Policy for the Prevention of Pressure Ulcers. Date Issued/Approved: 17/05/2013. Date Valid From: 17/05/2013. Date Valid To: 30/09/2016

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1 POLICY UNDER REVIEW Please note that this policy is under review. It does, however, remain current Trust policy subject to any recent legislative changes, national policy instruction (NHS or Department of Health), or Trust Board decision. For guidance, please contact the Author/Owner. Document Title Date Issued/Approved: 17/05/2013 Date Valid From: 17/05/2013 Date Valid To: 30/09/2016 Directorate / Department responsible (author/owner): Contact details: Heather Newton, Tissue Viability Nurse Consultant Brief summary of contents This policy sets out the framework to guide evidence based care in the prevention and management of pressure ulcers. Suggested Keywords: Target Audience Executive Director responsible for Policy: Ulcer, Pressure, Tissue viability, RCHT PCH CFT KCCG Medical Director Date revised: 20 Feb 13 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Pressure Ulcer Action Group Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Andrew MacCallum Not Required {Original Copy Signed} Internet & Intranet Intranet Only Clinical / Dermatology Links to key external standards CQC Outcome 4 Related Documents: Tissue Viability Referral Pathway NICE Guidance Prevention and Treatment of Page 1 of 2

2 Pressure Ulcers CG29 Training Need Identified? No This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 2 of 2

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4 Table of Contents 1. Introduction Purpose of this Policy/Procedure Scope Definitions / Glossary Ownership and Responsibilities Standards and Practice Pressure Ulcer Prevention Principles of Practice Risk Assessment Skin Assessment Grading Pressure Damage Management of Pressure Ulcers Patient Information Patient Repositioning Care of Patients Nursed on Trolleys Patient Nutrition Patient Continence Equipment Selection Obtaining Equipment Discharge of Patients Requiring Specialist Equipment Cleaning & Decontamination of Equipment and Reporting Faults Reporting of Pressure Damage Audit/ Monitoring Complaints and Legal Dissemination and Implementation Monitoring compliance and effectiveness Updating and Review Equality and Diversity Equality Impact Assessment Appendix 1. Policy Mobile Summary Appendix 2. Pressure Ulcer Prevention Clinical Pathway Appendix 3. Pressure Relieving Equipment Selection Guidelines Appendix 4. Range of Equipment Guide Appendix 5. Serious Incident (SI) Reporting Process Appendix 6. Standard Operating Procedure (SOP)- RCHT Pressure Ulcer Prevention Data Collection Page 2 of 35

5 Appendix 7. Complaints Response Process Appendix 8. Legal Claims Response Process Appendix 9. Governance Information Appendix 10.Initial Equality Impact Assessment Screening Form Page 3 of 35

6 1. Introduction 1.1. This policy sets out the framework to guide evidence based care in the prevention and management of pressure ulcers This version supersedes any previous versions of this policy. 2. Purpose of this Policy/Procedure 2.1. The purpose of this policy is to ensure that the Trust meets best practice standards for the prevention and management of pressure ulcers in line with national, regional and local guidelines Implementation of this policy will help to ensure that: There is clear guidance to ensure that the prevention and management of pressure ulcers is standardised across the Trust. All staff act in accordance with this policy to prevent the development of pressure ulcers or to prevent the deterioration of existing pressure damage. 3. Scope This document is applicable to all staff regardless of grade or profession, working within a clinical setting, caring for patients with, or at risk of, pressure ulcers. 4. Definitions / Glossary 4.1. Pressure Ulcer Localised 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 these is yet to be elucidated. (EPUAP 2009) 4.2. Unavoidable Unavoidable means that the person receiving care developed a pressure ulcer even though the provider of the care has evaluated the persons clinical condition and pressure ulcer risk factors; planned and implemented interventions consistent with the persons needs and goals, and recognised standards of practice; monitored and evaluated the impact of the interventions and revised the approaches as appropriate; or the individual person refused to adhere to prevention strategies in spite of education of the consequences of non-adherence. 5. Ownership and Responsibilities 5.1. Role of all staff- to be responsible for acting to reduce the number of patients developing pressure ulcers and achieving no avoidable pressure ulcers in NHS care (Department of Health, 2009) All staff must act to achieve the Principles of Practice outlined in Section All staff will be responsible for reporting pressure ulceration in accordance with this policy. Page 4 of 35

