BOARD OF DIRECTORS PAPER COVER SHEET. Meeting Date: 25 June 2008

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1 BOARD OF DIRECTORS PAPER COVER SHEET Meeting Date: 25 June 2008 Agenda Item: 15 Paper No: L/6/08 Title: PRESSURE ULCER MANAGEMENT Purpose: To inform the Board about the Trust s actions and plans for the prevention and treatment of pressure ulcers Summary: Pressure ulcers are complex in their origin and can be acquired in hospital or already exist at admission but regardless of origin cause distress and pain to people who have them. The Trust has been working hard to manage both the prevention and the treatment of pressure ulcers. When benchmarked against other Trusts and nationally available data the Trust is identified as performing well (1.32% prevalence against 4-10% nationally). A detailed action plan has been implemented with additional resources put into new beds, mattresses, chairs and training of staff. The highest incidence of pressure ulcers is in older people, particularly those immobilised because of trauma and those who are acutely ill. Reporting of pressure ulcers across the Trust is improving. Recommendation: For noting Prepared by: ANDREA GRAHAM Tissue Viability Nurse MARTIN SMITS Director of Nursing & Patient Services Presented by: MARTIN SMITS Director of Nursing & Patient Services This report covers: (Please tick relevant box) Assurance Framework Healthcare Standards: Please specify which standard Business Planning Local Delivery Plan Complaints Performance Management Finance Strategic Development Foundation Trust Compliance Financial implications YES / NO Other (Please specify) Legal implications YES / NO

2 POOLE HOSPITAL NHS FOUNDATION TRUST Report to the Board of Directors 25 June 2008 PRESSURE ULCER MANAGEMENT WITHIN POOLE HOSPITAL NHS FOUNDATION TRUST 1. INTRODUCTION 1.1 The aetiology of pressure ulcer development is complex and multifaceted, external physical forces upon the skin combined with the intrinsic health of an individual are synonymous with pressure ulcer development. Individuals who are most at risk of developing pressure ulcers are those who are elderly and acutely ill (NICE 2005). 2. BACKGROUND 2.1 For the patient pressure ulcers are painful, debilitating and potentially life threatening. The cost to the NHS in financial terms is estimated at billion annually this is said to be equivalent to 4% of total NHS expenditure. With a single pressure ulcer of the greatest severity (grade 4) estimated to cost up to 24,214 (Bennett et al 2004) balanced against the human cost it is important that pressure ulcers, as an adverse incident of patient care, are part of the risk management process within health care provision. 2.2 Doreen Norton in the 1960s initially raised awareness on the prevalence of pressure ulcers amongst hospitalised patients. Since the publication of her research in 1975 pressure ulceration was seen very much as a nursing problem, there was a tendency to deny the existence of pressure ulcers and many nurses claimed that the only pressure ulcers they saw came from elsewhere (Dealey 2004). A key positional paper (Hibbs 1988) stated that 95% of all pressure ulcers could be prevented, despite the increasing acuity of hospital patients today this supposition is still regarded as indicative (Clark 2004). Thankfully, since the publication by the Department of Health (1993) of Pressure Ulcers A key Quality Indicator there has been a gradual increase in awareness of pressure ulcers prevalence within the UK population. 3. DEFINITION OF A PRESSURE ULCER 3.1 The following table gives both the definition of a pressure ulcer and the grading of severity used in Poole Hospital: DEFINITIONS Pressure Ulcer Pressure Ulcer Grade 1 Pressure Ulcer Grade 2 An area of localised damage to the skin and underlying tissue these are caused by the external forces of prolonged pressure, shear, friction and/or a combination of these. Non-blanchable erythema (redness) of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness can also be used as indicators, particularly on individuals with darker skin. Partial thickness skin loss involving epidermis or dermis. The ulcer is superficial and presents clinically as an abrasion or blister.

