BOARD OF DIRECTORS PAPER COVER SHEET. Meeting Date: 30 June 2010 MANAGEMENT OF ACQUIRED PRESSURE ULCERS

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1 BOARD OF DIRECTORS PAPER COVER SHEET Meeting Date: 30 June 2010 Agenda Item: 8 Paper No: E Title: MANAGEMENT OF ACQUIRED PRESSURE ULCERS Purpose: To update the Board of Directors on progress in the management of pressure ulcers across the Trust. Summary: The Trust has set a quality improvement target for of reducing the number of hospital acquired grade 3 and grade 4 pressure ulcers. This paper looks at the learning from the root cause analysis of the hospital acquired grade 3 and grade 4 pressure ulcers in the last two quarters of There are two recommendations concerning unavoidable pressure ulcers and root cause analysis. Recommendation: The Board of Directors is asked to scrutinise this report and to note the recommendations Prepared by: ANDREA GRAHAM Nurse Consultant Tissue Viability Presented by: MARTIN SMITS Director of Nursing and Patient Services This report is relevant to: (Please tick relevant box) Assurance Framework Risk Register I/D No. Healthcare Standards: Financial implications YES / NO Please specify which standard Monitor compliance Human Resources implications YES / NO Internal monitoring Legal implications YES / NO

2 POOLE HOSPITAL NHS FOUNDATION TRUST DIRECTORATE OF NURSING & PATIENT SERVICES Report to the Board of Directors 30 June 2010 MANAGEMENT OF GRADE 3 AND 4 HOSPITAL ACQUIRED PRESSURE ULCERS IN QTR 3 AND QTR 4 ( ) 1. INTRODUCTION 1.1 The Trust has set an improvement target for avoidable grade 3 and grade 4 hospital acquired pressure ulcers in This update for the Board of Directors is intended to review those types of ulcers for the last two quarters of BACKGROUND 2.1 Pressure ulcers graded 2 and above are considered a local incident (NICE CG ) with grade 3 and 4 pressure ulcers viewed as an issue for clinical governance and adult safeguarding (DoH 2010). The incidents of grade 3 and 4 pressure ulcers occurring within Poole Hospital NHS Foundation Trust has been relatively low over the last year, recently this has changed and this report outlines all the cases which have occurred over the previous two QTRs and raises points which have been discussed at Risk Management and Safety Committee and at the Complaints, Claims, Incidents and PALs review group. 2.2 Grade 3 and 4 incidents Acquired GRADE 3 Inherited GRADE 3 Acquired GRADE 4 Inherited GRADE QTR 3 QTR 4 A total of 7 grade 3 incidents and 2 grade 4 incidents have occurred of which 8 have been analysed by root cause analysis (RCA) with 1 case pending. 1

3 2.3 Summary of RCA Patient characteristics Average age= 80 years (range years) 50% of patients were considered to be in multi-organ failure. 50% of patients died with 2 months of the pressure ulcer developing. 100% of patients had low haemoglobin and albumin levels and 100% never achieved a minimum level. 87% of patients had issues with repositioning including declining intervention, repositioning not complete or being unable to reposition due to medical reasons. 2

4 Root Causes of Pressure Ulcer Development 9 8 Problem Areas MULTI ORGAN FAILURE CANCER DEATH WITHIN 2 MONTHS PATIENT CHOICE OUTLYER SKIN INSPECTION RISK ASSESSMENT PVD LACK OF KNOWLEDGE POOR SKIN CONDITION PATIENT DEPENDENCY WARD ACTIVITY EPIDURAL ANAESTHESIA INOTOPIC SUPPORT MOISTURE PLASTER CAST COMMUNICATION INCREASED MUSCLE TONE No of patients affected

5 SUMMARY Case by Case Patient Grade of pressure ulcer Age (years) Diagnosis 1 Male Grade 3 sacrum 83 Malignant neoplasm of stomach, secondary liver neoplasm 2.Female Grade 3 sacrum 63 Advanced stage 3c primary peritoneal ovarian cancer Laporotomy, bilateral salpingooopherectomy RCA SKIN INSPECTION RISK ASSESSMENT PATIENT DEPENDENCY WARD ACTIVITY MULTI ORGAN FAILURE OUTLYER RISK ASSESSMENT SKIN INSPECTION LACK OF KNOWLEDGE EPIDURAL ANAESTHESIA 3.Male Grade 3 Occipital and Sacrum 64 Community acquired pneumonia, Septic shock required ITU care and artificial ventilation. MULTI ORGAN FAILURE INOTOPIC SUPPORT MOISTURE Patient ID Grade of pressure ulcer Age (years) Diagnosis RCA 4.Male Grade 3 lateral aspect left foot 96 Right Sided Cerebral Infarct MULTI ORGAN FAILURE PVD POOR SKIN CONDITION 4

