BOARD MEETING. Document is for: (indicate with an x) Assurance x Information Decision. Executive Summary

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1 Document Title: Presenter: Author: Contact details for further information: BOARD MEETING Review of Pressure Ulcer Prevalence across DCHS services March June 2012 Kath Henderson, Chief Nurse Michelle O Connor Senior Matron Infection Prevention & Control Sue Dakin, Matron Infection Prevention & Control michelle.o Date of Meeting: 26 July 2012 Agenda Item No: Document is for: (indicate with an x) Assurance x Information Decision Executive Summary No of pages 8 inc. this one: In order to provide DCHS Board members with assurance regarding the reporting of pressure ulcer activity across all DCHS services, a systematic review of all reported incidents has been undertaken for the period March June This review was conducted over a 4 day period commencing 19 July 2012, supported by the IP&C team and the Governance Information Manager. Data analysis Each pressure ulcer incident reported via the Datix system was reviewed and the following data extrapolated. Total number of pressure ulcer incidents reported in March = 203. (see graph 1 for breakdown) This data provides a refreshed internal baseline for DCHS. Total number of pressure ulcer incidents reported for Quarter 1 = 708 (see graph 2 for breakdown)

2 The review has identified the following anomalies when compared with previously submitted data within the Trust performance report. These are outlined in the table below: STEIS All unavoidable and avoidable Grade 3&4 deteriorated or developed within DCHS care Ambition One Avoidable Grade 2, 3, 4 and multiples deteriorated or developed within DCHS care Month Reported via SHA PMR and Trust Performance Report Actual number of STEIS to date Reported via Trust Performance Report Baseline data (March) April May June Not reported to date Identified reasons for the anomalies are: Duplication of reporting Tissue viability team not being notified of incidents Total excluding baseline data 15 Actual Total excluding baseline data Delay in specialist review and subsequent rejection of incident as not pressure damage During the review a number of incidents were identified as requiring avoidability reclassification Some of the incidents had been wrongly graded or determined not to have developed or deteriorated within our care and should not have been reported onto STEIS Current RCA management process within the tissue viability team 24 Following the review it is now possible to say that DCHS have 24 avoidable incidents for Quarter 1 which is below the agreed trajectory of 27. The trends over the 3 month period indicate that a significant reduction between April and June.

3 Overall summary of activity Graph 1 March 2012 total avoidable incidents within DCHS care baseline, including multiples (Grade 2) total unavoidable incidents within DCHS care, including multiples (Grade 2) total incidents inherited (all grades) 51 STEIS avoidable incidents within DCHS care, including multiples (grade 3 &4) 105 STEIS unavoidable incidents within DCHS care, including multiples (grade 3 &4) rejected incidence eg already reported or not pressure damage grade 1 reported Graph 2 April June 2012 total avoidable incidents within DCHS care baseline, including multiples (Grade 2) total unavoidable incidents within DCHS care, including multiples (Grade 2) total incidents inherited (all grades) STEIS avoidable incidents within DCHS care, including multiples (grade 3 &4) 379 STEIS unavoidable incidents within DCHS care, including multiples (grade 3 &4) rejected incidence eg already reported or not pressure damage grade 1 reported

4 Ambition One Summary The data relating to the monthly number of avoidable incidents across DCHS against the agreed trajectory can be found in the following graph. As can be seen the current incident rate is below trajectory at 3 (trajectory for Quarter 1 is 9) Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Grade 3 & 4, including multiples Grade 2, including multiples Trajectory The monthly number of unavoidable pressure ulcer incidents are reflected in the graph below: Grade 3 & 4, including multiples Grade 2, including multiples Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

5 Analysis and Trends The implementation of Ambition One and Harm Free Care has increased awareness across services of the need to assess all patients within their care for potential pressure ulcer damage. Whilst this may have resulted in an increase in the number of incidents reported there has also been a reduction in the number of avoidable pressure ulcers. Reviewing the incidents has highlighted some areas of good practice where different community based services and families communicate with each other effectively. There are examples of GPs concerned in the deterioration of patient s health referring patients to the district nursing services for assessment, carers and family members contacting the district nursing services directly for advice and referrals from care home settings asking for advice and support. This approach across the whole of DCHS would benefit patients from incurring a harm or deterioration and would have an impact on the whole health economy reduction in harm. The adoption of this approach would have an impact on the DCHS community services as there is potential to see an increase in the number of inherited cases initially. Inherited cases currently form 53% of the activity and workload relating to pressure ulcers for DCHS services. The following graph provides a breakdown of the inherited pressure ulcer activity during the period from March to June CRHFT RDHFT Nottingham SHH/ Maccelsfield 214 Sheffield 71 QHBT other from home or other community setting DCHS Services