7 5.2. Role of the Tissue Viability service- to advise and support staff in achieving the principles of practice through visible role modelling and clinical support in practice and through education and training in the form of study days, self-directed learning resources, and practical workshops Role of the Equipment Library- to supply equipment to protect patients skin integrity whilst in hospital. Nursing staff will be responsible for requesting and documenting the use of equipment. 6. Standards and Practice 6.1. Pressure Ulcer Prevention Principles of Practice 6.2. All staff must adhere to the following principles of practice to ensure care is delivered in accordance with the best available evidence and every possible step is taken to reduce the risk of pressure ulcers occurring. All patients will be assessed for their risk of pressure ulcer development and any existing pressure damage immediately, within four hours of admission to hospital, when their condition changes, and on transfer or discharge. This will be documented in the patient s record and communicated as part of the nursing handover using the Waterlow risk assessment tool for adults, the Glamorgan score for paediatrics and the Maternity Pressure Ulcer risk assessment for maternity patients. All patients will have a skin assessment carried out immediately, within four hours of admission, and throughout their stay according to the clinical pathway (Appendix 1). This will be documented on the Risk Assessment tool on admission and the skin assessment tool throughout their stay. Any pressure ulcers present on admission must be documented at the top of the Waterlow risk assessment tool and reported on the Safety Cross and on Datix. Where a patient develops pressure ulceration during their hospital stay this must be reported on the safety cross and as a clinical incident. If the pressure ulcer deteriorates during their stay the Datix must be updated. The risk and patient safety team can do this for staff. If a Grade 3 or 4 pressure ulcer this is investigated as a Serious Incident and patients are to be informed according to the Being Open policy Pressure damage must be described on the wound assessment tool by stating the Grade of damage, the site of damage, the size of the damaged area and the condition of the wound bed. Where a patient is at risk of pressure damage a pressure ulcer prevention care plan must be written in agreement with the patient. Patients, carers and relatives must be made aware of the reason for the assessment and intervention, and provided with the Trust information leaflet RCHT 153. Page 5 of 35

8 Patients, carers and relatives must be involved in decision making regarding pressure area care and the use of devices to prevent and/or treat pressure ulceration. Communication with all members of the multi-disciplinary team involved in caring for the patient at risk of pressure damage is vital to ensure prompt recovery and optimum management of pressure areas across care settings. All patients at risk of pressure damage must have regular CARE rounds and skin assessments and immediate action must be taken if any signs of pressure damage are identified. See Appendix 1 for clinical pathway for prevention of pressure ulcers. Where necessary action will be taken to improve patients nutritional status. Where moisture may impact upon skin integrity and contribute to pressure damage (i.e. incontinent patients) action must be taken to protect the skin. Skin breakdown from moisture is not classified as pressure damage unless pressure, shear and / or friction damage is also present. Patients at risk of pressure damage must be advised to keep moving or be repositioned as determined by individual assessment and skin condition. This is incorporated within the principles of the SKIN bundle and will be documented in the patient records. S surface. K keep moving, I incontinence, N nutrition. All patients assessed as at risk of pressure damage must be nursed on high density foam, pressure reducing mattresses. Patients with a very high risk or with pressure ulcers grade 2 or above must be provided with an alternating pressure replacement mattress. Specialist equipment will be available 24 hours a day, seven days a week Patients at high risk of pressure ulceration should not sit out in a chair for more than two hours at a time and an appropriate pressure reducing cushion must be used. All care provided to prevent pressure damage must be recorded in the patient s records and evaluated to determine the need for further intervention. All health care professionals are required to attend education about pressure ulcer prevention and use of pressure relieving equipment Risk Assessment 6.4. For adults, excluding women in labour, the Waterlow Risk Assessment Calculator must be used. This is to encourage a structured approach to the identification of a patient s risk of developing pressure ulcers. It should be used in Page 6 of 35

9 conjunction with a nurse s clinical judgement and experience. The Waterlow risk assessment tool forms part of the patient assessment documentation. When possible it should be completed with involvement of the patient and/or carers to ensure accurate collection of data (Anthony et al 2003). Immediately, or within six hours of admission On transfer of a patient to another clinical area/environment of care Prior to discharge from hospital If a patient s condition changes Weekly, if the Waterlow score is Every three days if the Waterlow score is Daily if the Waterlow score is 20 or greater For maternity patients, the Maternity Risk Calculator must be used according to the guidance provided as part of the Pregnancy and Birth Hand held record. (CHA2624) 6.6. For paediatric patients, the Glamorgan Risk Assessment Scale must be used. (CHA2957) 6.7. When assessing risk, the following factors must be considered (EPUAP 2009): Activity and Mobility Nutrition Skin Condition Perfusion and oxygenation of the tissues Age Build/weight for height Continence Tissue Malnutrition Surgery Neurological Deficit 6.8. Activity and mobility 6.9. Consider all individuals who are bedfast and/or chairfast to be at risk of developing pressure ulcers (EPUAP 2009) Chair bound patients have almost 50% of their weight on only 8% of their body, therefore the sacrum and buttocks are at increased risk of damage (Collins 1999) Restlessness and fidgeting may cause blistering and abrasions to the skin s surface Traction or splints reduce one s ability to reposition. In addition they may rub and cause damage to the surface of the skin and underlying tissues When patients are sedated, unconscious or unable to move staff must take responsibility for protection from pressure damage Nutrition Page 7 of 35

