Basic research
A retrospective analysis of the findings of pressure ulcer investigations in an acute trust in the UK

https://doi.org/10.1016/j.jtv.2016.02.008Get rights and content

Highlights

  • Severe PUs tend to result from a chain of events rather than a single root cause.

  • RCA should be performed by someone external to the patient's care to minimise bias.

  • Patient & staff interviews should be included in all RCAs to give greater insight.

  • Malnutrition affects the majority of patients who develop a severe PU in acute care.

Abstract

The root cause analysis (RCA) process has been applied in this organisation since 2010 to investigate all severe pressure ulcers. A previous analysis of the findings from all RCAs completed during 2011–2013 identified actions for practice improvement. The current study reports the results of a further retrospective analysis following implementation of new evidence based investigation process.

Aim

To analysis the findings from pressure ulcer investigations; compare the results to the previous study and reflect on the new investigation process.

Methods

Analysis was performed on data from completed RCAs during January–October 2014 to identify key themes and learning points.

Results

Thirty two pressure ulcer RCAs were included. Nutrition was the most common contributory factor, highlighting the issue of malnutrition in an acute care setting. The second most common contributory factor was medical conditions that lead to poor tissue perfusion.

Conclusion

Severe pressure ulcers rarely occur due to a single root cause, but often due to a sequence of events. Patients frequently have multiple complex needs that increase their susceptibility, when this is in combination with a failure of care, a severe pressure ulcer can occur. The new investigation process had limited success in identifying organisational factors. Further work is needed to support staff in the investigation process.

Introduction

It has long been known that pressure ulcers (PU) cause patients significant pain and distress [1], however in recent years PUs have become an indicator of quality care and safety within the NHS [2], [3]. Category 2 or above PUs [4] are required to be reported in line with National Institute of Health and Care Excellence Guidelines [5], [6] and investigated.

The authors' organisation commenced root cause analyses (RCA) investigations for all severe (category 3 or 4 or non-resolving unstageable/suspected deep tissue injury according to European Pressure Ulcer Panel grading [4]) hospital acquired PUs in 2010 in line with the commissioning for quality and innovation (CQUIN) targets [7]. In 2004 the National Patient Safety Agency had published guidance for RCA investigations [8] but it had not been applied to PU incident investigation in the authors's organisation or any others known to the authors. The RCA process is designed to identify the root causes and contributory factors that lead to a patient safety incident. Key learning points can then be identified to improve practice and patient care. As this process was new for PU incidents, tissue viability staff looked to other established investigation processes (e.g. infections) to adapt documentation and guidance.

In 2013 when the PU RCA process was thoroughly established throughout the trust, an evaluation of all the investigations was performed in order to identify key themes and make improvements to the documentation and process. Details of root causes and contributory factors for all completed RCAs during April 2011–March 2013 were identified and extracted. A thematic analysis was then performed on the extracted data; these were then coded and grouped into themes and subthemes [9]. Four key themes were identified: Individual patient factors, Education and training, Communication and Organisational/Environmental. ‘Education and training’ was the most frequently occurring theme, identifying that there was a lack of knowledge in PU prevention by nurses. PU competency frameworks were therefore developed which became mandatory for all registered and non-registered nursing staff. The next most frequently occurring theme was ‘individual patient factors’ e.g. co-morbidities, nutrition and compliance. This was taken into account when developing the competencies to ensure that staff were aware of how individual patient factors could impact upon a patient's susceptibility to developing a PU. ‘Communication’ identified issues regarding patient transfers between different wards or departments – in particular the patient's level of risk not being communicated at hand over and therefore the receiving area would not be adequately prepared. ‘Environmental/organisational’ issues included patients being cared for in inappropriate care settings (lodgers or outliers), being transferred to multiple different ward areas during their stay and delays in going to theatre or having a procedure.

One of the problems encountered with the original RCA process was that it could be subjective and lead investigators were searching for ‘fixable’ outcomes. One example of this was that throughout the 2 year period documentation would be a prominent factor; it was thought that as documentation improved on the ward, so would standards of care; additionally this was something that could be easily audited to demonstrate improvement. It is clear that poor documentation does not cause a PU, however it should reflect the standard of care given so needed to be considered in improvement plans. As a result of this previous analysis the tissue viability team identified that the RCA process needed improving to try and make it less subjective and to identify the true root causes and contributing factors.

