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Kent, Surrey and SussexPatient Safety Collaborative

Pressure Damage is Everybody's Business

A National Perspective

Caroline Lecko Patient Safety Lead

NHS England

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Aims of the session

• To provide an overview of role and responsibility of NHS England in relation to the reduction of pressure ulcers

• To provide an overview of the challenges of measuring improvement from an national perspective

• To consider how the Serious Incident Framework can assist in meaningful learning

• To consider the potential opportunities in transferring learning to change system failure

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The role of NHS England

• Domain 5 NHS Outcomes Framework

• Treating and caring for people in a safe environment and protecting them from avoidable harm

• Improvement area 5.3

Proportion of patients with category

2, 3 and 4 pressure ulcers

Indicator in development.

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Patient Safety Priority Area

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Monitoring improvement

• National• NHS Outcomes Framework• Proportion of patients with category 2, 3 and 4 pressure ulcers• NHS Safety Thermometer Data

Local• Serious Incident Reporting• National Reporting and Learning System• NHS Safety Thermometer• Local systems

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NHS Safety Thermometer

• The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and 'harm free' care.

Reported patients with a pressure ulcer• September 2015 4.2% • September 2014 4.5%

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All

Cat 2

Cat 3

Cat 4

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Serious Incident Reporting

Pressure UlcersMeeting the SI criteria

30 May – 2 Aug 2015

Accounted for 36% ofall SI reported

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Serious Incident Reporting Caveat…

• Please bear in mind………

‘That the reporting of PUs to STEIS is heavily influenced by some commissioner demands for SI reporting of all grade 3-4 PUs, and that this does not represent anything like an accurate view of PU prevalence or incidence.

Nor indeed is it particularly indicative of the proportions of various SI types in the sense that we would define an SI given lots of this reporting is done to comply with external demands rather than because these are genuine SIs according to our definition.’

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Pressure Ulcer and Wound Audit in Hospitals

• Undertaken by the Clinical Trails Research Unit Leeds University

• Funded by the Tissue Viability• Supported by NHS England Patient Safety Domain

• A response to concerns raised over the inconsistencies of local implementation and over interpretation of data

• To inform interpretation and further development of pressure ulcer monitoring

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Pressure Ulcer and Wound Audit in Hospitals

• 24 participating trusts• 121 wards from a range of specialities• Total bed-base = 2468 beds• 2239 patients fully assessed as part of the audit

• Prevalence of existing pressure ulcers:

- PUWA = 7.1%

- NHS ST = 4.7%

But ………..

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There are wider problems

• Existing and healed pressure ulcers

- PUWA = 8.4%

- Incident reporting = 6.0%

• Of the 2239 patients 83 had one or more potentially serious pressure ulcers (cat 2, 3 or 4)

• Of those 8 were reported on STEIS• There were a couple of patients with no pressure

ulcers reported on STEIS

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Key findings

• High levels of under reporting on all systems

• The adoption of different definitions and variation of data collection and validated processes which preclude Trust-to-Trust comparisons of pressure ulcer prevalence and incidence

• Information has been shared with colleagues at DH.

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Serious Incident Framework

• Definition

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Risk Management and Prioritisation

• Prioritising

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So are we really learning

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Or have we got ………..

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Is there a different way?

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Isolated aims

• We all have our own aims; for example, how to change behaviours and practice to:

• Identify and treat sepsis• Eliminate avoidable falls• Eliminate pressure ulcers• Improve hydration and nutrition• Identify the deteriorating patient• Eliminate VTE

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“We have tended to focus on problems in isolation, one harm at a time, and our efforts have been simplistic and myopic.

If we are to save more lives and significantly reduce patient harm, we need to adopt a holistic, systematic approach that extends across cultural, technological and procedural boundaries – one that is based on the evidence of what works”

Darzi, A, (2015) Health Service Journal, The NHS safety record needs to be as good as

the airline and motor industries, [11 February, 2015]

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Shift from

Topic based approach• Harm based problems

such as: • Falls• Sepsis• Dehydration and

malnutrition• Deterioration• Pressure ulcers• VTE

System and human factors approach

• Cross cutting themes such as:

• Communication failures• Design of equipment,

pathways and tasks• Individual factors• Observation failures• Information failures

to

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Thank you for listening