10 6.15. Reduced weight, impaired nutritional intake, dehydration and low serum albumin levels may increase the risk of pressure ulcer development (Ferguson et al 2000). However under nutrition is a reversible risk factor (EPUAP 2009) Nutritional indicators include anaemia, haemoglobin and serum albumin levels, measurement of nutritional intake (e.g. food charts) and weight. Weight loss may result in loss of fatty tissue and muscle wastage, which can increase pressure on bony prominences. Good nutrition and hydration is vital for maintenance of skin function and prevention of pressure damage. Protein is required for cell metabolism and the production of collagen, which gives the skin its strength Carbohydrates and fats allow the body to use protein efficiently, generating new cells and reducing the risk of breakdown Iron, zinc, vitamin A, C, B1, B2 and B6 are also required for collagen synthesis Nutritional assessment using the MUST (Malnutrition Universal Screening Tool) tool must be carried out on all patients on admission and weekly thereafter. For patients who score as medium or high risk of malnutrition commence a nutritional care plan and refer to the dietician if necessary to ensure optimal nutritional support for patients (EPUAP 2009) Be aware that the MUST may not give a high score for obese patients who may be at increased risk of developing pressure ulcers Skin Condition All individuals with alterations to intact skin are at risk of developing pressure damage. This includes dry skin, erythema, excessive moisture and non-blanching erythema Incontinent patients may have permanently moist skin. This reduces their tolerance of pressure shear and friction. Moist skin is 5 times more likely to break down than healthy skin (Gibbon 2009) Patients with thin friable skin are at increased risk of blistering or abrasions Dry skin is at risk of cracking when under pressure Oedematous skin may have a reduced blood or lymphatic supply, resulting in toxins building up in the tissues. Oedema can leak onto the skin causing maceration and increasing the risk of breakdown Discolouration may indicate poor blood supply or early pressure damage and pressure relief or a change of position is required A break in the skin should only be recorded on the Waterlow score if it is due to pressure damage Perfusion and Oxygenation of the Tissues Page 8 of 35

11 6.30. Factors affecting perfusion include diabetes, cardiovascular instability, norepinephrine use, low blood pressure, reduced ankle brachial pressure index and use of oxygen (EPUAP 2009) Age As the skin ages the amount of collagen and elastin in the dermis reduces. This results in thinning of skin, loss of tensile strength and increased risk of breakdown (Wounds UK 2008) Build/weight for height Distribution of weight requires consideration and bariatric patients may be at risk of pressure damage. Where excess weigh occurs on specific areas of the body there may be an increased risk of deep pressure damage secondary to friction If weight is below average the amount of tissue covering bony prominences is reduced, resulting in a concentration of pressure onto a smaller area Continence Moisture on the surface of the skin can result in maceration and the skin is less able to resist damage (Cutting and White 2002). Urine and faecal fluid cause changes in the skin s ph and reduces its tensile strength, this can then make it more susceptible to pressure ulceration (see skin condition above) Tissue Malnutrition Some conditions can reduce blood flow through the arteries and capillaries. This can result in poor perfusion of the tissue. The addition of pressure when circulation is already poor can increase the risk of damage Surgery Immobility during and after surgery may result in pressure damage. The longer the surgery, the greater the risk of pressure damage (Clinch 1996). Some patients may need to be cared for in certain positions post operatively, (e.g upright) limiting the extent to which they can be repositioned Anaesthetics and analgesia can prevent patients from experiencing pain associated with pressure damage. It is important to inform them that they may be at risk and closely monitor skin condition Patients undergoing surgery will have a raised Waterlow score for 48 hours post operatively however this may be for longer if their post-operative recovery is slow Neurological Deficit Damage to the nerves can prevent patients being aware that they are experiencing pressure damage Other factors requiring consideration are: Page 9 of 35

12 Acute, chronic or terminal illness Co-morbidity, (e.g. pain, infection, medication) Body temperature Posture Psychosocial issues Exposure to pressure, shear or friction prior to admission When a patient is identified as at risk of pressure ulceration action is required to reduce or manage the risks to prevent tissue damage occurring. The following sections focus upon risk management and the prevention of tissue damage Skin Assessment The key principles of skin assessment are as follows: All patients to have a top to toe skin assessment immediately or within six hours of admission to hospital. Following a lower limb fracture, assessment must be undertaken within one hour of admission. This is to be recorded on the Waterlow assessment page in the patient profile by circling YES or NO and recording the skin condition in the specific pressure damage box at the bottom of the page. All patients to have a repeat skin assessment following transfer to a new clinical area or to theatre. This is to be recorded on the skin assessment sheet which is found on the back of the CARE round documentation. (CHA3061) Following admission, all patients at risk of pressure damage, Waterlow 10-14, require a daily skin assessment. For all patients at high risk of pressure damage, Waterlow 15-19, a twice daily skin assessment is required. For all patients at very high risk of pressure damage, Waterlow 20+, a three times daily skin assessment is required. All ongoing skin assessments must be recorded on the skin assessment sheet which is found on the back of the CARE round documentation. A daily skin assessment should be viewed as a minimum standard Maintaining healthy skin: The following principles should be considered in maintaining healthy skin: Keep the skin clean and dry, but do not let it dry out. Avoid excessive moisture from urine, faeces, wound exudates, saliva and perspiration, as this can increase the risk of friction and shearing, reduce skin integrity and lead to maceration. Cleanse the skin with a soap substitute. Page 10 of 35