3 Pressure Ulcer Grade 3 Pressure Ulcer Grade 4 Prevalence Incidence Acquired Pressure Ulcer Inherited Pressure Ulcer Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Extensive destruction, tissue necrosis, or damage to muscle, Bone or supporting structures with/without full thickness skin loss. The total number of people in a defined population with pressure ulcers at a specified time. The total number of people developing a new pressure ulcer who are admitted to hospital over a set period of time. Ulcer developed during hospital stay. Ulcer present on admission to hospital. 4. PROCESSES FOR REPORTING PRESSURE ULCERS 4.1 Early patient assessment and documentation of skin condition on admission to the Trust is essential. This means knowing where and when pressure ulcers develop which, is critical to developing a strategic improvement plan to prevent pressure ulcers. 4.2 The NICE clinical guideline No 29 (2005) The Prevention and Treatment of Pressure Ulcers recommends that grades 2-4 pressure ulcers are reported as a clinical incident. Since its publication the Trust through its Tissue Viability Nurse Specialist has been working towards achieving accurate reporting all pressure ulcers of Grade 2-4 to Risk Management via the Adverse Incident Reporting System (AIRs). 4.3 There has been a progressive increase in pressure ulcer reporting partially due to an increased awareness of staff on the need to report pressure ulcers but also with the trial of simpler methods of reporting, namely the PURs (Pressure Ulcer Reporting) form on the elderly care wards (one form to complete details of patients who have or develop pressure ulcers over 1 week. The completed form is then sent every Tuesday to Risk Management) and the Pressure Ulcer Hotline on ward B3 and TAU (staff report pressure ulcers via a designated phone line answer machine which is managed by the Tissue Viability Nurse Specialist). The Pressure Ulcer Hotline has proved to be the most cost effective in terms of staff time and most accurate method of reporting. 5. PREVENTING AND MANAGING PRESSURE ULCERS 5.1 There are two key elements to the prevention and management of pressure ulcers. Education 5.1 Essentially all patients admitted to hospital are at risk of pressure ulcer development, however, pressure ulcer prevention training is not mandatory. 2

4 5.2 Government policy states that: The UK national guideline on the prevention of pressure ulcers outlines the indicative content of specific training programmes and states, All health care professionals should receive relevant training or education in pressure ulcer risk assessment and prevention. 5.3 There is no pressure ulcer prevention training on induction of clinical and non-clinical staff although the NVQ level 3 core curriculum contains a unit on tissue viability. An optional formal taught pressure ulcer prevention education session is offered and delivered by the Tissue Viability Nurse Specialist at the Newfoundland Centre. Ward/department pressure ulcer leads (ANTs) attend a prevention study day (2 days) per annum and receive formal updates on the Prevention and Management of Pressure Ulcers. There is reliance upon the ward/department ANT to provide education on Pressure Ulcer Prevention for their colleagues. Risk Assessment 5.4 Critical to the prevention of pressure ulcers is the assessment of risk and inspection and monitoring of skin condition in all patients. 5.5 The Braden Scale risk assessment tool and management plan is used for all patients admitted to the hospital (Appendix 1). The Braden risk assessment tool triggers the appropriate patient care intervention to be instigated including: nutrition; manual handling and repositioning; equipment selection; skin protection. 5.6 Nursing documentation triggers the need to record skin condition on admission to hospital. Patient care plans promote the need to monitor and record skin condition. 6. RESOURCES AVAILABLE TO CLINICAL STAFF Agents of Nutrition and Tissue Viability (ANTS) 6.1 The Tissue Viability Nurse provides and supports a rolling education programme for ward based nursing staff ANTS to equip them with the skills and knowledge to provide advice on tissue viability issues in the clinical areas. This is a role that would benefit from more education and supervisory time. Equipment 6.2 All standard foam mattresses within the Trust are made of a high specification pressure reducing foam which conforms to NICE CG There is 24 hour access via the Equipment Library to 125 dynamic air mattresses for patients at a very high risk or those with existing pressure ulcers. 3

