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.

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

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 …… NOTES FOR PRESENTERS SLIDE FOR ALL Warning: the following slides contain images of real pressure ulcers 3

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Think that ALL of these people and their families trusted their professional carers to look after them and protect them from harm…. NOTES FOR PRESENTERS SLIDE FOR ALL 27

This is why we must stop the pressure! NOTES FOR PRESENTERS SLIDE FOR ALL 28

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.

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.

Negative Publicity

Litigation

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

“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.

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.

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 SLIDE FOR ALL A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC. 36

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.

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.

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.

Friction and Shear Forces

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.

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 SLIDE FOR ALL 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.

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 NOTES FOR PRESENTERS SLIDE FOR CLINICIANS REMEMBER! Reassess on an on-going basis

Which areas are prone to pressure ulcers?

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 NOTES FOR PRESENTERS SLIDE FOR CLINICIANS

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 SLIDE FOR ALL A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

Pressure Ulcer Pathway http://www.stopthepressure.com/path/ A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

Five simple steps to prevent and treat pressure ulcers

© NHS Midlands and East 2012

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 NOTES FOR PRESENTERS SLIDE FOR ALL A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC. 62

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 NOTES FOR PRESENTERS SLIDE FOR ALL A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC. 63

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

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