13 Use emollients on a regular basis to prevent skin dehydration. Avoid using talcum powder and excessive rubbing of the skin. Use skin barrier products topically to protect the skin from excessive moisture and potential irritants. Ensure that the patient has adequate nutritional and fluid intake Grading Pressure Damage Pressure damage is graded according to severity and depth as follows: Grade one Grade two Grade three Grade four Non blanching erythema Red discolouration of the skin that does not blanch when pressed Blistering or abrasion Partial thickness skin loss involving the epidermis and possibly the dermis Full thickness skin loss (visible fat) Full thickness skin loss involving the epidermis, dermis and sub-cutaneous layer, but not extending into the fascia Deep ulcer Extensive destruction of fascia, muscle and bone, with or without skin loss Tissue necrosis Blue/purple/black colouration of the skin Note: Hard necrosis and or blue/purple discolouration of the skin may indicate deep tissue damage and must be treated as grade 4 pressure damage unless identified as otherwise. If the grade remains difficult to determine the tissue viability team must be contacted for advice and a period of watchful waiting may be required Management of Pressure Ulcers The most important factor in management of pressure damage is pressure relief. Repositioning and use of pressure reducing/relieving equipment is key When pressure damage does occur the position, grade and appearance of the ulcer needs to be assessed and documented, and care planned to reduce the risk of any deterioration in skin condition. A holistic assessment is required with specific consideration given to repositioning, nutrition, continence, mobility, psychosocial issues and pain (EPUAP 1998) Any breaks in the skin should be treated as wounds and dressed to protected them from infection and promote healing. Debridement should only be carried if the tissue is well perfused, otherwise necrotic tissue should be left dry. The Dressing Page 11 of 35

14 Selection Guideline in the Wound Care Guidelines can be used to support clinical decision making Patient Information It is essential to ensure patients, relatives and carers are aware of the risk of pressure damage. Patient information should include: What is a pressure ulcer Who is at risk What to do to prevent damage What to look for When and how to report changes in skin condition Repositioning Where to go for further information All clinical areas should keep copies of the Trust information leaflet available for patients and carers. This can be obtained from the publications department, Leaflet No Additional resources available to patients and carers and staff include NICE, NHS Direct and the Your Turn website Where possible patients should be involved in decision making regarding their care, these include repositioning times, and use of pressure relieving equipment. (EPUAP 1998; NICE 2005) Patient Repositioning All patients at risk of pressure damage should be repositioned if it is safe to do so. Medical condition, comfort and over all care (e.g. physiotherapy) need to be considered and incorporated into a turning plan (Bonomini 2003) Timing of repositioning is determined by individual assessment of the patient s risk and the skin s response to pressure Repositioning should be done in a way that does not put pressure on bony prominences. Tilting the patient 30º and placing a pillow in the small of the back to relieve pressure on the sacrum and ischial tuberosities can be effective. Pillows can also be used lengthways along the calf to raise the heels, protecting them from the surface below The use of an electronic profiling bed can assist in repositioning without turning. Reduce shear factors by maintaining the head position at the lowest position possible. The use of the knee break will also help to break heel pressure It is an important part of recovery to allow patients to sit out in a chair, however where the patient is at risk of damage, or has a pressure ulcer, a pressure reducing cushion should be used and sitting out limited to two hours at a time. The patient s seating position may influence the development of a pressure ulcer, therefore the correct size chair should be used and the patient observed to ensure he/she is comfortable and not at risk of sliding (Collins 1999). Page 12 of 35

15 6.69. The patient s position must be recorded on the Skin Assessment Tool at every assessment of skin condition or when he/she is repositioned Care of Patients Nursed on Trolleys If a patient is lying on a trolley for more than 1 hour the trolley must have a pressure reducing high density foam surface If patients have a Waterlow score of 10 or above they must not be on trolleys for more than 4 hours Patients with existing pressure damage must be placed on a bed with the correct mattress as soon as possible after admission The flow chart below provides guidelines for the prevention of pressure damage: Patient has a pressure ulcer grade 2 or above Patient at high or very high risk or has grade 1 damage Patient is at risk but skin intact Place on a bed with an alternating pressure mattress as soon as possible Encourage repositioning at least hourly, monitor skin, transfer to a bed within 4 hours. Reassess skin every 4 hours Encourage repositioning. Reassess skin and Waterlow No bed availablereposition at least hourly and prioritise finding a bed If skin condition deteriorates, transfer to a bed and alternating mattress NICE (2005) recommend that all patients with grade 2 or above pressure damage should be nursed on alternating pressure mattresses, therefore trolleys are not recommended for these patients Patient Nutrition All patients should be assessed on admission and reassessed throughout their stay, for the nutritional risk using the MUST tool. All nutritional care requirements should be implemented according to the patient s level of risk and a care plan must be in place Patient Continence Page 13 of 35

