1. Stop the Pressure! Pressure Ulcer Prevention and Management
Suffolk Community Healthcare Training
Hello and welcome to Suffolk Community Healthcare’s Pressure Ulcer Prevention and Management Training Programme.
My name is Judith Brewer and I am the Pressure Ulcer CQUIN Lead for Suffolk Community Healthcare.
CQUIN stands for Commissioning for Quality and Innovation, and is a way in which the commissioners of NHS services, now known as Clinical Commissioning Groups or CCGs, set targets for the providers of services such as Suffolk Community Healthcare to deliver improved services for our patients.
The Pressure Ulcer CQUIN for Suffolk Community Healthcare includes achieving a reduction in the incidence of pressure ulcers in our care, particularly the number of pressure ulcers which are referred to us from residential care homes.
One of the ways in which we aim to meet this target is by delivering training, education and support to care homes, so that is why I have come here to see you today.
Judith Brewer BSc (Hons) BAOT HPC
Pressure Ulcer CQUIN Lead
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

2. Overview of the Session
Costs, Prevalence, Definition
Causes & Risk Factors
Grading, Assessment & Prevention
So, what are we going to cover today?
We will look at what is meant by a pressure ulcer;
What are the consequences and costs associated with pressure ulcers;
How common are pressure ulcers;
And what causes pressure ulcers to develop.
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC. 2

3. But Before We Begin…….. Let’s take a few moments to think
about what a pressure ulcer means for the people affected
Imagine that ANY of these people could be someone you love or care for ……
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Warning: the following slides contain images of real pressure ulcers 3

4. NOTES FOR PRESENTERS
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5. NOTES FOR PRESENTERS
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27. Think that ALL of these people and their families trusted their professional carers to look after them and protect them from harm….
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28. This is why we must stop the pressure!
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29. Costs - financial This is 4% of total NHS expenditure!
Treatment costs vary depending on the grade of ulcer:
from £1,064 for a grade 1 ulcer To £24,214 for a grade 4
The total cost in the UK is estimated to be £1.4 - £2.1 billion annually
This is 4% of total NHS expenditure!
NHS Institute for Innovation and Improvement 2013
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

30. Costs - individual reduced quality of life
difficulties for patients, their carers and families
even a grade one pressure ulcer is very painful
estimated that up to 30% patients in nursing and residential homes may be affected
increased risk of secondary infection
~ 4 x increase of risk of death in older people in ICU
increased morbidity
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

31. Negative Publicity

32. Litigation

33. 95% OF ALL PRESSURE ULCERS ARE PREVENTABLE!
The bottom line is….
95% OF ALL PRESSURE
ULCERS ARE
PREVENTABLE!
Hibbs 1987

34. “No avoidable pressure ulcers in your provided care”
Skin matters
You should take action to ensure that there are ….
“No avoidable pressure ulcers in
your provided care”
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

35. Avoidable pressure ulcers…
Means that the care provider did not do one or more of the following:
Evaluate the patient’s clinical condition and risk factors
Plan and implement interventions consistent with the patients needs, goals and recognised standards of practice
Monitor and evaluate the impact of the interventions, or revise the interventions as appropriate
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

36. What is a pressure ulcer?
A Pressure Ulcer is Defined as:
“an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and/or a combination of these factors”
European Pressure Ulcer Advisory Panel EPUAP
NOTES FOR PRESENTERS
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A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC. 36

37. Pressure
Pressure is an external force where soft tissue is compressed between a bony prominence and a hard surface e.g. a mattress or a chair
The capillaries become occluded and the tissues starved of vital nutrients and oxygen, and become ischaemic
If pressure is unrelieved, tissue necrosis will take place
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

38. Shear
Shear is an external force which causes distortion, stretching and eventual tearing of the blood vessels
Shearing occurs if the patient slides down in the bed or chair
The skeleton moves, but the skin stays still
The tearing of blood vessels can also lead to ischemia and cell death
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

39. Friction
Friction is a surface force which occurs when two surfaces rub together e.g.
dragging the patient up the bed
rubbing vigorously when washing
Friction leads to superficial damage
the uppermost layers of epithelial cells are scraped off, leading to skin grazes
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

40. Friction and Shear Forces

41. Risk Assessment
Effective risk assessment can prevent pressure ulcer development
The Waterlow Score is a risk assessment tool used throughout the country to identify patients who are at risk of developing pressure ulcers
Recognising patients at risk of pressure damage:
enables resources to be effectively allocated, such as pressure reducing equipment
Holistic assessment increases the effectiveness of the care being delivered
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

42. Risk Assessment
Initial risk assessment should take place within 6 hours of admission using the Waterlow risk assessment tool and clinical judgement
If not at risk initially, reassessment should occur if there is a change in the patient’s condition
NOTES FOR PRESENTERS
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When viewing the following slides, please ensure audience members have a copy of the quick reference guide (QRG)
There is a need to ensure initial assessment of patient is documented as the patient may have a pressure ulcer(s) when admitted
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