6 Patient Grade of pressure ulcer Age (years) Diagnosis 5.Male. Grade 4 sacrum 82 Spinal cord compression, multiple levels secondary to colonic carcinoma RCA PATIENT CHOICE MULTI ORGAN FAILURE 6.Male Grade 3 sacrum 90 Fractured neck of femur PATIENT CHOICE OUTLYER 7.Female Grade 3 heel 88 Falls PVD PATIENT CHOICE OUTLYER 8.Male Grade 4 elbow 78 Painful left elbow, (left elbow replacement 16/1/10 for chronic dislocation) Cerebella ataxia 9.Female Grade 4 sacrum 78 Trauma and multiple fractures RCA pending PLASTER CAST SKIN INSPECTION COMMUNICATION LACK OF KNOWLEDGE POOR SKIN CONDITION INCREASED MUSCLE TONE 5

7 2.4 Compliance with NICE CG 29 (2005) patient case had full implementation of pressure ulcer prevention strategy as recommended by the NICE clinical guidance of the patient cases had full implementation of NICE CG with acceptable variation of: Unable to move patient due to medical reasons i.e. cardiac instability and cord compression. Unable to use pressure relieving equipment due to medical condition Patient declined preventative intervention of the patient cases did not comply with NICE CG 29 as there was incomplete documentation of one or more of the following; Repositioning regime, Initial and ongoing skin inspection, Ongoing risk assessment 3. DISCUSSION 3.1 It can be argued that pressure ulcer formation is a complex process that may not be halted, even with excellent multidisciplinary care (Thomas, 2003). The skin is the largest organ in the body and its integrity is dependent upon the function of all other organ systems for nutrition, circulation, and immune function (Langemo & Brown, 2006). The burden of disease can overwhelm the skin, even with appropriate preventive interventions, if the body's organs can fail, why not the skin? (Witkowski & Parish, 2000). Yet, the responsibility of healthcare to adopt best practices aimed at pressure ulcer prevention should not be minimised. There are increasing reports of success in reducing the prevalence and incidence of pressure ulcers by implementing evidence-based clinical practice guidelines (Ayello & Lyder, 2008). 3.2 It does however appear there are clinical circumstances in which a pressure ulcer becomes unavoidable? In order to define unavoidable an international definition of avoidable has been proposed (WONC 2009). Avoidable Pressure Ulcer: Avoidable means that the patient developed a pressure ulcer despite optimum care in that the healthcare provider did not do one or more of the following: evaluate the patient s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with the patients needs and choices; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. A definition of unavoidable is then proposed as:- Unavoidable Pressure Ulcer: Unavoidable means that the patient developed a pressure ulcer even though the healthcare provider had evaluated the patient s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with the patients needs and informed choices; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. 6

8 3.3 It appears from the RCA to date that there is occasion when the prevention of all pressure ulceration within the acutely unwell and/or the dying population becomes unattainable. 3.4 In October 2009 a consensus panel of experts published a series of statements regarding the concept of the unavoidable pressure ulcer. Although mainly concerned with the issue of Skin Changes at Life s End (SCALE) the paper does raise questions about the expectations of skin viability in the wider population including acutely ill patients. 3.5 If the concept of unavoidable pressure ulcers were to be applied on the cases examined within this paper, 62% (n=5) could have been considered unavoidable. 4. CONCLUSION 4.1 Detailed analysis of the Grade 3 and 4 hospital acquired pressure ulcers has demonstrated that the internationally defined skin failure syndrome or unavoidable pressure ulcer is a reality for Poole Hospital NHS Foundation Trust. Root cause analysis has clearly demonstrated the majority of Grade 3 and 4 cases have developed despite our best efforts and compliance with NICE clinical guidance. 5. RECOMMENDATIONS 5.1 Poole Hospital NHS Foundation Trust adopts the concept of the unavoidable pressure ulcer. 5.2 RCA of all grade 3 and 4 pressure ulcers remains collaborative but progresses to a more inter-disciplinary process which incorporates safeguarding adults. ANDREA GRAHAM Consultant Nurse Tissue Viability Poole Hospital NHS Foundation Trust References Ayello, E., & Lyder, C. (2008). A new era of pressure ulcer accountability in acute care. Advances in Skin & Wound Care, 21, DoH (2010) Clinical Governance and Adult Safeguarding: an integrated process. HMSO Langemo, D., & Brown, G. (2006). Skin fails too: Acute, chronic, and end-stage skin failure. Advances in Skin & Wound Care, 19, NICE (2005) Clinical Guideline 29 The prevention and treatment of pressure ulcers. HMSO SCALE Expert Panel (2009), Skin Changes At Life s End (SCALE) available at Thomas, D. (2003). Are all pressure ulcers avoidable? Journal of the American Medical Directors Association, 4, Witkowski, J., & Parish, L. (2000). The decubitus ulcer: Skin failure and destructive behavior. International Journal of Dermatology, 39, WOCN Society Board of Directors (2009). Position Paper: Avoidable versus Unavoidable Pressure Ulcers. Available at 7