5 6.4 In addition, the Trauma wards have been allocated 59 combined foam and dynamic mattress systems. 6.5 The 556 electric profiling bed frames within the Trust also assist in the prevention of pressure ulcers. 6.6 Recently 524 bedside chairs with integrated pressure reducing foam cushion have been purchased. These have been allocated to the wards with the most vulnerable patients. 6.7 Advice and access to external companies for hiring more specialist equipment can be made via the Tissue Viability Nurse. 7. PERFORMANCE DATA Nursing and Midwifery Audits 7.1 Based upon the Essence of Care positional paper (2003) the Vital Aspect of Nursing Care Audit (VANC) is undertaken prior to the Quarterly Performance Report, on 42 clinical areas, questions asked in respect of pressure area are: is there an up to date manual handling care plan that details equipment and amount of handlers necessary? has the Braden score been completed? does the patient have all the equipment they require to meet their pressure ulcer prevention needs? on admission to the ward is the patient s skin condition/status documented? has the patient s requirement for a repositioning regime been documented? is there an up to date manual handling care plan that details equipment and amount of handlers necessary? the ward has a named ANT there is participation in ANT audits and these are available on the ward with action plans has the Malnutrition Universal Screening Tool (MUST) been completed for patients with a Braden score of 3 or less, or have unexplained weight loss? 7.2 The outcome of these audits are reported on an exception basis at Quarterly Performance Review. Pressure Ulcer Incidents 7.3 Poole Hospital NHS Foundation Trust is leading the way forward locally with reporting of pressure ulcers. No other local trust at present tests the accuracy and reliability of reporting. Within these trusts there is reliance upon the data provided by Adverse Incident Reporting to show a true reflection of the hospital population. To compare data we would need to be confident we had achieved the same level of 4

6 reporting. To under-report may be considered a safe option, however to prevent pressure ulceration sensitive reporting is crucial and must be supported; as a Trust however, we must be conscious that a balanced view on these figures are conveyed to other NHS organisations and the public domain. Case-mix adjusted data alongside reporting accuracy need to be considered. 7.4 A limitation of the VANC audit is that most clinical areas only undertake this audit on 5 patients to provide a snap shot, however recurrent themes are beginning to be revealed. These include: lack of Braden score completion; poor documentation; the need of more equipment Qrt 1 Qrt 2 Qrt 3 Qrt 4 Reported Patients with Acquired Sores All Patients with Sores (includes inherited sores & no duplicates) Number of Patients in Hospital Qrt 1 Qrt 2 Qrt 3 Qrt 4 Incidence 1.15% 1.10% 1.96% 1.32% Prevalence 2.25% 2.16% 3.27% 2.45% Qrt 1 Qrt 2 Qrt 3 Qrt 4 % of Patients with Pressure Ulcers Reported as AIRs 19.5% 45.5% Not completed 64.5% Missing Data Hospital Acquired Pressure Ulcers by Grade Qrt 1 Qrt 2 Qrt 3 Qrt 4 Grade Grade Grade Commentary on Performance 7.3 Reporting and the accuracy of reporting pressure ulcers have increased. Despite this increase in the last financial year the amount of pressure ulcers developing within the Trust has remained static with an increase in reporting you would normally expect an increase in pressure ulcer incidents. 5

7 8. TREND ANALYSIS 8.1 The majority of pressure ulcers which occur within the Trust are: Grade 2, predominately developing on the sacrum/buttocks. 8.2 There are two issues arising from investigation into Grade 2 ulcers: differential diagnosis, are all Grade 2 pressure ulcers correctly diagnosed or is there a tendency to report all tissue damage of the sacrum/buttocks as a pressure ulcer? Differential diagnoses for example include incontinence dermatitis, moisture lesions and herpes; are patients sitting in chairs for prolonged periods without suitable seating or intervention to move? 8.3 The number of Grade 4 pressure ulcers developing within the Trust has decreased, however the number of Grade 3 pressure ulcers has marginally increased and this warrants further investigation. Initial analysis suggests that due to the increase in accuracy of reporting, the grades of pressure ulcers are now recorded. However, the accuracy of the grade may, in some circumstances, still require help with the diagnosis for reasons stated above. 8.4 Acquired Grade 4 pressure ulcers are investigated by the Tissue Viability Nurse. 8.5 Common trends from the findings of these investigations and analysis reveal: acuity of illness; malnutrition; poor peripheral vascular supply to skin e.g. Peripheral Vascular Disease, oedema; decrease in mobility; incontinence; poor skin inspection and monitoring. Example of this is included as a case study in Appendix On occasion a reported incident of a Grade 4 pressure ulcer on investigation has a differential diagnosis; example of this is included as a case study in Appendix FEEDBACK ON QUARTER 4 DATA IN TRAUMA 9.1 On reviewing data collected, specifically from the Trauma ward there is no doubt that the occurrence of pressure ulcers will naturally be more prevalent within the demographic of our most vulnerable age group, the pressure ulcer incidents confirm that Elderly, Medical and the Trauma wards have the highest number of incidents. These clinical areas are the wards which have the greatest accuracy and rate of reporting. 6