16 6.79. All patients should be assessed on admission and throughout their stay for their continence status. Care must be planned according to the risk of skin damage and their level of incontinence. See section 8, Skin Assessment Equipment Selection Guidelines for equipment selection based on individual patient assessment can be found in Appendix 2. Types of equipment are listed in Appendix All patients will be provided with a pressure reducing high density foam or viscoelastic foam mattress An alternating pressure mattress is required when: The patient is assessed as being very high risk via the Waterlow and/or holistic factors When the patient is unable to reposition independently or with assistance When the patient has a pressure ulcer grade 2 or above The following factors also need to be considered: Patient comfort The patient s ability to reposition on the mattress Patient choice Site of pressure damage When patients with or at high risk of pressure damage sit out in the chair a pressure reducing cushion is needed All staff are responsible for attending training on specific pressure relieving equipment and the equipment library staff will inform the wards of training dates The Range of Equipment Guide (Appendix 3) outlines all equipment available from the equipment library Heels- Placing a pillow from the ankle to below the knee allows the heel to be free from pressure, and is an acceptable method of relieving the pressure. Heel troughs, heel pads or Heelift boots can also be used to protect the heels (see Heel pressure ulcer prevention, equipment selection guide appendix 3) Obtaining Equipment Pressure reducing and alternating pressure mattresses are available from the equipment library and can be obtained by contacting extension 3049 or bleep 2951, between 08:00 and 16:00. Outside these hours when a mattress is required, reassess all patients in your clinical area to determine whether anyone can be stepped down to a high density foam mattress If not, contact the porters on extension 3700 as they have a list of available equipment. If there is none available, please contact the other wards to check for availability. The Repose overlay mattress is available in clinical areas for out of hours Page 14 of 35

17 use. These are to be considered for short term use (maximum 72hours) and a full replacement mattress should be obtained as soon as possible For clinical advice on pressure relieving equipment please contact the tissue viability service on bleep To ensure alternating pressure mattresses are utilised effectively, patients should be reassessed and stepped down onto a pressure reducing surface as soon as possible. Mattresses should then be cleaned, labelled and returned to the equipment library Static mattresses not in use should be cleaned, labelled and returned to the equipment library for storage A selection of cushions and heel troughs are available from the Equipment library. When there are none in stock it will be necessary to contact other wards to obtain these resources Heelift heel protectors are single patient use only and can be obtained from the Equipment Library on completion of an Appliance form. Repose Heel wedges and boots are also available in some clinical areas Discharge of Patients Requiring Specialist Equipment For discharge to patients own home or residential home Ward staff to identify the type of pressure relieving equipment required Grade 2 pressure damage but can move independently Grade 2 pressure damage or 20+ Waterlow score but unable to move independently Grade 3 / 4 pressure damage High density or Visco foam mattress Dynamic overlay mattress Dynamic replacement mattress Consider the need to provide cushions for high risk seated patients and also heel protection where appropriate Consider the needs of palliative care patients as they may require a higher specification of support surface Discuss requirements with ward based Occupational therapists who will order the equipment via the Community Loan Store system (CELS) Where possible ensure equipment is requested at least 48 hours in advance of the discharge date. Once the order is vetted by the Community TV team (usually on the same day) the equipment is ordered Equipment will usually be delivered to the patient s home within hours For patients being discharged to nursing homes: Page 15 of 35

18 Equipment is provided for the treatment of pressure ulcers. It is the nursing homes responsibility to provide equipment for prevention unless there are special circumstances such as end of life care Discuss requirements with the Discharge Liaison Nurses who will liaise with the Community Tissue Viability team regarding funding. Complete the relevant continuing health care needs form The Community TV team will then organise the equipment where appropriate: equipment should not be ordered via the CELS system for these patients Ensure that discharge planning is started early to allow for timely provision of equipment. At least 24 hr notice is required in order to put equipment in place for patient discharge to home. The Occupational Therapist or Discharge Liaison Nurse will confirm when the equipment is in place, to then enable the discharge to proceed Cleaning & Decontamination of Equipment and Reporting Faults Reporting Faults- All mattresses must be checked between patients for cover, foam, and operational faults. Any equipment not fit for use must be dealt with as detailed in the table below in section Static foam mattresses that are no longer fit for use must be condemned when: The cover is damaged and fluids permeate through to the foam The foam has bottomed out and the base of the bed can be felt through the mattress Alternating pressure mattresses should be set up in accordance with the manufacturer s instructions for use. When a mattress fails to work correctly ensure: It is correctly attached to the mains and switched on It is not in static mode The setting are adjusted in accordance with patient need The CPR is not activated Cleaning & Decontamination- All pressure relieving equipment should be cleaned prior to returning to the equipment library following the Trust Decontamination Policy and the guidelines below Decontamination of pressure reducing/relieving equipment is carried out through cleaning or disinfection depending on the extent to which the equipment is exposed to bacteria which are likely to cause infection Clean all mattresses between patients with mild detergent and warm water, paying particular attention to the mattress folds and loose flaps. Rinse and dry thoroughly. Page 16 of 35