In 2009 a National Institute of Heath Research (NIHR) funded programme grant for Applied Research on PUs commenced (RP-PG-0407-10056). A co-author of this paper was an investigator in the study. One of the work streams in this project aimed to understand why patients develop severe PUs. This study used a retrospective case study design method to produce accounts of individual patients who developed severe PUs. An iterative review, involving reviewers (including patients) with different backgrounds, was used to validate and interpret the accounts [10]. An additional output of the study was to develop a methodology for RCA, suitable for use in current NHS practice. Based on the findings of the research study, the new investigation process needed to incorporate organisational themes and the patients' perspective. It needed to include a narrative of events as well as a timeline from the records; identify good practice; considering resource issues and organisational constraints.

A pilot of the new evidence based process was held with Tissue Viability link nurses in October 2013. This identified that staff had reservations about involving patients; they felt that this would not be possible due to capacity issues with many or it would lead to litigation. It was also apparent that staff did not identify the systematic or organisational issues. The template for recording the investigation was therefore amended and some guidance developed to support the process. This was tested with another patient and found to successfully identify contributing factors and issues not revealed through the traditional record review. The new investigation process was implemented in January 2014.

Section snippets

Methods

A second thematic analysis was performed to evaluate the new RCA process and the effectiveness of the PU competencies that had been implemented and completed throughout the trust. Thematic analysis is similar to content analysis, in that it provides a numerical description of the features of a set of text, but also allows for qualitative aspects of the extracted material to be analysed [11].

All of the completed RCA documents from January 2014 to October 2014 were analysed and all root causes or

Results

A total of thirty two incidents were investigated. The mean age (range) of patients involved was 71 (5–96) and there were 14 males and 18 females involved (Table 1). The most common body site for PU occurrence was to the sacrum, followed by the buttocks.

For only nine of the RCAs was a singular root cause found. In the majority of cases there would be a number of contributory factors which together would form a “sequence of events” which led to the PU developing. An example of this was an

Discussion

These results are based on the specified root causes and contributory factors given in the reports. It appears that there has been little patient involvement in the process with less than half of the patients who developed a severe PU being interviewed (Table 1). Previous research [10] has identified that organisational factors are often key in identifying the root cause; however this was not reflected in this study.

Damage caused by pressure from medical devices are not always reported and

Recommendations

  • To improve the quality of the RCA process, and to help to identify the systemic and organisational failures that lead to a severe PU developing, the authors recommend including the patient's voice and interviews with staff involved in the patient's care. This can help in describing the scenes of events around the time of the incident.

  • The research evidence suggests that lead investigators should be independent to the incident in order to minimise bias [10], however this is often not possible due

Conclusion

The current investigation process has identified key patient factors contributing to severe ulcers but the development of systems and organisational explanations is limited.

The quality of the RCA process is improved when it is completed by someone external to the patients care as it minimises bias. Patient and staff interviews also provide more of an insight into the ward environment and care delivery issues during the period leading up to the patient developing a PU. Despite a new evidence

Conflicts of interest

None to declare.

Acknowledgements

We would like to acknowledge all of the staff in the tissue viability department at Leeds Teaching Hospitals for their help in the development of the PU prevention competencies and the new RCA process. We would also like to thank Dr Jimmy Choo for his help with the first thematic analysis.

References (14)

  • S. Coleman et al.

    Patient risk factors for pressure ulcer development: systematic review

    Int J Nurs Stud

    (2013)
  • C. Gorecki et al.

    Impact of pressure ulcers on quality of life in older patients: a systematic review

    J Am Geriatr Soc

    (2009)
  • NHS Institute for Innovation and Improvement. Your skin matters – one of the high impact actions. 2010:...
  • NHS to adopt zero tolerance to pressure ulcers National Patient Safety 2010:...
  • National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance
  • National Institute of Health and Clinical Care Excellence (NICE)

    Pressure ulcers: the management of pressure ulcers in primary and secondary care

    (2005)
  • NHS Commissioning Board: Serious incident framework 2015...
There are more references available in the full text version of this article.

Cited by (0)

View full text