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Prevention and Management of Pressure Ulcers in Adults and Children Policy and

Guidance

Approved By: Policy and Guideline Committee Date of Original Approval:

21st November 2014

Trust Reference: B23/2014 Version: V3 Supersedes: V1 and V2 Trust Lead: Karen Weafer, Tissue Viability Specialist Lead,

Jivka Dimitrova, Pressure Ulcer Prevention Lead Michael Clayton, Head of Safeguarding & Tissue Viability

Board Director Lead: Chief Nurse

Date of Latest Approval

18 August 2017 Policy and Guideline Committee

Next Review Date: November 2020 10/09/20 Review Extension Date Agreed at 21st August PGC.

yasmin.v.suleman

Highlight

CONTENTS

Section Page 1 Introduction and Overview 4 2 Policy Scope 5 3 Definitions and Abbreviations 5 4 Roles- 6

5 Policy Implementation and Associated Documents- 5.1 Pressure Ulcer Risk Assessment and Skin Inspection 5.2 The importance of repositioning patients at risk of pressure damage 5.3 Care of patient pressure ulcers in last few days of life 5.4 The use of pressure relieving devices, including seating 5.5 The use of aids for moving and handling 5.6 Preventing heel damage 5.7 Medical Device Related Pressure Ulcers 5.8 Patient and Carer education 5.9 Discharge / transfer 5.10 Reporting, Monitoring and RCA Checklists and Investigation 5.11 Safeguarding and Pressure Ulcers

9 10 10 12 11 12 13 13 14 14 15 16

6 Education and Training 16 7 Process for Monitoring Compliance 17 8 Equality Impact Assessment 17 9 Supporting References, Evidence Base and Related Policies 18 10 Process for Version Control, Document Archiving and Review 18 11 Policy Monitoring Table 19

Appendices Page 1 Categories of Pressure Ulcers 20 2 Documentation Samples – ADULT (including BEST SHOT poster) 21 3 Documentation Samples – CHILDREN 24 4 30 Degree Tilt 25 5 Mattress Flowchart 27 6 Checklist for the investigation of grade 2, 3, 4 & sdti pressure ulcers 28 7 Medical Device Related Pressure Ulcers – Poster 38 8 Tissue Viability referral Process 39 9 Root Cause Analysis Pathway – Category 2 40 10 Root Cause analysis Pathway – Category 3 and 4 41

REVIEW DATES AND DETAILS OF CHANGES MADE DURING THE REVIEW

Details of changes made to the policy since the previous version must be clearly identified here or if significant changes are made these should be attached as a separate Appendix. If the document is a complete re-write then this must also be documented here.

This document is a re write to reflect changes in local practice since the development of the previous policy.

KEY WORDS

Pressure ulcers, skin damage, moisture lesion, mattress, category

Policy for Prevention and Management of Pressure Ulcers in Adults and Children of 38 V3 Approved by Policy and Guideline Committee on 18 August 2017 Ref: B23/2014 Next Review: November 2020

NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents

1 INTRODUCTION AND OVERVIEW

1.1 This document sets out the University Hospitals of Leicester (UHL) NHS Trusts Policy and Procedures for;

• The identification of patients potentially at risk of developing pressure ulcerswhen admitted to hospital

• Treating patients with existing pressure damage

• Preventing the development of new skin damage

1.2 The aim of this policy is to standardise practice around the prevention and management of pressure ulcers aiming to eradicate avoidable pressure ulcers.

1.3 The policy provides procedures, advice and guidance on the following: a) When pressure ulcer risk assessments and skin inspections should take

placeb) The importance of repositioning of patients at risk of pressure damagec) Implementing individualised treatment plans to manage existing pressure

ulcers effectivelyd) The use of pressure relieving devices including seating, limb protection and

medical devicese) The use of aids for moving and handlingf) The importance of good nutrition and hydrationg) Patient and Carer educationh) Reporting, monitoring and Root Cause Analysis (RCA) Investigation and

when to alert the Safeguarding Team.

1.4 Pressure ulcers cause considerable harm to patients, hindering recovery, frequently causing pain and can potentially cause development of serious infections. Pressure ulcers have also been associated with an extended length of hospital stay, sepsis and mortality

1.5 This policy supports the Stop the Pressure Campaign and implementation of the SSKIN: A five step model for pressure prevention and patient assessment supported by NHS England

1.6 The policy is also based on the National Institute for Health and Care Excellence (NICE) Guideline on Pressure Ulcers (2014), the European Pressure Ulcer Advisory Panel (EPUAP) Pressure Ulcer Treatment Guidelines (2014) and SCALE (Skin Changes at Life’s End) Consensus Statement (2009) NICE Quality Standards QS 89-2015, Safeguarding Adults Protocol (Pressure ulcers and the interface with a safeguarding enquiry 2018)

2 POLICY SCOPE Policy for Prevention and Management of Pressure Ulcers in Adults and Children of 38 V3 Approved by Policy and Guideline Committee on 18 August 2017 Ref: B23/2014 Next Review: November 2020


2.1 This policy applies to all Health Care professionals working within UHL including those on bank, agency or honorary contracts who care for adults and children admitted to UHL as an inpatient, including Day Case areas and Alliance units. This Policy also applies to all adult and child patients seen in UHL Outpatient areas including the Emergency Department (ED)

2.3 This policy does not cover the treatment of other types of wounds. To support their clinical decision about dressing’s choices, staff must use the UHL Wound Care Formulary and the First Line Clinical Decisions Guide for Dressings available on the Trust Webpage

3 DEFINITIONS AND ABBREVIATIONS

3.1 Pressure Ulcer – is a localised injury to the skin and/or underlying tissue, usually over a bony prominence, as a result or pressure, or pressure combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers (e.g. microclimate, friction, excessive moisture etc). (EPUAP, 2014)

3.2 Medical Device Related Pressure Ulcer – is a pressure ulcer that had developed due to sustained pressure and shear from a medical device such as plaster casts, splints, oxygen therapy masks, tracheostomy tubing or urinary catheters etc.