8 9.2 The Trauma wards in particular have made improvements: the allocation of dynamic air mattresses from admission to recovery; repositioning regimes; assessment of nutrition; increased awareness and vigilance with regard to pressure ulcer detection and early intervention. 9.3 The amount of pressure ulcers developing in these areas has reduced but further work is still ongoing within these teams. 9.4 Conversely, the Emergency Assessment Unit and the Accident and Emergency Department consistently appear to be one of the lowest reporters of pressure ulcers. Pressure ulcers are attributed as being acquired to these departments by wards receiving patients on transfer. Therefore, education is needed to ensure all clinical staff are aware of the importance of recording the skin inspection they perform on initial patient assessment. 10. BENCHMARKING 10.1 Nationally NICE (2005) report the prevalence of pressure ulcers within the UK as 3-5%. In comparison, a European study conducted in 2001 within UK hospitals reported a prevalence rate of 22%. In October 2006, evidence submitted to Parliament from 21 UK NHS organisations stated that pressure ulcers affected approximately 1: 5 of the hospital population (20%) Poole Hospital NHS Foundation Trust overall pressure ulcer prevalence rate of 2.45% is significantly below the national figures The incidence of pressure ulcers within an acute hospital is reported as being between 4%-10% (NICE 2005). The incidence of pressure ulcers with a traumatic orthopaedic ward is reported to be as high as 42.7% (DOH 1993). Poole Hospital NHS Foundation Trust consistently achieves pressure ulcer incidence rates of below 2% despite increasing pressure ulcer reporting. 11. ACTIONS IN PROGRESS 10.4 The Trust employs a Tissue Viability Nurse Specialist who has led action across the Trust in tackling pressure ulcers. This has included: TAU was targeted to increase the availability of dynamic pressure relieving devices with every bed space now equipped with a dynamic system; education is provided for staff who voluntarily attend; review of the hospital policy on pressure ulcers is in progress; root cause analysis is conducted on Grade 4 pressure ulcers which develop within the Trust; NICE CG29 action plan has been implemented and completed (Appendix 4); 7

9 Pressure Ulcer Reporting Hotline on TAU and B3 identifies accurate data and allows monitoring of pressure ulcer live status by Tissue Viability Nurse. 12. FUTURE PLANS 12.1 Future plans include: appointment of 0.6 WTE Band 6 post to assist in providing education on pressure ulcer prevention; continue Adverse Incident Reporting of pressure ulcers looking for trends; evaluate the ANT (Agent for Nutrition and Tissue viability) role; develop STEP approach (a simplified method which will trigger early detection and intervention) to prevention of pressure ulcers. 13. CLOSING ANY GAPS IN ASSURANCE 13.1 Good progress has been made in the management of pressure ulcers in Poole Hospital, particularly when benchmarked against other similar Trusts. With additional investment the Trust could take the following actions to further progress the management of pressure ulcers: - Inter-disciplinary Tissue Viability Group led by Tissue Viability Nurse Specialist, similar to Nutrition Group and Infection Control Committee; mandatory education in pressure ulcer prevention for all staff, this could possibly be incorporated into the manual handling training; assistance in reporting of and analysis of pressure ulcer incidents, NICE (2005) states an additional 0.36 WTE per trust is required to enable reporting of pressure ulcers; implement the Pressure Ulcer Hotline across the whole Trust with the aim to capture reporting of the pressure ulcers present on admission to the Trust; data from the Hotline to be cascaded down to the wards so comparisons in performance can be made; refer all severe pressure ulcers to the Tissue Viability Nurse Specialist. 14. CONCLUSION 14.1 This report shows that good progress is being made in the management of pressure ulcers. However, every quarter some patients develop pressure ulcers. Although the vast majority of these are superficial they represent a significant discomfort to the patient and an increased risk of the pressure ulcer becoming more serious To close the gaps identified in section 13 it is recommended that the Board of Directors supports a Business Case, for increased pressure ulcer education time and administrative support to the Tissue Viability Service, being presented to the Hospital Executive Committee. 8