19 If soiled with body fluids, a chlorine releasing agent such as sodium hypochlorite and di-isochlorocyanurate (NaDcc) e.g. Actichlor, can be used to clean the mattress in line with RCHT Decontamination Policy Please follow the guidance in the table below for specific cleaning and disposal of mattresses. Mattress Normal Working Hours Out of Hours STATIC- Clean, not condemned, no longer required ALTERNATING- Clean, not faulty, no longer required ALTERNATING- Faulty STATIC- Dirty/ condemned ALTERNATING- Contaminated Clean mattress as per policy. Attach clean label and send mattress to Equipment Library via the Porters Clean mattress as per policy. Place in clear plastic bag. Label as clean and return to the Equipment Library via the Porters Clean as above. Contact the Equipment Library to report the fault (x 3049) and return to the library with a fault label attached Place mattress in a large clear bag (available to order via EROS). Label as condemned and leave message for the Equipment Library (x3049). Label as condemned and leave the mattress on the ward for the Equipment Library to check as soon as possible. Replacement mattresses can be requested via the Porters Clean mattress as per policy. Place in large clear bag. Label as contaminated and contact the Equipment Library staff (x3049). Return to the Equipment Library via the Porters As per normal working hours As per normal working hours As per normal working hours As per normal working hours. A condemned mattress should no be left on a ward for more than 72 hours once reported. As per normal working hours Reporting of Pressure Damage When a pressure ulcer occurs or deteriorates, re-assessment of the patient and the grade, position and appearance of pressure damage must be documented. A new care plan should reflect intervention to heal existing ulceration and prevent further damage All pressure ulcers should be reported as follows: Grade 1 & 2 on Safety Cross and Datix. Root cause analysis to be completed as part of Datix investigation Grade 3 and 4 on Safety Cross and Datix. A Serious Incident (SI) is to be completed on all hospital acquired Grade 3 and 4 pressure ulcers. See Appendix 4 for SI process. Page 17 of 35

20 When reporting pressure ulcers on the DATIX system the report must include: Patient details Grade of pressure damage Site of pressure damage Hospital or non-hospital acquired damage Equipment in use Action taken to manage the increased risk Where skin damage occurs in a vulnerable adult the Reporting Skin Damage in a Vulnerable Adult as Safeguarding Alert guidance should be followed. This can be found in the Safeguarding Adult folder kept in the clinical areas Audit/ Monitoring The following audit activity will be undertaken. The results will be reported through the RCHT Quality Action group. This is detailed in the Standard Operating Procedure (SOP) in Appendix 5. Audit / Outcomes Frequency Method Persons Responsible Pressure Ulcer Monthly Data obtained from Tissue Viability Team Incidence DATIX. SKIN bundle and risk assessment and care planning compliance Monthly Quality Care indicators Ward sisters / charge nurses / matrons Alternating and Static mattress audits Annually All available mattresses checked within the Trust Equipment Library Manager Complaints and Legal All complaints relating to pressure ulcers will be investigated by the Divisional teams with support from the Tissue Viability team. See Appendix 6 for the complaint response process There is a very robust legal process that must be followed in the event of a claim against the Trust. (See Appendix 7) 7. Dissemination and Implementation 7.1. This policy, once ratified, will be stored electronically on the Trust s Document Library The Senior Nursing teams across the Divisions will be made aware of the updated policy and will be responsible for the dissemination of the information within. 8. Monitoring compliance and effectiveness Page 18 of 35

21 Element to be monitored Lead Tool Frequency Reporting arrangements Incidence reporting Heather Newton Monthly Divisional Nurses will receive report monthly Divisional teams will report via the Divisional Quality and Learning group action plans and SI and CI outcomes Governance Committee will receive exception reports Acting on recommendations and Lead(s) Change in practice and lessons to be shared Divisional Nurses will be responsible for leading the actions/changes required to improve compliance Changes will be monitored and reported monthly as part of the report. Divisional Nurses will discuss findings and actions at the Pressure ulcer quality action group monthly. 9. Updating and Review 9.1. This is managed via the document library. Review will be undertaken every two years unless best practice dictates otherwise. 10. Equality and Diversity 10.1.This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 19 of 35

22 Appendix 1. Policy Mobile Summary Summary guidance published separately available via Document Library (search for pressure ulcer prevention or click here) Page 20 of 35

23 RE- ASSESSMENT ACTIONS ASSESSMENT Appendix 2. Pressure Ulcer Prevention Clinical Pathway New Patient to RCHT Immediately and within 4 hours: - Pressure Ulcer Risk Assessment - Skin Assessment On transfer to new clinical area, if condition changes or on discharge- - Pressure Ulcer Risk Assessment - Skin Assessment AT RISK: HIGH RISK: VERY HIGH RISK: >20 OR if patient has Grade 2, 3 or 4 pressure ulcer Surface- Static Mattress Skin Assessment- Daily Keep Moving- Encourage patient to reposition/ mobilise Incontinence- Assess continence status and plan care accordingly Information- Provide patient leaflet Nutrition- Assess Nutritional Status and plan care accordingly Surface- Static Mattress Skin Assessment- Twice daily Keep Moving- Reposition 2, 4, or 6 hourly depending on skin tolerance Incontinence- Assess continence status and protect skin Information- Provide patient leaflet Nutrition- Assess Nutritional Status and plan care accordingly Surface- Dynamic Air Mattress Skin Assessment- Three times daily Keep Moving- Reposition 2, 4, or 6 hourly depending on skin tolerance Incontinence- Assess continence status and protect skin Information- Provide patient leaflet Nutrition- Assess Nutritional Status and plan care accordingly Risk Assessment- Weekly unless condition changes Risk Assessment- 3 x weekly unless condition changes Risk Assessment- Daily Skin Assessment- Daily Skin Assessment- 2 x daily Skin Assessment- 3 x daily Page 21 of 35