3.3 Moisture Lesion – is a reactive response of the skin to chronic exposure to excessive moisture from sweat, urine, faecal matter or wound exudate, which could be observed as an inflammation and erythema with or without erosion. Typically there is a loss of the epidermis and the skin appears macerated, red broke and painful

3.4 Category – Used to be described as grade/grading. This is the term used for the classification of a pressure ulcer – category 1, 2, 3 or 4 (please see Appendix 1 for more details of the UHL recommended Classification system based on SHA 2012 Classification tool adapted from EPUAP (2009). Staff must not use the pressure ulcer classification system to describe tissue loss in wounds other than pressure ulcers.

3.4.1 Suspected Deep Tissue Injury – Purple of marron localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Further description: The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar For the purpose of this policy the term Category will be used throughout.

3.5 Avoidable / Unavoidable – National Patient Safety Agency (2010) Defining avoidable and unavoidable pressure ulcer (www.patientsafetyfirst.nhs.uk) 3.5.1 Avoidable Pressure Ulcer: For a pressure ulcer to be considered “Avoidable”, the care-provider did not:

a) evaluate the person’s clinical condition and pressure ulcer risk factorsb) plan and implement interventions that are consistent with the person’sneeds, goals and recognised standards of practice



http://www.patientsafetyfirst.nhs.uk/

c) monitor and evaluate the impact of the interventions; or revise theinterventions as appropriate

3.5.2 Unavoidable Pressure Ulcer: For a pressure ulcer to be considered “Unavoidable”, the person receiving care developed a pressure ulcer even though the care-provider had: a) evaluated the person’s clinical condition and pressure ulcer risk factorsb) planned and implement interventions that are consistent with theperson’s needs, goals and recognised standards of practicec) monitored and evaluated the impact of the interventions; and revisedthe approaches as appropriated) the individual person refused to adhere to prevention strategies in spiteof education of the consequence of non-adherence

4 ROLES

4.1 Executive Lead a) The Executive Lead for the prevention and management of pressure ulcers isthe Chief Nurse

4.2 Head of Safeguarding and Tissue Viability a) overseeing the UHL Pressure Ulcer Pathway and reviewing all avoidable

category 3 and 4 pressure ulcers (avoidable and admitted with) to ensure thatsafeguarding measures are appropriate

b) Provide all necessary monthly reports e.g. themes, trends and analysis orexception reports to the Chief Nurse and nursing Executive Team

4.3 CMG Head of Nursing and Clinical Director a) Implement the initiatives set out in this policy to ensure there is a zero

tolerance to all avoidable Hospital Acquired Pressure Ulcersb) Maintain oversight of all pressure ulcer related incidents and organise /

undertake monthly RCA checklist validations of reported category 2, 3 and 4pressure ulcers including Suspected Deep Tissue Injuries (SDTI)

c) Monitor the implementation of the CMG action plans produced fromvalidations and serious incident report investigations. Undertake spot checkaudits on high reporting areas as necessary

d) Review and sign off the checklists and Serious Incident reports on an on-going basis and within the set timescales

4.4 Matrons / Ward Sisters / Department Managers a) Ensure all staff are up to date with their knowledge regarding prevention and

management of pressure ulcers, addressing any education and trainingneeds identified

b) Ensure all staff practising within their clinical area are aware of therequirement to report all pressure ulcer related incidents category 2, 3, 4 andSDTI’s



c) Ensure all staff are using the current UHL Pressure Ulcer Prevention NursingDocumentation and undertake regular audits including the Nursing Metrics,Ward Review Tool and Safety Thermometer Validations

d) Ensure all staff follow the policy statements and procedures set out in thisdocument

e) Must investigate every pressure ulcer related incident, disseminate thelearning from the investigation and ensure that the appropriate changes aremade and embedded in clinical practice. Ensure the RCA checklist iscompleted for all Hospital Acquired Pressure Ulcers categories 2, 3, 4 andSDTIs and submitted to the Tissue Viability Team within the seven daytimeframe and present the fully completed RCA checklist at the monthlyvalidation meeting

f) Where patients are admitted with pressure ulcer and there are safeguardingconcerns, make a safeguarding adult referral to adult social care

4.5 Registered Nurses, Midwives and Nursing Associates under the supervision of the Registered Nurse a) Follow the policy statements and procedures set out in Section 6 and the

appendicesb) Assess patients at risk of pressure damage and plan, implement and review

care plans to reduce the risk within agreed timescalesc) Report identified category 2, 3, 4 (including Suspected Deep Tissue Injuries

and Unclassified category 3 / 4) pressure ulcers on DATIX and ensure thecommencement of the RCA process

d) Where patients are admitted with pressure ulcers and there are safeguardingconcerns, make a safeguarding adult referral to adult social care

e) Ensure they are up to date with their knowledge regarding prevention andmanagement of pressure ulcers, discussing any education and training needsidentified with their line manager

4.6 Doctors and Allied Health Professionals a) Support the patient to maintain their skin integrityb) Document any repositioning they may do during all patient interaction on the

daily pressure ulcer prevention care plan / repositioning chartc) Document any skin damage identified during any physical examination of the

patientd) Inform the nurse looking after the patient of any concerns they may have

regarding the patient’s skin condition and ability to maintain their pressureareas

e) Ensure they are up to date with their knowledge regarding prevention andmanagement of pressure ulcers, discussing any education and training needsidentified with their line manager

4.7 All Support Staff (HCA’s, Porters, Housekeepers) a) Support the patient to maintain their skin integrity



b) Document any repositioning they may do during all patient interaction on thedaily pressure ulcer prevention plan

c) Inform the Registered Nurse looking after the patient of any concerns theymay have, e.g. observation of any skin changes based on BESTSHOTdocumentation, a change in the patient’s ability to comply with repositioning,problem with the equipment e.g. mattress not switched on/alarming, anythingthat might affect the pressure areas care plan

d) Ensure they are up to date with their knowledge regarding prevention andmanagements of pressure ulcers, discussing any education and trainingneeds identified with their line managers

4.8 Tissue Viability and Pressure Ulcer Prevention Team 4.8.1 Tissue Viability / Pressure Ulcer Prevention Specialist Nurse

a) To support and empower nursing and medical staff to providecompetent, evidence based practice in the prevention and management ofpressure ulcers through direct clinical support, professional advice andeducation and training.b) Provide professional advice and support to the therapy bed andmattress providers for the prevention and management of pressure ulcersto ensure that the correct specification of mattress is being used.c) Support the monthly validation pathway including:

• monitoring incidents reported through Datix and Tissue Viabilityreferrals, where possible undertake a visual inspection of allreported category 3, 4 pressure ulcers and Suspected Deep TissueInjuries within 72 hours

• providing specialist advice and input into the investigations relatingto pressure damage and Tissue Viability opinion for the RCAchecklists or SI reports as requested

• Ensure Tissue Viability representation at the monthly CMGvalidation

d) Support the Safety Thermometer data validation process

4.8.2 Tissue Viability Administrator Manage the Pressure Ulcer database and RCA pathways administration process for identification, escalation, validation, final report signs offs

4.9 Quality and Safety Team a) Report all pressure ulcers which meet the criteria as a serious incident (as per

UHL SI framework) onto STEIS as advised by the Head of Safeguarding andTissue Viability and the Tissue Viability Team following the monthly validationprocess within 72 hours

b) Lead the investigation for all pressure ulcers which meet the serious incidentcriteria following the current UHL SI investigation pathway (ref. UHL SI Policy)



5. POLICY IMPLEMENTATION AND ASSOCIATED DOCUMENTS

The SSKIN Bundle (as pictured below) is the framework used for patient assessment and care planning to prevent pressure ulcers (NHS England – Midlands and East 2012) The process for managing pressure ulcer prevention is described below

5.1 Pressure Ulcer Risk Assessment and Skin Inspection All patients arriving in the Emergency Department and short-stay areas must be screened using the Anderson screening tool within 2 hours of arrival. If they trigger, a full skin assessment and Waterlow risk assessment must be completed within 4 hours of arrival and all preventative interventions initiated. a) All patients who trigger on the Anderson screening tool must have their skin

checked and must be risk assessed within 6 hours of admission to hospitalusing the Waterlow score (modified Braden Score for Children) and theBESTSHOT tool completed. The assessment must be recorded on the Trustapproved Documentation (See Appendix 2 for Sample Documentation forAdults, Appendix 3 for sample Documentation for Children)

b) Further assessments must be undertaken as follows:

• All hospital inpatients must have risk areas asseesed usingBESTSHOT Appendix 2 as a minimum twice a day

• Waterlow risk assessment must be undertaken twice weekly, on anychanges to the patient’s condition, based on the care needs identified,and on transfer from another ward/department

c) All patients identified at risk of pressure damage must have a nutritionalassessment completed using the Malnutrition Universal Screening Tool(MUST) or the equivalent for Children. Protein or calorie deficiency mayincrease a patients risk of pressure ulcer development due to a reduction inthe body’s ability to heal or repairs itself

d) All patients with a category 3 or 4 pressure ulcers must be referred to aDietician, irrespective of their MUST score. They must also be referred toTissue Viability Team via ICE (on-line) and Datix completed

e) Nursing staff must maintain patient hydration in order to promote adequatecirculatory volume and good skin and tissue perfusion.



5.2 The Importance of Repositioning Patients at Risk of Pressure Damage All patients with a pressure ulcer or at high risk of pressure ulcer development will have a documented re-positioning schedule using the Daily Pressure Ulcer Prevention Care Plan (document in the ‘Keep Moving’ section of Regime 1, if the patient condition changed, revised repositioning regime can be documented in Regime 2).

5.2.1 The re-positioning schedule will be based on: a) the patient’s clinical condition / comfort (e.g. breathlessness, end of life)b) the pressure-redistributing qualities of the support surfaces in se (foamor dynamic)c) all surfaces used by the patient i.e. bed, chair etcd) the frequency of repositioning will be reviewed regularly and determinedby the results of skin inspection and the individual needs of the patient

5.2.2 Re-positioning will: a) Contribute to patient comfort, dignity and functional abilityb) Avoid pressure, friction and shearc) Ensure that prolonged pressure on bony prominences is minimisedd) Avoid positioning directly over a pressure ulcere) Avoid a slouched position or an upright position in bed (these positionsmay lead to pressure and shear on the sacrum and coccyx)f) Be undertaken using the 30 degree tilt positions (see Appendix 4illustration)g) Avoid the 90 degree side-lying positions as this puts additional pressureover the hip (see 5.2.2c)h) Include patient position such as lying prone, mobilising, standing orsitting out in a chair as well as turning side to sidei) Utilise the profiling bed frame to alter patient’s position and increase thepatient’s ability to alter their own positionj) Reduce both the time and of pressure a patient is exposed to. Highpressure over bony prominences for a short period of time or low pressureover boney prominence for a long period of time are equally damagingk) Be undertaken every hour for patients at risk who are sitting in a chair

5.2.3 Implement mobilising and re-positioning interventions for all patients with actual or potential pressure damage Unless this is medically contra-indicated. This includes wheel-chair users, those confined to a bed or chair and patients on pressure relieving surfaces (mattresses and/or cushions)

5.2.4 The Use of Pressure Relieving Devices Including Seating a) Decisions about the use of pressure relieving devices must be based on

holistic assessment of the patient



b) All patients will be nursed on a high specification foam mattress / supportsurface as a minimum. The choice of which type of mattress used, i.e. foamor dynamic, will be based on the nurses assessment with specialist advicebeing available

c) A quick reference guide flowchart regarding which mattress to choose is inAppendix 5

d) Patients assessed as being high risk or with category 1 or 2 pressure damagecan be nurse on a viscoelastic foam mattress in conjunction with profiling bedframe, provided they are able to move or be moved as required. It isnecessary that before every use the mattress is checked to ensure that it is ingood condition and there is no evidence of contamination or “bottoming out”.Please refer to the Process for Inspecting and Condemning Foam Mattressesin Appendix 6

e) Patients with category 3 or 4 pressure ulcers who can not toleraterepositioning should be nursed on a pressure redistributing (dynamic)mattress and cushion. If the appropriate equipment is not available, completean incident form and inform the Ward Sister or Matron. Adjust the care planaccordingly.