10 15. RECOMMENDATIONS 15.1 The Board of Directors is asked to: I) Note this report. II) III) Note the incidence of Trust pressure ulcers and the good benchmarked performance. Support the submission of a Business Case to increase the resources put into the management of pressure ulcers in the Trust. ANDREA GRAHAM Tissue Viability Nurse June 2008 MARTIN SMITS Director of Nursing & Patient Services References Bennett G, Dealey C and Posnett J., The cost of pressure ulcers in the UK. Age and Ageing. 33 (3): Clark M, Pressure Ulcers: recent advances in tissue viability. Salisbury. Quay Books MA HealthCare Dealey C, Review of advances in pressure ulcermanagement since In Clark M, Pressure Ulcers: recent advances in tissue viability. Salisbury. Quay Books MA HealthCare. Ch1. Department of Health Pressure Sores: A Key Quality Indicator. DoH. London. Hibbs P, Action against pressure sores. Nursing Times. 84(13): NICE, The prevention and management of pressure ulcers CG 29. DoH. London. Parliament, Written Evidence (Def 64) available via [ 9

11 Patient name: For full version refer to Appendix 1 (NPP-18) in Pressure Sore Policy folder Hospital No: WARD SENSORY PERCEPTION Ability to respond meaningfully to pressure related discomfort MOISTURE Degree to which skin is exposed to moisture ACTIVITY Degree of physical activity MOBILITY Ability to change and control body position NUTRITION Usual food intake pattern FRICTION AND SHEAR SCORE 1- Completely Limited 2- Very Limited 3- Slightly Limited SCORE 1- Constantly Moist 2- Often Moist 3- Occasionally Moist SCORE 1- Bedfast 2- Chairfast 3- Walks Occasionally 4- Walks Frequently SCORE 1- Completely Immobile 2- Very Limited 3- Slightly Limited SCORE 1- Very poor 2- Probably Inadequate 3- Adequate 4- Excellent SCORE 1- Problem 2- Potential Problem 3- No Apparent Problem 4- No Impairment 4- Rarely Moist 4- No Limitation ACTION PLAN ACTION PLAN ACTION PLAN Score = 1, 2 or 3 Ensure patient relieves pressure. Observe skin for damage and document condition on each shift Score = 1, 2 or 3 Apply barrier cream as required, use continence aids. Score = 1 Consider use of a low air loss therapy mattress. SCORE = 1 or 2 Refer to physiotherapist Ensure patient changes position regularly Start an individualised repositioning regime and chart. Ensure patient sits no longer than 2 hours. Score = 1 Consider use of an air mattress Score = 1, 2 or 3 or unexplained weight loss MUST to be completed and action plan followed (See overleaf) Score = 1 or 2 Consider using a profiling bed frame. Consider raising the foot of the bed 10 degrees If seated refer to Physiotherapist for posture assessment. Record all scores Date &Time SENSORY PERCEPTION MOISTURE ACTIVITY MOBILITY NUTRITION FRICTION & SHEAR Total Score Signature Overall Risk of Pressure Ulcer Development = AT RISK = MODERATE RISK = HIGH RISK 9 OR BELOW =VERY HIGH RISK ENSURE THE ACTION PLAN FOR EACH RISK ELEMENT IS IMPLEMENTED Repeat score as patient condition and circumstances change