43. Reassess on an on-going basis
Risk Assessment
Risk factors include:
level of mobility
sensory impairment
continence
level of consciousness
acute, chronic and terminal illness
Co-morbidity (blood supply, infection, pain, medication)
posture
cognition
previous pressure damage
extremes of age
nutrition and hydration status
moisture to the skin
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REMEMBER!
Reassess on an on-going basis

44. Which areas are prone to pressure ulcers?

45. Assessment - Continence
Continent/Catheterised – patients are less likely to develop skin damage due to moisture
Incontinent – patients are at high risk of developing moisture lesions, and developing infections
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

46. Assessment - Mobility Patients with reduced mobility
Are at higher risk of pressure damage due to their inability to alter their position themselves
Patients who are Bed-bound
Are at higher risk of pressure damage
But in areas different from those in a wheelchair
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

47. Do not position a patient directly on a pressure ulcer
Positioning
All patients with pressure ulcers should actively mobilise and change position if able OR Be repositioned
Minimise pressure on bony prominences
Do not position a patient
directly on a pressure ulcer
Consider restricting sitting time
Aids, equipment and positions – seek specialist advice
Record using a repositioning chart/schedule
NOTES FOR PRESENTERS
SLIDE FOR CLINICIANS
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

48. Assessment - Nutrition
Malnutrition is: a major contributing factor to pressure ulcer development
Patients who are malnourished are: at very high risk of pressure damage due to the increase in pressure over bony areas
Poor food and fluid intake: effects the patient’s ability to heal
Patients with wounds:
require a high protein diet to enable the body to heal
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

49. Assessment - Medication
Particular medications can have an
effect on healing rates
Steroids and other anti-inflammatory medications:
reduce the skin’s elasticity and tensile strength increasing the risk of damage
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

50. Assessment - Pain Pain:
should always be assessed when determining risk
often causes reduction in mobility
affects the patient’s mental status which affects healing
may require analgesics which slow down the healing process
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

51. Skin Care Skin of vulnerable patients should Skin should be:
be inspected daily
any changes skin condition documented and reported to a senior member of staff
Skin should be:
moisturised at least once a day
particularly for patients with very dry skin
Barrier cream should be:
applied to patients at risk of moisture damage
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

52. Assessment Cause/Site/Location/Wound appearance
Dimensions/Category/Stage/Odour
Exudate/sign of infection/Pain
Surrounding skin/Undermining/tracking
Support with photography
Document all pressure ulcers categorised Grade II and above as a clinical incident
NOTES FOR PRESENTER
SLIDE FOR CLINICIANS
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

53. European Pressure Ulcer Advisory Panel Classification (EPUAP)
Category/Stage I - Discolouration of intact skin (non-blanching erythema)
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

54. Category/Stage II
Stage/Category II – Partial-thickness skin loss or damage involving epidermis and/or dermis
The pressure ulcer is superficial and presents as a blister, abrasion or shallow crater
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

55. Category/Stage III
Category/ Stage III – Full thickness skin loss involving damage of subcutaneous tissue but not extending to the underlying fascia
This presents as a deep crater with or without undermining of adjacent tissue
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

56. Category/Stage IV
Category/Stage IV – Full thickness skin loss with extensive destruction and necrosis extending to underlying tissue
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

57. Pressure relieving devices
Initial and on-going ulcer assessment is the
responsibility of a
registered healthcare professional
Consider all surfaces used by the patient
Patients should have 24 hour access to pressure relieving devices and/or strategies
Change pressure relieving device in response to altered level of risk, condition or needs
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SLIDE FOR CLINICIANS

58. Equipment Selection
All patients vulnerable to pressure ulcers should as a minimum be placed on a high specification foam mattress
Patients with category/stage III-IV pressure ulcers should be:
- placed on a high specification alternating pressure relieving mattress replacement system or overlay
- a sophisticated continuous low pressure system
NOTES FOR PRESENTERS
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A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

59. Pressure Ulcer Pathway
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

60. Five simple steps to prevent and treat pressure ulcers

61. © NHS Midlands and East 2012

62. Expected Benefits Financial
If fewer Grade II and above Pressure Ulcers occur in residential care homes
i.e. ‘Prevention’
And if pressure ulcers are identified at an earlier stage
i.e. ‘Management’
Then it follows that:
Each Pressure Ulcer prevented/well managed means:
Savings on costs of repeated visits by SCH clinicians
Savings on costs of treatment
Savings on hospital admissions
Avoided complaints/litigation
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A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC. 62

63. Expected Benefits Public Perception
Service users will experience quality care
Complaints and possible litigious claims will be avoided
Greater public awareness of pressure ulcer prevention
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A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC. 63

64. Scroll and click your way along the Pressure Ulcer Path, using SSKIN
Scroll and click your way along the Pressure Ulcer Path, using SSKIN.
© NHS Midlands and East 2012

65. Thank you Any Questions? NOTES FOR PRESENTERS SLIDE FOR ALL 65
A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC. 65