f) Patients being nursed on these types of mattresses will still requirerepositioning every 2-4 hours depending on the patient’s condition andnursing assessment

g) Patients nursed on a pressure redistributing (dynamic) mattress will be re-assessed every 48-72 hours or as clinical need determines to ensure thismattress is still required. They will be returned to a foam mattress as soon astheir clinical condition allows or upgraded if their clinical needs change

h) Appropriate pressure-relieving aids must be used, i.e. foot protectors, pillowsbetween bone prominences or equipment specifically designed for pressurerelief. However, some aids are not appropriate, i.e. synthetic sheepskins,doughnut-type devices or fibre-filled mattress overlays i.e. ‘Spence’ and mustnot be used

i) Aids such as pillows, gel pads or foam wedges may be used to prevent boneprominences from direct contact with one another, i.e. knees and ankles.These aids should not affect the action of a dynamic pressure-relievingsurface being used as long as they are positioned correctly

j) Patients with a spinal, sacral/coccyx or ischial (buttock) pressure ulcer mustnot be sat out in a chair if the pressure ulcer is not showing signs ofimprovement

k) Patients with an improving spinal, sacral/coccyx or ischial (buttock) pressurerequiring sitting out as part of their rehabilitation and a clear plan should bedocumented

l) Specialist advice on aids, equipment, needs of bariatric patients and suitablepositioning is available from the Manual Handling Team or the Tissue ViabilityTeam if required.

m) If a patient develops a pressure ulcer or an existing pressure ulcerdeteriorates, staff must check that any pressure relieving equipment is ingood working order. It is essential that following every episode when patienthas attended a procedure or appointment off the ward, the mattress isplugged back in for charging and switched on.



n) Once a pressure ulcer has healed, the patient’s risk of pressure ulcerdevelopment must be reassessed and appropriate interventions undertakene.g. downgrade of mattress etc .

5.3 Care of Patients’ Pressure Areas in the Last Few Days of Life a) For patients approaching the end of their life, an individualised plan of careshould be discussed and agreed with patients and their families which takes intoconsideration their preferences and wishesb) It may be the wish of either the patient or their families that they are notrepositioned as often as this policy recommends. If a patient has capacity, theirwishes must be followed.c) If a patient lacks capacity around this decision then a ‘best interests’ decisionneeds to be made. The final decision must be made by the appropriate decisionmaker, this may be the nurse (please refer to MCA Code of Practice and UHL’sMCA Policy (Trust ref B23/2007))d) A discussion, which shapes the goals and plan of care about pressure areas,should be clearly recorded and include:-

• Potential for SCALE (Skin Changes at Life’s End)

• Skin changes at life’s end can be unavoidable and may occur with theapplication of appropriate interventions that meet or exceed the standardof care

• Patient’s preferences for repositioning, i.e. taking into considerationpatient comfort and breathing difficulties when moved

e) Patients approaching end of life should have their holistic needs regularlyreassessed (minimum 4 hourly) in accordance with the Individualised End of LifePlan. Clear and concise documentation about decisions made, includingrationale and patient and family preferences, is essential. The decisions mustalso be clearly communicated with all teams involved in the patient’s careincluding their families and carers.f) For further advice or information regarding this information, please contact theUHL Tissue Viability or Palliative Care Teams

5.5 The Use of Aids for Moving and Handling Manual handling equipment, e.g. slide sheets, hoist slings, will be used correctly to prevent friction and shear damage and should never be left in contact or underneath the patient after a manoeuvre. Please refer to the Safer Handling Policy (trust Reference B65/2011) for further advice

5.6 Preventing Heel Damage a) The heel is one of the most common sites for pressure ulcers after thesacrum. This is due to the thin layer of subcutaneous tissue between the skinand bone and patient specific risk factors such as the wearing of anti-embolicstockings, diabetes, vascular disease etc.

Policy for Prevention and Management of Pressure Ulcers in Adults and Children of 38 V3 Approved by Policy and Guideline Committee on 18 August 2017 Ref: B23/2014 Next Review November 2020


b) Heels must be inspected in line with BESTSHOT documentation and the dailypressure ulcer prevention care plan.c) If there are any signs of pressure damage, utilise foot protectors (Repose,gutter splints, Devon foot protectors or elevate the heels from the surface of thebed). A pillow may be placed lengthways under the calves for this purpose.Placing the pillow lengthways distributes the weight over a greater surface area.d) Heel protection devices should completely elevate the heel (off-loading) insuch a way as to distribute the weight of the leg along the calf without puttingpressure on the Achilles tendon. The knee should be in slight flexion in order toavoid obstruction of the popliteal vein which could predispose to VenousThrombo-Embolism (VTE)e) Carefully assess the patient prior to the use of anti-embolic stockings (AES)and only apply them if this is indicated by local VTE prophylaxis protocols. IfAES are used, twice daily skin inspections must continue in line withBESTSHOT, one inspection must be complete removal of the AES for a full leginspection and the other is a partial removal of the AES to inspect the heels andtoesf) Particular care must be taken for patients with potential or known circulatorydisorders (i.e. diabetes, cardio-vascular or peripheral vascular disease) as theywill be at increased risk of foot / heel damage, AES may be contraindicated forthese patientsg) Ensure heels are well moisturised and protected from friction. A film dressingmay be applied if necessary to help prevent friction damage.

5.7 Medical Device Related Pressure Ulcers (MDRPU’s) a) Medical devices are often made out of rigid materials such as plastic, rubber

or hard silicon, which can cause rubbing or create pressure on the skin / softtissue

b) The most susceptible areas are the device insertion site or some boneyanatomical locations with no / little fatty tissue, e.g. bridge of the nose

c) Many MDRPU’s occur because of poor device positioning or fixation, poorselection of the equipment, poor padding (e.g. Plaster of Paris related PU) orfailure to check that the patient is not lying or sitting on a medical device, e.g.catheter tubing

d) Most frequently affected anatomical sites are ears, nose, neck, heels/Achillesarea, toes, back of thighs and buttocks

e) To prevent MDRPU’s follow the following three steps and documentinterventions on the daily BESTSHOT and repositioning chart

• Position – ensure correct position of the device so it is not pressure overpatient’s skin and patient not lying / sitting on the device / tubing

• Protection – use a protective dressing (or gel pad) to prevent friction andsheer