12 Appendix 2 CASE STUDY 1 Female patient 69 years Acquired Grade 4 pressure ulcer to sacrum. Past Medical History Recent diagnosis 1 month ago of Type 2 Diabetes, has been poorly controlled because of the inability of patient to swallow her tablets for 3 weeks. Polymyalgia rheumatica. Psoriasis. Osteoarthritis and history of total knee replacement. Elective admission for an ERCP and oesophageal dilatation under general anaesthetic, first attempt at ERCP was unsuccessful (and was found to be due to an undiagnosed oesophageal web). Unfortunately, during the oesophageal dilatation the patient suffered an oesophageal perforation (just above the level of the carina), which resulted in a right pneumothorax and the necessity for an apical chest drain insertion. Oesophageal perforation was managed conservatively. Due to pneumothorax and subsequent diagnosis of empyema patient became acutely unwell, was very breathless and unable to tolerate lying or sitting on side. Required continuous oxygen via nasal cannula. Nil by mouth since the ERCP, naso-gastric (NG) feed commenced 5 days post ERCP not tolerated (diarrhoea and abdominal pain) only 1 feed given. Total parental nutrition commenced 10 days post ERCP. Diarrhoea with incontinence was present for 16 days following the initial NG feed. Diarrhoea was not related to any infection, all tests were negative. Broken sacrum recorded in medical and nursing notes 8 days post onset of diarrhoea. Barrier cream applied to sacral breaks. Doctors asked nurses to refer patient to Tissue Viability Nurse Specialist no referral was made. 3 days later sacral pressure ulcer described as sloughy, wound chart and appropriate dressing commenced. 3 days later Specialist Surgical Registrar contacted Tissue Viability Nurse, patient seen together surgical debridement of necrotic pressure ulcer required. Patient was nursed on an air mattress and profiling electric bed although the nursing notes do not indicate when this was provided. Discharged from hospital with healing pressure ulcer one month from admission. Root Causes Acuity of patient, poor tissue perfusion due to hypoxia and oedema. Immobility of patient and need to sit upright due to shortness of breath. Diarrhoea. Poor nutritional intake.

13 Appendix 3 CASE STUDY 2 Female 96 years Patient was admitted to Trauma Admissions unit on early 2008 from Accident and Emergency. She had fractured the proximal end of her left hip prosthesis. The patient underwent surgical revision of uncemented arthroplasty of the hip. She slowly recovered and was transferred to ward B3. On transfer to Kimmeridge Ward the nursing documentation reports a small sloughy ulcer present on the left leg and Comfeel was in situ. Documentation about the left leg showed that a Mepore dressing was applied to the left leg, this was described as a very small ulcer. Several days later within the nursing notes a wound to the left leg (calf) is described as? necrotic pressure ulcer. They also asked the Doctor to see the patient and the Doctor has written the following: asked to see patient. Necrotic sore noted posterior calf area surrounding erythema 4 x 2 ins in size, hot and tender to touch. A wound chart is started for that wound, there are subsequent wound charts for the same wound. Via Datix however, the pressure ulcer is recorded as inherited from Trauma Admissions Unit, this is described as an inherited Grade 3 pressure ulcer from transfer from the Trauma Admissions Unit. This is a discrepancy against the clinical record. Despite all this it is the Tissue Viability Nurse Specialists clinical opinion that this wound is not a pressure ulcer at all it is more consistent in clinical presentation with a haematoma which may have happened as a result of previous bruising or trauma, there is a history of the patient banging her leg. There are subsequent injuries. The patient has required surgical debridement of the necrotic tissue and there was an extensive wound down within the muscle, which required topical negative pressure therapy. What remains is a concern that the incident was described as a pressure ulcer and is reported on Datix as being inherited from Trauma Admissions Unit and this is not the case.

