Kent, Surrey and Sussex Patient Safety Collaborative Pressure Damage is Everybody's Business A National Perspective Caroline Lecko Patient Safety Lead NHS England

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

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.

Patient Safety Priority Area

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

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 % September %

All Cat 2 Cat 3 Cat 4

Serious Incident Reporting Pressure Ulcers Meeting the SI criteria 30 May – 2 Aug 2015 Accounted for 36% of all SI reported

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.’

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

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 ………..

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

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.

Serious Incident Framework Definition

Risk Management and Prioritisation Prioritising

So are we really learning

Or have we got ………..

Is there a different way?

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

“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]

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

Thank you for listening