• Prevention – incorporate regular STOP checks 2-4-6 hourly (dependenton patient’s condition) into the daily SSKIN bundle interventions

f) Please see Appendix 7 for a Medical Device Related Pressure Ulcers Posterwith the above information



5.8 Patient and Carer Education a) The results of the assessment and care-planning will be discussed with the

patient, multi-disciplinary team and family members / carers. The nurse willensure that information is given to promote participation by carers if desiredand if the patient has consented to this.

b) Assess the patient’s mental capacity to agree to their care and record thepatients agreement with their pressure ulcer prevention care plan in thepatient’s notes

c) Staff must also document if patients with capacity decline to comply withpressure ulcer prevention advice

d) Patients will be given information regarding pressure damage, including riskfactors and prevention strategies. Copies of the NICE Pressure Ulcer guidefor patients and cares and the ‘STOP the pressure – make the MOVE’ leafletsare available in all ward / department areas or can be accessed throughINsite.

e) All patients able to move independently should be encouraged to do so anddocument their movements on charts such as the ‘Mark a Move’ Chart(available on the Tissue Viability web pages on INsite). Patients with reducedmobility will be taught / encouraged to re-distribute their weight, within theirlimits, using appropriate equipment i.e. monkey poles. Encourage patients torelieve their pressure areas every 15-30 minutes if they are available.

f) Patients without capacity must have care planned in their best interests andlack of ability to comply with prevention measures documented in the casenotes.

5.9 Discharge / Transfer a) The Nurse in Charge will inform other departments of continued preventative

care needs when a patient with a pressure ulcer, or who is assessed as atrisk, is transferred to another area, e.g. patients requiring x-ray, dischargelounge, physiotherapy etc.

b) The Patient Daily Pressure Ulcer Prevention Care Plan should be sent withthe patient to ensure any specific issues are highlighted and ongoingpreventative care is documented by the receiving department.

c) On discharge or transfer, written information concerning risk assessment,existing pressure ulcers and current treatment will be provided to allappropriate personnel, including the receiving ward / unit, carers, communitystaff, patient and relatives.

5.10 Reporting, Monitoring a) A Data incident form must be completed for all patients with a category 2, 3 or

4 pressure ulcer or SDTIs (present on admission or UHL acquired) as soonas it is identified and at least within 24 hours. Where it is suspected that thedamage is as a result of harm or neglect then a safeguarding referral must



also be made if a score of 15 or above is reached using the safeguarding decision guide contained within the checklist

b) Category 2 must be initially graded as minor incidents, category 3 andSuspected Deep issue Injuries as moderate and category 4 as majorincidents / ‘never events’ (Serious Incidents). The Duty of Candour Sectionmust be completed.

c) A referral to the Tissue Viability Team must also be completed via an ICE forall category 3, 4’s and SDTIs. An at a glance referral process for the TissueViability Team is available as Appendix 8.

d) It is considered best practice to photograph category 2 and above pressureulcers in order to support the evaluation process. However, this may alwaysbe appropriate, e.g. End of Life care. Staff must follow the current UHLguidance in relation to Clinical Photography Appendix A section 4 – Policy forconsent to examination or treatment trust ref. A16/2002

e) The Tissue Viability Team monitors to the Hospital Acquired Pressure Ulcer(HAPU) related Datix incidents and escalates the cases as per theappropriate Root Cause Analysis pathway (see 6.10.2 below)

f) The Tissue Viability Team Administrator is responsible for the administrationof the whole UHL Pressure Ulcer Pathway

5.10.1.1 Root Cause Analysis (RCA) Checklists and Investigations a) All Hospital Acquired category 2, 3 and 4 Pressure Ulcers undergo an RCA

Checklist. This process follows two specific pathways, one for category 2s(see Appendix 9) and one category 3 and 4 (See Appendix 10)

b) Once a Datix report for HAPU category 2, 3 or 4 s generated theward/department manager must complete a ‘Checklist for the investigation ofcategory 2, 3 and 4 HAPUs’ (Root Cause Analysis Report) within 7 days ofthe incident date.

c) This checklist is presented at the monthly validation meeting where the finaldecision about the HAPU avoidability is agreed by the CMG Head of Nursing,Head of Safeguarding and Tissue Viability Specialist. All pressure ulcerswhich meet the criteria of a serious incident will be reports on STEIS by theQuality and Safety Team within 72 hours of the final validation decision.

d) All avoidable category 4 HAPU’s must be treated as serious incidents.Please refer to the Trust’s SI Policy.

e) All full investigation is required for pressure ulcers, graded as seriousincidents as per the local SI policy (reference A10/2002) and this investigationis led by the Quality and Safety Team.

5.11 Safeguarding and Pressure Ulcers a) There is a recognised link between pressure ulcers and safeguarding.

Pressure ulcers may be as a result of neglect, which is regarded as behaviourby care staff that results in the persistent or severe failure to meet thephysical and/or psychological needs of an individual in their care. Neglectmay consist of either deliberate acts or acts of omission.



Staff who have a concern about neglect must make a safeguarding referral to the relevant agency / person in line with the UHL Safeguarding Policy (B26/2011) For all reported pressure ulcers a checklist must be completed which includes the use of the Safeguarding Decision guide which will determine if a safeguarding referral should be made Appendix 6

6 EDUCATION AND TRAINING REQUIREMENTS

6.1 All nurses and HCA’s will receive training on the risks, classification, prevention and management of pressure damage as part of their induction

6.2 Update sessions on Pressure Ulcer Prevention for Nurses and HCA’s are available to book via HELM or can be provided as part of existing education programs on request

6.3 The Tissue Viability Team will provide education and training to Allied Health professionals and Medical Staff on request

6.4 All staff engaged in direct patient care will receive Moving and Handling training on Trust induction and update as per the Statutory and Mandatory Training Policy (Trust Ref B21/2005)

6.5 A comprehensive range of pressure ulcer resources are provided by the Tissue Viability Team and these are available on INsite for all staff to access. Raising awareness of these resources will be through INsite and the usual Trust communication channels