24 Appendix 3. Pressure Relieving Equipment Selection Guidelines If patients are at risk or have pressure ulcers the following guidelines should be used to select appropriate equipment. If patients have heel pressure ulcers, heel troughs, heel boots or gel pads should be considered with or without dynamic mattresses, depending on clinical need. Use bed cradles to relieve pressure of bed clothes on heels. Where patients have a manual handling need electric profiling bed frames should be used. PATIENTS AT RISK PATIENTS AT HIGH RISK PATIENTS AT VERY HIGH RISK No damage/grade 1 Grade 2 4 No damage/grade 1 Grade 2 4 No damage/grade 1 Grade 2-4 High specification Dynamic replacement High specification Dynamic replacement Dynamic replacement Dynamic replacement foam mattress mattress foam mattress mattress mattress mattress Reposition according Reposition according Reposition according Reposition according Reposition according Reposition according to clinical need to clinical need to clinical need to clinical need to clinical need to clinical need Foam cushion Foam cushion Memory foam or Memory foam or Memory foam or Gel cushion if patient Gel cushion Gel cushion can reposition or Alternating pressure cushion Limit time sat out Electric bed frame Electric bed frame Electric bed frame Page 22 of 35

25 Appendix 4. Range of Equipment Guide HIGH SPECIFICATION FOAM MATTRESS PENTAFLEX WEIGHT SUPPORT 39 STONE (248kg) TRANSWAVE SUPREME WEIGHT SUPPORT 39 STONE (248kg) MEMAFLEX MEMORY FOAM WEIGHT SUPPORT 39 STONE (248kg) PERMAFLEX PLUS SUPPORT 39 STONE (248) OUT OF HOURS / SHORT TERM USE STATIC OVERLAY REPOSE OVERLAY MATTRESS 21 STONE (139KG) DYNAMIC HIGH RISK REPLACEMENT MATTRESS NIMBUS 3 WEIGHT SUPPORT 39 STONE (248kg) QUATTRO ACUTE WEIGHT SUPPORT 39 STONE (248kg) PHASE III WEIGHT SUPPORT 36 STONE (229kg) FOAM CUSHION GEL CUSHION HEEL PROTECTORS MEMAFLEX WEIGHT SUPPORT 20 STONE (127kg) DYNAFLEX FLO-TECH WEIGHT SUPPORT 20 STONE(127kg) SOFTFORM GEL SACS REPOSE HEEL WEDGES AND BOOTS HEEL TROUGHS HEEL LIFT SUSPENSION BOOTS Page 23 of 35

26 Appendix 5. Serious Incident (SI) Reporting Process Process for reporting Serious Incidents (SI s): Hospital Acquired Grade 3 and 4 Pressure Ulcers A patient develops a grade 3 or 4 pressure ulcer following admission to hospital Incident reported on Datix and TV team informed by risk and safety team TV team confirms Grade of of pressure ulcer. If Grade 3 or 4 hospital acquired, the patient is offered an apology and the investigation process is discussed. An entry is made in the patient s records to evidence compliance with the Being Open policy. Incident is declared as a Serious Incident Once SI is declared, risk and safety team send the 72 hour form, SI tool and Being Open template letter to the relevant Divisional Nurse who will allocate and Investigating Officer. 72 hour form to be competed at this stage. Completed SI report to be returned to risk team within 15 days, with outcomes and action plan TV Consultant Nurse to review SI report and finalise prior to sending to executive lead for sign off Report uploaded to Divisional SI action plan log on the shared drive Report sent to PCT SI themes shared with Pressure Ulcer Quality Action Group and Matrons to ensure shared learning Page 24 of 35

27 Appendix 6. Standard Operating Procedure (SOP)- RCHT Pressure Ulcer Prevention Data Collection IT IS THE RESPONSIBILITY OF ALL USERS OF THIS SOP TO ENSURE THAT THE CORRECT VERSION IS BEING USED Staff must ensure that they are adequately trained in the process and must make sure that all copies of superseded versions are promptly withdrawn from use unless notified otherwise by the SOP Controller. If you are reading this in printed form, check that the version number and date below is the most recent one as shown: SOP Reference: Version Number: Author: Implementation date of current version: Approved by: Name/Position: Signature: Date: Name/Position: Signature: Date: V2 Heather Newton 31 st January 2013 This SOP will normally be reviewed every 2 years unless changes that require otherwise Version History Log This area should detail the version history for this document. It should detail the key elements of the changes to the versions. Version V1 March 2012 V2 January 2013 Date Implemented March 2012 Details of significant changes January 2013 Data collection methodology has changed. Changes made to reflect Incidence monitoring Data collection changed to reflect the need to count number of pressure ulcers as well as number of patients. Regional Quality Improvement Framework now in place detailing specific organisational requirements. SOP updated to reflect Governance pathway, Divisional structures for reporting and learning from incidents and complaints Page 25 of 35

