As part of a new Datix Insights feature, we're going to be taking a look at the latest industry news to break within the NHS and the wider healthcare industry.
We'll offer our own unique perspective on the news, what it means for the patient safety landscape, potential effects on our customers and recommendations on how to deal with new regulations and guidance.
In the headlines last week: new classifications and guidance for pressure ulcers.
In June, NHS Improvement released new guidance and starts by saying “Pressure ulcers remain a concerning and mainly avoidable harm associated with healthcare delivery.” The new guidance will be in force from April 2019.
The guidance states that healthcare staff should no longer determine whether a pressure ulcer is avoidable/unavoidable and pressure ulcers during end of life care are no longer allowed to be referred to as 'Kennedy Ulcers' (a Kennedy ulcer is the rapid onset and breakdown of skin tissue, that usually occurs in the end stages of life). The new guidance also recommends that the 72 hour rule – where an ulcer is only identified as “new” if developed more than 72 hours after admission should be abandoned. Instead a new pressure ulcer is said to be new when they are “first observed in the current episode of care”.
Why did this change happen?
The change in guidance is to promote consistency in the classification, monitoring and expectations to report and investigate pressure ulcers across the country. Previously, there had been variation in local approaches leading to inconsistencies in reporting and investigations being carried out. Here at Datix we are doing our utmost to bring consistency in the quality of investigations through our investigations module with the ability to upload clinical measurements and medication taken by the patient, which are then represented in a graphical form.
What are the possible impacts?
By not making the distinction between the terms avoidable/unavoidable creates an expectation to investigate all pressure ulcers, provided they are ‘first observed in the current episode of care’. This will have a great impact on resources and the additional time required to undertake the additional investigations and ensure they are of a sufficient standard. We believe there is likely to be a marked increase in the number of Root Cause Analysis (RCA) investigations in connection with pressure ulcers.
How can Datix help?
The change in guidance further demonstrates the importance of a full and well carried out investigation. The Datix Cloud IQ Investigations module can be utilised to complete thorough investigations.
Also, the Enterprise Risk Manager module has a new feature allowing the software to pro-actively monitor risk associated with pressure ulcers by setting up appropriate queries within the module. You can quickly and easily see how many incidents, claims and complaints are connected to harm arising as a result of pressure ulcers.
Want more information?
Guidance sets out change in pressure ulcer recording at end of life
NHS Improvement recommendations:
Pressure ulcers: revised definition and measurement.