7 PROCESS FOR MONITORING COMPLIANCE

Element to be monitored

Lead Tool Frequency Reporting arrangements

1. Category 2, 3or 4 PressureUlcers are reported on DATIX within 24 hours of identification

Tissue Viability Team

DATIX Form Reviewed Daily Monday-Friday by Tissue Viability Team Administrator

Incidences reported to Tissue Viability Team to follow up as they are reported. Information also presented on the Dashboard

2. RCA’s will becompletedwithin 7 days

Ward Sister / Charge Nurse / Matron

RCA Checklist

Checklist by Tissue Viability Team Administrator

Escalated by Tissue Viability Team PA to CMG Head of Nursing

3. Number of AvoidableHospitalAcquiredPressureUlcers

CMG Head of Nursing

RCA Validation tool

Monthly HON Lead on Validation meetings, report to Head Of Safeguarding and Tissue Viability by 10th of every month

4. Procedureswithin thispolicy for theprevention of pressure ulcers

CMG Head of Nursing

Ward Review Tool Nursing Metrics

Every three months Monthly

Nursing Executive Team Meeting (Data)

5. Prevalence ofnew pressureulcers

Head of Safeguarding and Tissue Viability,

National Safety Thermometer

Monthly Nursing Executive Team Meeting (Data)



Element to be monitored

Lead Tool Frequency Reporting arrangements

Chief Nurse

8 EQUALITY IMPACT ASSESSMENT

8.1 The Trust recognises the diversity of the local community it serves. Our aim therefore is to provide a safe environment free from discrimination and treat all individuals fairly with dignity and appropriately according to their needs.

8.2 As part of its development, this policy and its impact on equality have been reviewed and no detriment was identified.

• judgment of the responsible clinician it is fully appropriate and justifiable – suchdecision to be fully recorded in the patient’s notes.

9 SUPPORTING REFERENCES, EVIDENCE BASE AND RELATED POLICIES

Bennett et all (2004) ‘The cost of pressure ulcers in the UK’. Age and Ageing: 33, 230-35 European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel. National Institute for Clinical Excellence (2014) Prevention and treatment of pressure ulcers NHS Institute for Innovation and Improvement. Royal College of Nursing (2000): Clinical Practice Guidelines: Pressure Ulcer risk assessment and prevention 2000 Wound care Society (2004). Principles of pressure ulcer prevention and management Department of Health Nurse Sensitive Outcomes Indicators for NHS commissioned care; June 2010 SCLE Expert Panel: Final Consensus Statement 2009

10 PROCESS FOR VERSION CONTROL, DOCUMENT ARCHIVING AND REVIEW

10.1 This document will be uploaded onto SharePoint and available for access by Staff through INsite. It will be stored and archived through this system.

10.2 This Policy will gave its first review 18 months after approval, and from then onwards it will be every three years or sooner in response to changes in practice or identified clinical risk



Categories of Pressure Ulcers

Appendix 1



Documentation Samples – ADULT (Including BEST SHOT Poster)

Appendix 2

Policy for Prevention and Management of Pressure Ulcers in Adults and Children of 38 V3 Approved by Policy and Guideline Committee on 18 August 2017 Ref: B23/2014 Next Review:November 2020


Documentation Samples - CHILDREN

Appendix 3



Documentation Samples - CHILDREN

Appendix 3 Paediatric Nursing Documentation

Paediatric Pressure Ulcer Prevention Care Plan Child's Name: Hospital Number: Date of Birth: Ward:

A score of 10 or below on the Paediatric Pressure Ulcer Assessment Tool (Br:sdtm Q 2010) constitutes the child being at risk.

Care for a child scoring 10 or lower Must Include 1 Formal reassessment twice weekly (as a minimum) or when any significant change

in child's condition i.e. pre/post-surgery; deterioration; improvement ;transfer or discharge

2 Daily inspection of the child's skin and 'at risk' areas such as bony prominences.

3 A regular wash of ‘at risk' areas W the child is incontinent or sweating profusely. Use mild soap or soap substitute and soft wipes. Gentle pat dl)'.Avoid unnecessary)' friction

4 Consideration of the prophylactic use of barrier 1ilm' creams tor children in nappies or pads.(eg Cav11/on)

5 The implementation of a repositioning regime (recorded on a repositioning chart) ideally level)' 2 hows. 11 the child cannot physiologically tolerate position change this must be explained to the child's parents and documented in the case notes.

6 Upgrade to a pressure relieving mattress and /or cushion based on clinical assessment and clinical need (Refer to Hill-Rom Flow Chart)

7 Assess child's nutritional status to ensure that child is not nutritionally compromised you must consider a high protein diet and referral to a dietician.

8 Educate parents about the importance of pressure ulcer prevention and involve them as appropriate, provide child and family with advice leaflets on skin care.

9 If the child has an pressure ulcer, please complete UHL Wound Assessment Chart and Care Plan

10 On discharge, liaise with Community Nursing Team regarding a follow up and the need for appropriate equipment

Preventative Nursing Care Plan

Date and Time

Protection of Risk Areas

Mattress Used

Cushion or Seating

Other Measures Used (Include Referrals)

Name / Sign

Paediatric Pressure Ulcer Prevention Care Plan Children's Hospital KVIfLCS 10910



30 Degree Tilt

Appendix 4



Mattress Flowchart

Appendix 5

Policy for Prevention and Management of Pressure Ulcers in Adults and Children of 38 V3 Approved by Policy and Guideline Committee on 18 August 2017 Ref: B23/2014 Next Review:November 2020


Appendix 6 CHECKLIST FOR THE INVESTIGATION OF GRADE 2, 3, 4 & SDTI PRESSURE ULCERS

Pt Initials Brief Medical History & Date and Details of Current Admission and Description of Incident (i.e. development of pressure ulcer, when, how, where etc) S Number: S

Date of Incident: DATIX Number: W DOB / Age STEIS Number (if applicable) Ward / Dept: Hospital Site: Grade of HAPU: (please list)

Anatomical location of HAPU:

POP related? Yes/No

CHRONOLOGICAL TIME TABLE

Date Ward Waterlow (please fill in score only on dates of actual review)

BEST SHOT (please specify time and findings) e.g. 12.00 md Sacrum score 3, heels score 4, rest 1

Change of Position (please specify times and give details of position) e.g. 12.00 md left side30o tilt