28 1 Purpose 1.1 This RCHT Pressure Ulcer Prevention SOP will guide the process of collecting data from Incident reporting, the Safety Cross and patients notes. Compliance with this data set is required as part of the NHS Safety Thermometer and the South West Quality and Patient Safety Improvement Programme (SWQPSIP). 1.2 This SOP reflects the commitment by the RCHT to monitoring pressure ulcer incidence with the overall aim to eliminate avoidable pressure ulcers and take a zero tolerance approach. 1.3 The objective is to achieve a level of understanding at ward level of why the data is required, how it is to be collected and when it is to be collected. This will provide assurance that the data collected is valid, robust and meaningful; in order to reduce all avoidable pressures ulcers in our care. 2 Who Should Use This SOP? 2.1 This SOP will be used by the Clinical teams who will be collecting the data. Clinical Matrons and Divisional Nurses will also have an understanding of the implications and the relevance of the data to improving quality, patient s safety, and harm free care. 2.2 The Tissue Viability team will use the data collected to analyse and report findings and required actions to the Senior Nursing and Executive teams. 3 When This SOP Should Be Used 3.1 This SOP may be subject to change and it is therefore the responsibility of all users to ensure that the most up to date version is being used. 3.2 Pressure Ulcer Incidence data will be collected using information from the Incident reporting system (Datix) 3.3 Pressure Ulcer Incidence (Quantitative data) When a patient develops a hospital acquired pressure ulcer this is to be reported as a clinical incident on the Incident reporting system (Datix) The ward sisters and charge nurses together with the Clinical matrons are responsible for ensuring that this information is correct on the system Incidence data is to be collected and analysed by the Tissue Viability Consultant Nurse at the end of each month. Outcomes will be reported to the Divisional teams and Governance committee as follows -Total number of patients with pressure ulcers both hospital and non-hospital acquired -Total number of pressure ulcers reported -The incidence (rate) of patients with hospital acquired pressure ulcers based on patient activity per 1000 bed days (SWQPSIP target) Page 26 of 35

29 -Pressure ulcers by Grade and Site (CQC and SHA targets) Any hospital acquired Grade 2 pressure ulcers will be investigated using a Root cause analysis methodology. Any hospital acquired Grade 3 and 4 pressure ulcers will be reported as Serious Incidents and investigated accord to Trust policy. Pressure Ulcer Risk Assessment, Care Planning and Skin Bundle compliance (Qualitative data) This data is to be collected by the ward teams on a monthly basis using the Quality care indicators This will include pressure ulcer risk assessment, care planning, skin assessment and compliance with the SKIN bundle all of which are required as part of the SWQPSIP programme. Safety Cross pressure ulcers The safety cross is to be completed at ward level to identify patients that develop pressure ulcers or are admitted with pressure ulcers. If there are no patients with pressure damage then this is reflected on the cross. At the end of the month the ward sister / charge nurse uses this information to reflect on the quality of care provided and the days between pressure ulcer incidents. This information is also used when collecting safety thermometer data. Safety Thermometer pressure ulcers This data will be collected from all in patient areas on one day each month by the ward / dept teams. The worse new and the worse old pressure ulcers will be reported by Grade. Old are defined as being present on admission and occurring within 72 hours of admission with new being those that developed 72hours after admission. Electronic data will be sent to a National database. 4 Procedure(s) 4.1 Procedure for the collection of pressure ulcer qualitative data using the Safety Cross. A new safety cross sheet is to be used per month. Complete ward, month and year on the form Complete the sheet on a daily basis. If no new pressure ulcers have developed please mark as an incident free day. When a new pressure ulcer develops record the incident by marking a red cross on the relevant date on the safety cross sheet. Complete the back of the form. If a patient is admitted with pressure damage mark with a blue cross. Complete the back of the form. Complete the information on the back of the sheet relevant to the specific pressure ulcer incident as follows: Page 27 of 35

30 1. Date of incident which corresponds with X on the safety cross 2. Patient ID required to ensure relevant investigations are undertaken on the right patient 3. Grade of pressure ulcer required for more detailed analysis 4. Site of pressure damage - required for more detailed analysis 5. Datix reference number required to remind staff that ALL pressure ulcers are to be Datixed as an incident. At the end of each month ward staff are to reflect on the number of incidents and implement actions to reduce the number of incidents for the following month. 4.2 Procedure for the collection of pressure ulcer qualitative data using the clinical care indicators. All wards and departments to collect quality data using the clinical care indicator metrics. This includes qualitative data relating to pressure ulcer risk assessment and care planning, skin assessment and skin bundle. 10 sets of patient records to be reviewed and evidence of compliance recorded on a central data base Page 28 of 35

31 Appendix 7. Complaints Response Process Letter of complaint received which involves the development of a hospital acquired pressure ulcer Complaint vetted by Patient Support Co-ordinators and details are checked top identify if reported on Datix and/or if an SI investigation is in process or completed If high risk, ie grade 3 or 4, refer to SI process Complaint letter and other relevant paperwork is sent to the divisional Investigating Officer and cc d to the TV Consultant Nurse Divisions investigate and respond to complaint TV Consultant Nurse or TV CNS investigates and provides response where relevant TV Consultant Nurse or TV CNS reviews complaint response If further issues are highlighted, response is sent back to the divisions for outcomes to be shared for learning and service improvements to be made Draft CEO response is written and/or meeting with complainant is held to resolve issues where possible Page 29 of 35