Case Studies                    

Stop The Pressure is a dynamic and ongoing programme that generates lots of interesting stories and case studies. We hope to use this section of the website to reflect and share some of those stories with you so that we can all benefit from the experiences and insights of our colleagues.

If you would like us to publish your story please get in touch via the Contact Us page of this website.

East Midlands Patient Safety Collaborative (EMPSC) - Prevalence of common care problems found in nursing and residential homes

EMPSC piloted an audit tool to measure the prevalence of common care problems found in nursing and residential homes. The tool is called the International Prevalence Measurement of Care Problems in Care Homes (Landelijke Prevalentiemeting Zorgkwaliteit, or LPZ for short, in Dutch). LPZ was developed in the Netherlands to provide a reliable mechanism for measuring the prevalence of common care problems within care homes and provide consistent recording of data to drive, or measure, the impact of quality improvement initiatives in the sector. It is currently used to deliver an annual audit of data for care settings in the Netherlands, Germany, Austria, Switzerland, New Zealand, Indonesia and Brazil.

The tool supplies participating care homes with insight into the quality of care provided in their setting through measuring the extent of common care issues. This can support decision-making by care homes, regulatory bodies and policymakers regarding implementing measures such as preventative screening and specific interventions to improve the quality and safety of care provided.

The EMAHSN Patient Safety Collaborative (PSC) worked with a selection of care homes to trial LPZ which covers the following six domains:

  • Falls
  • Pressure ulcers
  • Continence
  • Restraint
  • Pain management
  • Hydration & Nutrition
As a result we have been supporting the care homes to improve the care around pressure ulcers. This resulted in homes adopting the React to Red training for the detection, prevention and management of pressure ulcers. This led to a greater awareness of ‘Stop the Pressure’ campaign. The case studies are some example of the improvements the care homes have made as a result of being involved in LPZ.

Case Studies:

Care Home

Bailey House
Care Home

Beechdale House
Care Home

Care Home

Care Home

Patient Leaflet

EMAHSN Infographics

Case Study – Critical Care

There is a passion for reducing pressure ulcers throughout the Trust.

We have mandatory training sessions in our qualified practitioners orientation day and our clinical support staff induction programme, all clinical staff are required to complete a mandatory e-learning package yearly. We teach regularly at Anglia Ruskin University on the student nurse programme, and catch up with them again 6 months into being qualified as part of the preceptorship programme. We do ad hoc teaching on the wards, usually where a problem has been highlighted, we tailor the sessions to the wards needs and keep them short and based on the ward so staff are not taken from the clinical area.

We have most recently been focused on device-related pressure ulcers as we found an increase in PUs around naso gastric tubes particularly, though we think that there is a link to an awareness campaign leading to increased reporting. Our critical care nurse education team have done a lot of good work with teaching better techniques for securing tubes and posters, ward walks. The attached poster highlights the work being done.

We ask for all pressure ulcers to be reported via our Datix system (hospital and other acquired, all grades), any Datix involving a wound gets forwarded to our team for validation, we endeavour to see all grade 3 or 4, all suspected deep tissue injury, all unstageable and anything else that looks worrying on the reports. Depending how busy we are, we try to also see all other grades and moisture lesions (they are often also referred to us anyway). If we can’t get to see them, we will check the electronic notes and speak to staff via telephone to validate / confirm. There is still a lot of confusion around moisture lesions and pressure ulcers, hence trying to see as many as we can to catch the ones mis-identified.


Case Study - Addenbrooke’s Hospital ED

Sharing the patient story of our last grade 4 (with the consent of her and her family) across the Trust had a big impact. We presented to the Board, senior nurse forums, link nurse groups and at our Harm Free Care strategy group, The family have been fully supportive of us using the story to aid learning.

The investigation highlighted the need to think ‘pressure ulcer prevention’ right at the front door, we found although we had been doing some work in ED, it wasn’t consistent and sadly this lady didn’t get what we hoped was in place. This led to a change in approach in the ED, it made us look at the way ED were documenting on the electronic records system and how that was not being communicated as patients were being admitted. ED now have access to be able to do a Waterlow risk assessment as well as a quick screening tool if time is precious. They aim to get patients onto a bed with a high spec pressure reducing mattress if they are likely to be in the department longer than 4 hours and it is clinically safe to move them. They are actively rolling patients to check skin condition on arrival (which means we can identify much quicker and more accurately patients who are arriving with pressure damage already present).

A TVN on the team who had previously worked in ED, has instigated some great initiatives from teaching paramedics to highlighting to staff when they bring someone in who has had a long lie, to the provision of repose trolley toppers for immobile patients and providing steps for patients to get on and off trolleys to avoid shear (we are currently going through tender to source a trolley that drops low for our elderly frail). This downloadable poster reflects the work that was done. LINK


NH Case Study - Food First Warrington

The impact of the ‘Food First’ approach in a residential care home: Warrington and Halton NHS Foundation Trust


NH Case Study - RCA Leeds Teaching

Learning from root cause analysis investigation into a grade 3 pressure ulcer: Leeds Teaching Hospitals NHS Trust


NH Case Study - Weight Loss Sheffield

Supporting weight loss to minimise the risk of pressure ulcers: Sheffield Teaching Hospitals


NH - Key Messages

Eat well, drink well and keep the skin well. Key nutrition and hydration messages to prevent pressure ulcers and promote wound healing


NH Case Study - Top Tips

Five top tips to prevent pressure ulcers


North Cumbria University Hospitals NHS Trust: May 2018

In 2015/16, our Trust was identifying high numbers of hospital acquired pressure ulcers despite numerous interventions. We were set a target by our Director of Nursing to reduce the incidence by 50% with zero tolerance to grade 4 pressure damage. This initially appeared to be an ambitious goal but by raising the profile of pressure ulcer prevention and equipping staff with effective interventions, North Cumbria University Hospitals NHS Trust has seen a 61% reduction in hospital acquired pressure damage over 2 years.


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