Equipment (mattress, cushion, heel protectors, slide sheets, footwear etc)

Nutrition / Hydration (specify dietician referrals, reviews, food charts)

Incontinence / Moisture (specify type of continence problems if any, times and details of interventions) e.g. 12.00 md bowels opened, faecal incontinence ,pt cleaned with wet wipes, cavilon applied, pad changed etc

Policy for Prevention and Management of Pressure Ulcers in Adults and Children

V3 approved by PGC on 18 August 2017 Trust ref: B23/2014 next review: November

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The Pressure Ulcer is Unavoidable because: Yes/No If the answer to any of the questions is YES, please provide further details of the documented evidence

1. IT DEVELOPED PRIOR TO UHL ADMISSION

Was there evidence of an existing grade 2, 3, 4 or SDTI pressure ulcer or an incipient (pre-existing, developing) pressure damage Grade 2, 3, 4 or SDTI on admission to UHL?

a) Did the patient have a fall prior to admission withprolonged periods of lying on the floor?b) Is there a history of the patient being bed bound duringthe last few days prior to admission?c) Has the lesion / area of skin / tissue damage presenteditself on admission to UHL?

N.B. If there is sufficient evidence to support that this pressure ulcer was present on admission, please DISCONTINUE the checklist and send to the Tissue Viability Mailbox ([email protected]) as evidence for de-escalation of the incident

2. IT IS NOT A PRESSURE ULCER

Is there any possibility that this may not be pressure related? If YES please give details of possible causes:

a) Is this a Leg ulcer?i) Is the ulcer located around the ankle / shin area?ii) Is there evidence of varicose eczema?iii) Does the patient have a history of chronic legoedema?

b) Is this an inotropic lesion?i) It developed during a period when this patient wasreceiving high doses of Inotropes causing a peripheralcirculatory shut down?ii) Was patient general condition too unstable to allow

regular repositioning (e.g. critically ill or unstable fracture)?


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mailto:[email protected]



c) Is this a moisture lesion?i) Is there evidence of incontinence / leakingwounds etc problems?ii) Does the patient have a high BMI (please state)and / or problems with sweating?

Please provide location and presentation of the lesion

d) Is this a bruise / haematoma from recent trauma

e) Is this a skin tear or other traumatic wound e.g.radiotherapy burn or other type of burn?

(N.B. If there is sufficient evidence to support that the PU is was not a pressure ulcer, please DISCONTINUE the checklist and send to the Tissue Viability Mailbox ([email protected])

3. THE PATIENT HAS A CONDITION THAT COULD LEAD TO UNAVOIDABLE PRESSURE DAMAGE – please ensure details of ALLpreventative interventions are included in section 5 for this possible pressure damage to be deemed Unavoidable

Does the patient have any of the following? a) End of life skin failure

i) Is the patient terminally ill?ii) When was the appropriate End Of Life carepathway started?iii) Did the lesion / area of skin damage develop inthe last 3 days of the patient’s life?

b) Could this be a diabetic foot ulcer? If yes pleaseprovide details

c) Could this be an ischaemic ulcer caused by poorvascular supply?

i) Was Vascular opinion sought? (If yes pleaseprovide latest ABPI’s results / date)

4. THE PATIENT WAS NOT COMPLIANT

Is there evidence of patient non compliance with the treatment plan?

a) Is there sufficient evidence of regular patient educationabout the implications of non – compliance?


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b) Is there evidence that the patient understands theimplications of not complying with the Pressure ulcerprevention plans?c) Is the patient confused?d) If the patient was confused is there evidence ofpatient’s mental capacity being assessed?

5. UNAVOIDABLE PRESSURE ULCER (as per DOH definition 2011)

Is there sufficient evidence that the pressure ulcer is Unavoidable? If YES please provide details:

a) The staff have evaluated the patient’s clinical conditionusing all appropriate risk assessments in a timely manneras per NICE guidelines? (e.g. Waterlow, MUST score /Nutrition, Hydration, Repositioning regime, Wound charts,Manual Handling Assessment – please include dateassessments commenced and dates when evaluated)

b) Is there sufficient evidence in the patient’s notes thatdaily pressure area checks (BESTSHOT) wereundertaken?c) Appropriate pressure relieving devices have been usedand upgraded in a timely manner (i.e. all surfaces that areused by the patient have been provided in an appropriatetime scale to ensure prevention – please indicate date equipment ordered and implemented)?

Mattress – Cushion – Heel protectors – Appropriate footwear – Other- e.g. elbow, head protectors etc

d) Does the patient have an individualised, up to date PUPregime on the daily care plan / SSKIN bundle?

e) The daily regime on the care plan has been agreed withthe patient and is consistent with their needs and goals?





f) Is there evidence that the PUP regime has beenreviewed on a daily basis?

g) The staff are undertaking prompt actions to change thepressure ulcer prevention strategies in line with anychanges in patients condition (deterioration, improvement)

h) If this is a medical equipment/device related pressureulcer, is there evidence that preventative measure wereundertaken in a timely manner?

e.g. Siltape or Duoderm used prior to development of pressure damage

i) The safeguarding decision tool has been used and thescore is 15 or below.

6. IT WAS AN UNAVOIDABLE DETERIORATION OF AN EXISTING GRADE 2 PRESSURE ULCER(ONLY COMPLETE FOR GRADE 3 & 4 PRESSURE ULCERS)

Was this ulcer a result of deterioration of a pre-existing grade 2 pressure ulcer?

a) Is there sufficient evidence that all appropriatestrategies were put in place to prevent deterioration?(please make sure all details are completed in Section 5above)f) Was there evidence of general decline in the patient’smedical condition?

LESSONS LEARNT AND RECOMMENDATION FOR CHANGE IN PRACTICE (This section must reflect your findings, e.g. there is good evidence that all preventative actions were in place while the patient was on Ward X. However there are some areas for improvement on Ward Y. Then list the actions that need to be undertaken.) Please give details

••

AUTHOR DESIGNATION: DATE:




DUTY OF CANDOUR (the patient or family / carer must be informed that asuspected or actual patient safety incident has occurred within 10 working days of the incident being reported)

Yes / No Date informed and by who

Has the patient / carer been informed about this incident?

