Pressure ulcers (PUs) can have a devastating effect on individuals, affecting quality of life and in some cases proving fatal. The reasons why ageing skin is more vulnerable to pressure damage include reduced mobility, loss of skin elasticity and blood flow, which make skin more prone to damage.
East London Foundation Trust (ELFT) is a mental health and community NHS Trust. Reducing harm from pressure ulcers is high on the Trust's agenda and the responsibility for reducing PUs sits with every healthcare worker. We work closely with external organisations such as the integrated care board (ICB), acute providers, the local authority responsible for commissioning care packages for the older population, nursing home staff and GPs.
It was our ambition to reduce PUs acquired in our care by 10% over a 12-month period by implementing a quality improvement (QI) project. The QI team consisted of nurses, therapists, the peer support worker, patient quality and compliance staff, the QI faculty and senior leaders.
Our strategy was to engage all stakeholders in a collaborative project. We considered several change ideas, including improving our data collection and sharing PU data across all teams working with vulnerable older people and younger service users at risk of developing PUs due to reduced mobility. Data collection enables us to measure success: it is a powerful way to demonstrate whether change ideas are working and really helps to tell the story. It also helps prompt conversations within teams and inspires people when a change is working.
The QI project exceeded our aim, achieving a 31% reduction in PUs of all categories and a 50% reduction in moderate harm PUs.
At ELFT, we have a dedicated team of nurses specialising in PU prevention and management who support district nursing teams by providing specialist hands-on face-to-face care. They meet with team leaders every 2 weeks to discuss the PU caseload. The aim is to identify PUs not progressing towards healing, prompting a review. Specialist nurses also provide education and training to other Trust nurses, therapists, rehabilitation support workers and carers. Patients feedback on the benefits of a dedicated nurse specialising in PU prevention and management has been positive, for example:
‘I had category 4 pressure ulcer x2 which made me feel very bad. The pressure ulcer specialist did a good job in getting the proper equipment … which helped to relieve the pressure off my bottom and also helped my personal carer to be able to do personal care without hurting her back. The pressure ulcer nurse was caring, and assessed my mental health and provided me with encouragement to go out; she also referred to my GP and to the plastic team … I would like to see her more often as she's [a] brilliant nurse.’
A qualitative research study undertaken at the Trust (Taylor et al, 2021) demonstrated that having a specialist nurse working within community teams was a huge support and resource to staff.
Following the QI project we review PU incidents weekly and plot the data on control charts, which enables us to see the situation in real time and quickly identify whether a change is making a difference. All teams can access the data, which are broken down into localities and shared monthly with clinical leads and team leaders; they can take the data to team meetings and have conversations with their teams.
Throughout the QI project, several change ideas were introduced, such as weekly telehealth monitoring of patients at risk of developing a PU. The telehealth team sends test messages with questions linked to all elements of the SSKIN [Surface, Skin, Keep Moving, Incontinence and Nutrition] bundle. If a patient responds with a concern, a member of the telehealth team will call them and, if required, arrange a face-to-face visit. The aim is to stop early pressure damage developing into a PU.
We have introduced an improved triage process for new referrals that includes using digital photography to help with correct categorisation of pressure damage at the point of referral. We have also revisited clinician competencies, which include a theoretical element and a bedside assessment. Virtual consultations with staff were introduced to provide support remotely.
We have worked in partnership with the acute provider to develop aids to help nurses correctly identify sites on the body vulnerable to pressure damage. This involved producing a credit-card size resource that slips into a nurse's lanyard holder, providing information at their fingertips. We have also had input in educating care agency staff on the early signs of pressure damage, and when and how to report concerns. We have worked with physiotherapists, occupational therapists and rehabilitation support workers to help them translate the aSSKINg bundle (updated to include (a) assessment and (g) giving information) into their practice. All these changes have contributed to reducing PUs acquired in our care and improved safety.
Going forward in the spirit of QI, we plan to disseminate our learning and are working with members of the ICB to set up a working group across the integrated care system. The aim is to raise awareness of PU prevention and promote collaborative working. This will help standardise practice for staff on preventing and managing PUs in primary and secondary care settings.
The group aims to develop a project to address risk assessment, prevention and treatment in children and adults with, or at risk of, pressure area damage. The tissue viability team is also collaborating with the local authority to support care agency staff, and patients and staff in nursing homes, to improve standards in PU prevention. In addition, we are working with service users' family/carers to explore barriers and enablers to providing care for a person with a PU.