14 Appendix 4 POOLE HOSPITAL NHS FOUNDATION TRUST Updated Action Plan: NICE Guidance CG 29 The Management of Pressure Ulcers in Primary and Secondary Care Section number for action: Specify area of concern: Identify action proposed to resolve concern: Action to be taken by: Outcome 31/03/08 Update on Remaining Issues 2.2 A collaborative interdisciplinary approach to patient care Pressure Ulcers to become a regular agenda item on the CPDC meeting Andrea Graham Completed CPDC is not as fully interdisciplinary as we would wish 2.3 Education and Training PowerPoint presentation to be produced regarding the NICE guidelines Andrea Graham Completed None

15 PowerPoint presentation to be posted on the hospital intranet Keren Fitzgerald Completed This is now available on the intranet but there is no method of tracking who or when accesses the presentation. 2.3 Education and Training A collaborative approach to the production of competency framework across Dorset is required Dorset Tissue Viability Nurse Specialist Collaborative Completed Additional training post agreed for pressure care and equipment training. Appointment awaited 2.3 Adverse Incident Reporting Increase rate of reporting pressure ulcers from 7.9% Agents for Nutrition and Tissue Viability Completed and Ongoing Reporting rates have increased to 45% on last audit this will be a yearly audit to test accuracy and reliability of AIRs data. 2.3 Adverse Incident Reporting Investigation takes place for all Grade 3 and 4 hospital acquired pressure sores Role of Tissue Viability Nurse to investigate all 3 & 4 hospital acquired pressure ulcers. Role of Tissue viability nurse to interpret Adverse Incident Reporting for Care Groups rather than generating statistical reports from Datix. Care groups to Completed Additional support post agreed awaiting appointment 2

16 discuss AIR on pressure ulcers at their Clinical Governance meetings. 6.2 Ulcer Assessment All pressure ulcers of a grade 3 or 4 are photographed by medical photography Pressure sore policy is amended to reflects this Andrea Graham/Medical photography Completed 6.3 Support Surfaces Paediatrics Audit to be completed on Paediatrics Paediatric representative (ANT) Completed Focus group of interested staff has reviewed current provision and needs. Foam mattresses have been renewed. Dynamic air mattresses suitable for paediatrics have been identified and are available via equipment library. Work ongoing is the development of a risk assessment process and management plan for at risk children. 6.3 Support Surfaces Foam Mattress Dynamic Air mattresses Electric Profiling Business Plans are made to secure a recurring budget for equipment replacement. Martin Smits Completed Adequacy of recurrent equipment budget to be tested. Year on year replacement programme to be reviewed 3

17 Bed Frames 6.3 Support Surfaces Seating /cushions Identification of the seating/cushion requirement for Poole Hospital NHS Trust Andrea Graham & Julia Folder Completed Awaiting arrival of new chairs/cushions 6.3 Support Surfaces Seating/cushions Business case to be made for specialist seating/cushions. Martin Smits Completed Awaiting arrival of new chairs/cushions 6.3 Support surfaces Operating Department tables and Trolleys. Business Plans are made to secure a recurring budget for equipment replacement. Martin Smits & Operating Department Manager Completed Year on year replacement budget to be sorted 6.4 Dressings and Topical agents in the treatment of pressure ulcers NVQ role to be included in the hospital pressure sore policy Andrea Graham Ongoing Rewrite in progress 6.6 Mobility and positioning in the treatment of pressure ulcers Repositioning chart to be used for all patients identified at risk ANTS Andrea Graham Carole Plumb Completed 6.8 Surgery for the treatment of pressure ulcers The need for patients with a grade 3 or 4 pressure ulcer to be considered for surgical treatment is Andrea Graham Ongoing Rewrite in progress 4

18 highlighted within the pressure sore policy 8 Audit A hospital wide audit occurs regarding pressure ulcers via the nursing care audit ANTS Andrea Graham Carole Plumb Yvonne Jeffrey Completed 8 AIRs Data to be converted into incidence rates Andrea Graham Sylvia Moors Completed Although accuracy of reporting still an ongoing issue ANDREA GRAHAM MARTIN SMITS NURSE SPECIALIST (TISSUE VIABILITY) DIRECTOR OF NURSING & PATIENT SERVICES 31 MARCH