Has the patient / carer been informed about this investigation?

Was any agreement made with the family around investigation findings and how this would be shared with them? Were they offered this?

If so, did they decline?

Based on the above evidence the conclusion is that: 1. The pressure ulcer under investigation is UNAVOIDABLE and will bedowngraded to a 0 incident for grades 3 and 4

2. The above investigation does not provide sufficient evidence to supportan Unavoidable status and therefore the pressure ulcer will be classed asAVOIDABLE.The Safeguarding Decision tool has scored 15 or above and a safeguarding referral has been made

TISSUE VIABILITY OPINION




Tissue Viability Lead Signature Date

CMG Head of Nursing Signature Date

Head of Safeguarding (for Grade 3 / 4s)

Signature Date



CHECKLIST FOR THE INVESTIGATION OF GRADE 2, 3, 4 & SDTI PRESSURE ULCERS

If the score is 15 or over refer to Safeguarding

Patient Name ........................................................................... Patient No: ..................................................................

Risk Category Level of Concern Score Comments 1 Has there been an unexpected deterioration in the

patient’s skin integrity from the last opportunity to asses?

Progressive onset/deterioration of skin integrity.

5

Sudden onset/deterioration of skin integrity with a clinical reason explanation (if a lapse in care grade above).

0

2 Has there been a recent change in their/clinical condition that could have contributed to skin damage? Eg infection, pyrexia, anaemia end of life care (Skin Changes at Life End).

Change in condition contributing to skin damage.

0

No change in condition that could contribute to skin damage

5

3 Was there a pressure ulcer risk assessment or reassessment with appropriate pressure ulcer care plan in place and documented? In line with each organisations policy and guidance, if this is a new pressure ulcer an appropriate pressure ulcer care plan would not be in place. A risk assessment would be.

Current risk assessment and care plan carried out by health care professional and documented appropriate to patient needs.

0

Risk assessment carried out and care plan in place documented but not reviewed as person needs have changed.

5

No or incomplete risk assessment and/ or care plan carried out.

15

4 Is there a concern that the Pressure Ulcer developed as a result of the informal carer wilfully ignoring or preventing across to care or services.

No/Not Applicable 0 Yes 15



CHECKLIST FOR THE INVESTIGATION OF GRADE 2, 3, 4 & SDTI PRESSURE ULCERS

Risk Category Level of Concern Score Comments 5 Is the level of damage to the skin inconsistent with

the patient’s risk status for pressure ulcer development? eg low risk category/grade 3 or 4 pressure ulcer

Skin damage less severe than patient risk assessment suggests is proportional

0

Skin damage more severe than patients risk assessment suggests is proportional. 10

6 Answer (a) if you patient has capacity to consent to every element of the care plan Answer (b) if your patient has been assessed as not having capacity to consent to any part of the care plan or some capacity to consent to some but not all

a Was the patient compliant with the care plan having received information regarding the risk of non-compliance and documented they have been explained?

Patient not compliant with care plan (BHFT staff use non concordance forms) Patient compliant with some aspect of care plan but not all

3

Patient compliant with care plan or not given information to enable them to make an informed choice?

5

b Was appropriate care undertaken in the patient’s best interest, following the best interest’s checklist in the Mental Capacity Act Code of Practice? (supported by documentation, eg capacity and best interest statements and record of care delivered)

Documentation of care being undertaken in patient best interest.

0

No documentation of care being undertaken in the patient’s best interest.

10

Completed by: ...........................................................................

Date: ...........................................................................

Circle decision below:

Safeguarding Referral completed Not for Safeguarding Referral Pressure ulcer checklist



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Medical Device related Pressure Ulcers – Poster

Appendix 7


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Tissue Viability Referral Process

Appendix 8

Tissue Viability In-Patient Service Monday-Friday (09:00-17:00)

For out –patient queries, refer to link nurse / champion or refer to Community team via SPA Tel: 03003001000

WHAT WHO HOW • Patients with grade 3 or 4

pressure ulcers; significantdehisced wounds; severewound infection; severe skinexcoriation

• Patients not responding toinitial treatment (see Woundmanagement formulary onInsite)

• Very high-risk patients withcomplex needs

• Assessment for VACTherapy / larvae therapy.Patients admitted with VACtherapy in situ

• Lower limb patients Patientsreceiving compressionbandaging (see leg ulcerpathway)

• Patients with leg ulcerswhere no aetiology has beenestablished. To facilitatecomplex discharge planning

• Guidance, education and support for staff

• Advice on equipmentprovision

• To facilitate complexdischarge planning

Registered Nurses

Doctors

Therapists

Specialist nursing teams

Allied Health Professionals

Link nurse / champion Liaise with your link nurse / champion for initial review and confirm need to refer on to Tissue Viability service or other specialist team

Plastics & Burns / Vascular / Dermatology patients Consider direct referral to appropriate team

Diabetic foot Follow Inpatient referral pathway - all to be referred to Diabetic team within 24 hours of admission

All referrals to be made via ICE

• Referrals MUST be supported by acompleted wound assessment chart.

• Please give as much information aspossible relating to reason for referral.

• Referrals will be actioned within 5working days.

• TV service will endeavour to contactreferring ward / department (viatelephone) within 24 hours of receipt ofreferral.

• First line advice will be provided viatelephone.

• All verbal advice given prior to formalassessment should be documented byboth parties.

• TV service will negotiate agreed time toreview patient

• Urgent – within 24 hours – wherepossible

• Non-urgent – within 72 hours – wherepossible

• For more urgent support, pleasecontact Tissue Viability service viaswitchboard - ask for site based TissueViability or Pressure Ulcer nurse (seereferral process flowchart)

N.B. For wounds with uncontrollable bleeding, ischaemia or severe infection - refer directly to appropriate surgical / medical team

• Further reviews will be confirmed andagreed between clinicians and patients


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Root Cause Analysis Pathway – Category 2

Appendix 9

Policy for Prevention and Management of Pressure Ulcers in Adults and Children V3 approved by PGC on 18 August 2017 Trust ref: B23/2014 next review:November 2020

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Root Cause Analysis Pathway – Category 3 and 4

Appendix 10


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