Quality report 2021-2022

1. Improving Pressure Ulcer Management In 2021/22, we aimed for: • A 10% reduction in the number of patients who develop moisture associated skin damage (MASD) during admission based on the baseline data collected in 2019/20. • There will be no more than 30 Category 2 pressure ulcers, (deep tissue injury and unstageable pressure ulcers) developed during admission. • We will maintain our standard of no category 3&4 pressure ulcers developed during admission. In order to monitor pressure ulcer levels more effectively, we have begun to monitor them per 1000 occupied patient bed days. This demonstrates a general reduction through the year:

The quality improvement was monitored and measured through Friday FoCUS (Focus on Care Understanding Safety), a multi-professional learning event twice a month. We met all of the aims within this objective in 2021/22:

Target 21/22

Actual 21/22

Pressure ulcers developed after admission (all grades)

30

24

Category 3 and 4 pressure ulcers developed after admission Moisture associated skin damage

0

0

87

70 (this is a 20% reduction)

NHSI guidance advises that NHS Trust’s should no longer use the definition of avoidable or unavoidable. This has therefore not been included in this report. Despite achieving a reduction we continue to proactively review any pressure ulcers of Grade 2 and above to contribute to further improvement. Themes arising from Root CA investigations have been identified as: • Inaccurate calculation of pressure ulcer risk factors • Covid 19 patients acutely unwell and unable to move the mask or NG or reposition the patient • Increase in inpatient activity • Variation in practice when conducting a head to toe skin inspection • Variation in practice when conducting a repositioning regime for patients at risk of pressure ulcers • Requirement to initiate a repositioning regime for patients at risk of pressure ulcers • Requirement to increase knowledge about Skin changes at the end of Life.

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