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

1
The University Hospitals of North Midlands NHS Trust, Newcastle Rd, Stoke-on-Trent ST4 6QG, UK
2
Department of Nursing, School of Health and Social Care, Staffordshire University, Blackheath Lane, Stafford ST18 0YB, UK
3
VID vitenskapelige høgskole, Haraldsplass Bergen, Ulriksdal 10, 5009 Bergen, Norway
*
Author to whom correspondence should be addressed.
Healthcare 2019, 7(2), 59; https://doi.org/10.3390/healthcare7020059
Received: 13 December 2018 / Revised: 27 March 2019 / Accepted: 28 March 2019 / Published: 8 April 2019
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Abstract

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. View Full-Text
Keywords: pressure ulcers; deep dive; frailty; quality; safety; patient experience; older people pressure ulcers; deep dive; frailty; quality; safety; patient experience; older people
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Horton-Jones, M.; Marsh, E.; Fumarola, S.; Wright-White, H.; McSherry, W.; Rowson, T. Using Deep Dive Methodology to Investigate an Increased Incidence of Hospital-Acquired Avoidable Category 2 and 3 Pressure Ulcers. Healthcare 2019, 7, 59.

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