6 In relation to the 10 cases identified within DCHS, there is an anomaly within the Datix reporting system whereby services report incidents transferred to them from another part of DCHS as inherited. This will be rectified as part of the recommendations and a new category referral from another DCHS service included. This will ensure that the discharge processes within DCHS relating to pressure ulcer management are captured as part of the Root Cause Analysis (RCA) process. Financial Impact There will be a financial impact on DCHS if the number of avoidable pressure ulcers is above the agreed trajectory There will be a cost to the organisation and the patient relating to the management of patients with pressure ulcers and the provision of appropriate pressure relieving equipment The large volume of inherited pressure ulcers will have a financial impact on DCHS services, particularly within the community setting. A piece of work exploring long term and sustainable approaches to pressure ulcer management within the wider healthcare community would be of benefit to DCHS and their patients. Links to DCHS Strategy DCHS is committed to providing a clinically effective, high quality service for the whole of the population we serve. Incident Reporting is a key component of the Safety agenda to ensure Harm Free Care is embedded across all services. Recommendations Main themes and recommendations from the review: Recommendation 1. Some patients are extremely complex and may visit more than one service during their journey. This may result in a number of incident forms being completed, relating to the same pressure ulcer episode. A standardised approach to reviewing these incidents is required within the tissue viability team to prevent duplication and misrepresentation of data. Date for implementation 1 August 2012 Recommendation 2. Due to the high volume of incidents, the incident form for Grade 2 pressure ulcers is to be reviewed to provide the information required when deciding if a pressure ulcer is avoidable or unavoidable. This will reduce the impact of repeated requests to clinical services for data, especially those in the community, and enable the tissue viability team to assess the avoidability of incidents in a timely manner.

7 Date for implementation 1 August 2012 Recommendation 3 The bulk of DCHS activity relating to pressure ulcers is inherited from other providers of healthcare and from within the community setting. At present a letter is sent to other providers informing them of the incident. There is limited feedback within the DCHS incident reporting process relating to the discharge information provided by other providers and well as DCHS services. If a question was incorporated into the Datix form then this could be used to inform other providers of improvements required to enable DCHS to care for the patients appropriately on discharge. Date for implementation 1 August 2012 Recommendation 4. Within the community setting most of the pressure ulcer incidence is the result of patients or carers not using equipment correctly or following pressure relieving advice e.g. not sitting in a chair to sleep, changing position every 2 hours, using pressure relieving cushions on chairs. Using the harm free care patient information across the DCHS community proactively to raise awareness of the risk to individuals within their own home may help to reduce the development of pressure ulcers, or encourage individuals to seek help sooner (some cases referred to the community services were grade 3 or 4) Date for implementation 1 October 2012 Recommendation 5. To ensure timely reporting to DCHS Board and management teams of the pressure ulcer incidence, elements of the systematic approach developed during the 4 day review should be incorporated into the current tissue viability systems. This will ensure that the Board is provided with the verified figures and analysis of the previous month s data, with the caveat that there may be complex STEIS reportable incidents which cannot be completed within the new 10 day RCA timescale. These incidents will be exception reported to Board. A review of the July data will be completed by the 3 August Recommendation 6. Ongoing data will be reviewed weekly to provide real time data to the management teams and encourage learning across DCHS services. A detailed analysis of trends and themes will be included in future monthly reports to QSC to provide assurance, identify hot spots within DCHS and enable appropriate resources and actions to be implemented. Date for implementation 1 August 2012 Monitoring Information Brief Summary CQC Compliance Outcome 16, Regulation 10 - Assessing & monitoring the Quality of Service Provision

8 The provision of safe high quality care is an integral part of patient care provided to all DCHS patients Monitor Compliance Monthly progress report against the Ambition Action Plan Collation of monthly reports into a quarterly summary NHSLA Compliance n/a report Assurance Framework Ref: 1.1 Safe High Quality Services 1.2 Clinical Effective high quality services 1.3 Patient experience Other Ambition One Harm Free Care Are there Equality & Diversity implications? Are there Patient and Public Involvement implications? (If no, why) No all patients will be assessed on their individual need with regard to the prevention and management of pressure ulcers. Where advice or recommendations require adaptation to meet patient requirements, whilst ensuring the safety of the patient, this will be documented in the patient notes The development of a communication plan utilising existing patient information will assist in the effective management and prevention of pressure ulcers within the community setting

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