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Using Deep Dive Methodology to Investigate an Increased Incidence of Hospital-Acquired Avoidable Category 2 and 3 Pressure Ulcers

Horton-Jones, Martyne, Marsh, Emma, Fumarola, Sian, Wright-White, Helen, MCSHERRY, Wilfred and Rowson, Trish (2019) Using Deep Dive Methodology to Investigate an Increased Incidence of Hospital-Acquired Avoidable Category 2 and 3 Pressure Ulcers. Healthcare, 7 (59). pp. 1-13. ISSN 2227-9032

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Abstract or description

Background: Between October 2017 and March 2018, the Trust experienced significant winter pressures and an increase in category 2 and 3 hospital-acquired avoidable pressure ulcers. This review aimed to investigate the causal factors of this increase. Methods: A ‘Deep Dive’ review of 37 cases was undertaken in three stages: (i) assurance; ensure the increase was not due to insufficient equipment; (ii) collation of relevant data, including age, length of time in A&E, bed surface, number of internal moves; (iii) analysis identifying factors that might account for the observed increase. Findings: Age combined with prolonged length of time in A&E, being nursed on a trolley followed by three or four internal moves were observed in patients who developed pressure ulcers. Patient age was observed as a key factor, with those over 80 years experiencing pressure ulcers more frequently. Conclusion: The small size of this data suggests a need for the greater awareness of frailty issues in older people, timely assessment and intervention to prevent a chain of detrimental factors might be key to reduce and prevent hospital-acquired avoidable pressure ulcers. Recommendations for immediate action, education and future research have been made to the Trust Quality and Safety Committee.

Item Type: Article
Faculty: School of Health and Social Care > Nursing
Depositing User: Wilfred MCSHERRY
Date Deposited: 12 Apr 2019 14:41
Last Modified: 12 Apr 2019 14:41
URI: http://eprints.staffs.ac.uk/id/eprint/5568

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