however this is likely due to a change in the reporting and categorising process.  It is difficult to assess if the total number of pressure ulcers have increased as a result of other reasons until we can identify the full impact of the recent process changes.

6.3 Staff have had to adjust to a number of changes over the last year, including new terminology for pressure ulcers, changes in reporting processes and documentation changes whilst delivering pressure prevention care.  Given that all teams are under immense pressure in the present climate, the developments seen in numbers of holistic assessments, care planning and general improvements in practice are encouraging and a positive achievement.

6.4 However there are still improvements to be made in the quality of the assessments, ensuring they are accurate and up to date, and in the quality of care plans.  Teams continue to need support with the reflective discussion tools to ensure all aspects of care are detailed and reviewed. 

6.5 Actions have been highlighted and recommendations made for teams to improve over the next six months to develop staff performance, quality of assessments and pressure prevention care for patients.  These actions have been formatted to the Quality Improvement Plan spreadsheet used by teams to monitor service improvements.  These will be discussed at Divisional Patient Safety Meetings, disseminated to all teams and progress reviewed by the Clinical Governance Team.

Full details available in the QI pressure ulcer project review paper

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