2024 investigation of 2022 rise in the number of decubitus ulcers

There was a significant rise in the number of acquired stage 1 and 2 decubitus ulcers at the GGH ICU, beginning Jan 2022.

A sample of charts from the timeframe of concern was audited, and we collaborated with the GGH educator and manager and we were unable to determine a reason for this rise. Going forward, a recommendation will be forwarded to the OIT committee, and education about proper documentation of stages of decubitus ulcers will be reinforced across all sites. This will begin in March 2024. Up until March 2024 the data re. acquired decubitus ulcers is not reliable, as it often required the collector to subjectively interpret documentation on the stage of the decubitus ulcer.

Log

• 2024-03-20 Task - no change in education/guidelines found; not sure what is happening, but initiating more thorough documentation of stage of ulcers
• 2024-02-22 Task - no change in education/guidelines
• 2024-01-11 Task - no reporting differences found, investigating if education/guidelines changed
• 2023-11-23 Task - reviewed rate of Ulcers at GRA
• 2023-11-23 Task - issue discussed, decision to investigate if there was a change in how these are tracked
• 2023-10-26 Task - issue of increase in decubitus ulcers at GRA is first raised