Tissue Viability - The Royal Wolverhampton Hospitals NHS Trust

royalwolverhamptonhospitals.nhs.uk

Tissue Viability - The Royal Wolverhampton Hospitals NHS Trust

Apr-12May-12Jun-12Jul-12Aug-12Sep-12Oct-12Nov-123.1if so this is called health acquired as opposed to ‘inherited’ from elsewhere and if acquiredhere, was it avoidable, meaning we could have done more to have prevented it.The Trust has participated in a significant national project to ‘Stop the Pressure’ and reduceincidence and prevalence of pressure ulcers. This has resulted in a change in how the Trust’snurse leaders expect nurses to provide careFocus on more robust and timely assessment of the patient’s risks of developingpressure ulcers through personalised careImproved access and standardisation with education around equipment acrosshospital and homeMore emphasis on how nursing is delivered; the use of ‘comfort rounds’ to ensurepatients are comfortable, repositioned to stop the pressure, have access to a drinkand the call bell system.Non-acceptance of mediocre or absent documentation of what the nurse did to thepatient during their shift: If it is not documented it didn’t happen: E.g. absence ofevidence in the comfort round document indicates a pressure ulcer could havedeveloped because of an omission in care resulting in an avoidable harm. The nurseon duty who omitted this is held to account.Real focus on accountability when a pressure ulcer has been detected and reported,with true scrutiny at the highest level to ascertain whether nurses could have changedthe outcome if they had provided care differently.Pressure Ulcer numbers – an improvementThe results have demonstrated a reduction in grade 2 pressure ulcers both unavoidableand, most importantly, avoidable demonstrated in the graph and pictureGrade 2 Ulcers6050403020100Grade 2AvoidableGrade 2UnavoidableLinear (Grade 2Avoidable)Linear (Grade 2Unavoidable)However of significance is the reduction in Grade 3 pressure ulcers: avoidable which havereduced thus demonstrating improvements in risk assessment, continuous evaluation andinterventions to reduce the risk of deterioration to Grade 3.151050Grade 3 AvoidableGrade 3 AvoidableLinear (Grade 3 Avoidable)Page 3 of 5


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