Under Pressure: An Audit of Pressure Injury Documentation in Hospitalised Older Adults

Abstract Background Pressure injuries are common in hospitalised older adults. They are associated with adverse outcomes including reduced quality of life, pain, insomnia, mood disturbance and secondary infection. They can negatively affect mobility and prolong hospital stay with financial cost to the health service. Pressure injuries represent a geriatric syndrome with multifactorial risk factors, requiring multidisciplinary communication to optimise management. Methods Retrospective audit over three months in adults over 65 years, admitted to a geriatric rehabilitation ward. Audit aims were (1) Review medical staff pressure injury written documentation and (2) Review medical staff written communication and handover regarding pressure injuries. Data were gathered from medical records including written notes and discharge letters. Results Twenty-six patients had thirty-six individual pressure injuries. The mean age was 83 years, 53% female and 47% male. Total length of stay mean was 50 days (range 16 – 147 days). Thirty-nine percent of pressure injuries were stage 1, 42% stage 2, 3% stage 3, 6% suspected deep and 11% unstageable. Documentation in the medical admission occurred in 21% and medical notes in 33%. Documentation in multidisciplinary team (MDT) meetings occurred in 17% and discharge letters in 22%. The mean time between nursing pressure injury identification, and medical and MDT documentation was 17 and 16 days respectively. Conclusion Medical team written documentation of pressure injuries was low. Only one-fifth to one-third of pressure injuries were recorded. Although pressure injuries benefit from multidisciplinary management, they were documented in MDT meetings in under one-fifth of cases. Delays of more than two weeks between nursing and medical documentation occurs. Improving documentation and communication between the MDT can optimise pressure injury management, highlighting the need for ongoing medical education and more effective documentation processes.