PREVENTION OF HOSPITAL ACQUIRED PRESSURE ULCERS Mandatory session

1. Tissue Viability Specialist Service University Hospitals of Leicester NHS Trust PREVENTION OF HOSPITAL ACQUIRED PRESSURE ULCERSMandatory session

2. Pressure ulcer (PU) is “an area of localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers the significance of which is yet to be elucidated.” Definition EPUAP 2009

3. Why is Pressure ulcer prevention so important? • Pain and suffering • Reduced mobility • Prolonged hospitalisation • Depression and social isolation • Wastes limited resources • Increases nursing time • Septicaemia • Osteomyelitis • DEATH • PU development remains an indicator of quality of nursing care since Florence Nightingale • Costs for prevention - less than costs for treatment

4. Contributory factors: Internal/patient-related factors: Systemic disease: metabolic, neurological, vascular, terminal illness Reduced mobility or immobility Sensory impairment Psychological e.g. depression Anaemia Malnutrition Level of consciousness Extremes of age Previous history of pressure damage or poor skin condition Acute or chronic oedema Dehydration/fluid status- sweat, incontinence External factors: Pressure - support surfaces, change of position Shear - positioning, mobility Friction - moving and handling techniques, patient education, splinting, casts, positioning Other factors - Moisture - incontinence, sweating, pyrexia, wound exudate - Medication

5. Who and when should assess individuals at risk?? Nice Guidelines (2005) state that ‘A risk assessment should be carried out by personnel who have undergone appropriate training’. Should be undertaken within 6 hours of admission. Reassessment should occur on regular basis (at least weekly) and if there is a change in patient’s condition. Assessment should be made both during the day as well as the night Assessments should be documented & made accessible to all members of the MDT.

6. Pressure ulcer risk assessment Step 1 - Skin inspection: Check most vulnerable areas (utilise ‘Take your BEST SHOT’ poster +/- Daily pressure area checklist) Document pressure area status at least once a day Any pressure damage with or without skin loss i.e. grade 1 and above must be documented immediately on a woundassessment chart Watch for any signs, which may indicate incipient pressure ulcer development Patients who are willing and able should be encouraged, following education, to inspect their own skin (Your turn campaign, June 2006) • Step 2 – Waterlow risk assessment score: • Should be used as an adjunct to clinical decision of whether the patient is ‘at risk’ of pressure ulcers • Must be done within 6 hours of hospital admission and repeated every time there is a change in patient’s condition (deterioration/ improvement) or at least once a week • If patient identified ‘at risk’, actions must be clearly documented and a Pressure ulcer prevention (PUP) care plan started immediately. This must be agreed with the patient/carer and reviewed daily

8. Pressure Ulcer Classification Within Leicestershire everybody should be using the same classification - recommended by the Midlands and East of England SHA based on EPUAP grade 1-4 (from 2009 called categories) All patients with grade/category 2 and above should be reported on DATIX; grade 3 or 4 PU’s - major patient safety incidents must also be referred to TV team (NICE, 2005). All cases of hospital acquired grade 3 or 4 PU’s have to undergo a thorough investigation (unavoidable checklist or a full root cause analysis). All community acquired grade 3 and 4s are escalated to the PCTs as they will do the RCA investigation

9. Grade 1 Non – blanching persistent erythema Damage to the microcirculation Reversible therefore most important stage to recognise in people with darkly pigmented skin discolouration may not be visible therefore indicators will be local induration, warmer/colder patch, oedema

10. Grade 2 Superficial skin loss involving epidermis and/or dermis Painful as nerve endings are exposed Can present as a clear blister, abrasion or shallow crater Can be confused with moisture lesions (EPUAP 2005)

11. Grade 3 Full thickness skin loss Damage to subcutaneous tissue but not extending through the fascia into the underlying structures Different depth dependent on anatomical location Look for undermining/ cavity may be filled with necrotic tissue

12. Grade 4 Full thickness wound, possible damage to the underlying structures: muscle, bone or supporting structures with or without skin loss May be filled with necrotic tissue which masks true extent. High risk of sepsis. Can be life threatening.

13. Moisture Lesions (EPUAP 2005) • A lesion caused by excessive moisture (urine, faeces, perspiration or wound fluid) causing skin irritation and maceration • Superficial – partial thickness skin loss / erosion of the epidermis; no necrosis • A combination of moisture and friction may cause moisture lesions in skin folds • Commonly presenting as a symmetrical ulcer (copy lesion), or linear ulcer in the natal cleft / skin fold

14. Purple lesion / suspected deep tissue injury Purple or maroon area underneath discoloured intact skin or blood filled blister due to damage of the underlying soft tissue from pressure and/or shear. This signifies full thickness skin damage (grade/category 3) Darkly pigmented skin - the area may be painful, firm, mushy, boggy, warmer or cooler compared to adjacent tissue.

15. Key points: Patient / carer education Regular skin / pressure areas assessment Waterlow risk assessment Utilise equipment: mattresses / profiling beds / heel protectors / cushions Good hygiene standards and manageincontinence Skin protection / appropriate wound care Nutritional support and hydration

16. Key points - continued Regular repositioning Patient-centred holistic care Multi-disciplinary approach Utilise UHL documentation Vigilance / be proactive

17. INCREASED VIGILANCE!!! for all patients with diabetes – daily feet/heel inspection, patient education, utilise UHL diabetic foot care plan for patient that require Anti-embolic Stockings – ensure VTE assessment is completed by the medical staff and all PMHy taken into consideration e.g. diabetes, vascular problems, existing skin damage, etc.; well-documented daily heel inspection For all immobile patients especially if history of stroke, MS, paralysis, fractured lower limbs, etc.

18. DOCUMENTATION WATERLOW RISK ASSESSMENT PRESSURE ULCER PREVENTION CARE PLAN REPOSITIONING CHART WOUND ASSESSMENT CHARTS Take your BEST SHOT daily pressure area assessment tool +/- daily checklist DATIX REPORT

19. Documentation of assessment, plan of action and re-assessment is your only proof of good care. If it is not written down , it never happened!