Pressure Ulcer Grading and POVA Referral Procedure Version Number: 1 Page 1/13
-Contents- Page 1. Introduction 3 2. Aim 3 3. Procedure 3 4. Responsibilities 4 5. Implementation and Training 4 6. Equality 4 7. References 4 Appendix 1 Appendix 2 Appendix 3 Pressure Ulcer grading chart Pressure Ulcer Report (IR6) Va1 and VA1a forms Appendix 4 NICE Guidelines (2005) Version Number: 1 Page 2/13
1. Introduction ABM University Health Board 2. Aim There has been a marked increase in the number of Protection of Vulnerable Adult (POVA) referrals received by the Health Board with respect to pressure ulcers. Most of the referrals are for patients who are admitted to hospital from their own homes or from Nursing and Residential Homes. These usually fall under the category of alleged/suspected neglect however this procedure also applies when a patient develops a pressure ulcer in hospital. The rationale behind the procedure is: To give guidance on the correct grading of pressure ulcers through the Pressure Ulcer Grading Chart (see appendix 1). To implement a uniform approach to grading pressure ulcers across the Trust. To remind Staff that this procedure is based on the Nice Guidelines for Pressure Ulcers (2005), the ABM University Health Board Adult Safeguarding Policy, and the Inter-Agency Policy & Procedures for Responding to Alleged Abuse and Inappropriate Care of Vulnerable Adults in South Wales (2004). This Procedure aims to assist staff in grading and treating pressure ulcers and making a POVA referral. 3. Procedure 3.1 Referral Procedure A Pressure Ulcer Report Form IR6 (appendix 2) must be completed for all pressure ulcers of grade 2 and above. A POVA referral VA1 and V1a (see appendix 3) must be completed for all pressure ulcers where there is suspected abuse. Staff completing a VA1 form and VA1(a) form must immediately submit the form to their line manager on identifying a pressure ulcer where abuse is suspected. The Line Manager must submit the VA1 and VA1(a) to the Designated Lead Manager (DLM) of each Directorate (the DLMs are the Head of Nursing or their deputies) or in the case of community patients to the POVA Co-ordinator in Social Services. 3.2 Staff Response to Caring for Patients with/at risk of Developing Pressure Ulcers Nice Guidelines must be followed (see appendix 4) Version Number: 1 Page 3/13
3.2 DLM Response to Pressure Ulcer Referrals The Health Board DLM must forward the VA1 and VA1(a) to the POVA Coordinator in Social Services within 24 hours of receiving it from staff. The DLM must ensure that staff liaise with health colleagues involved in the care of the patient. A POVA Strategy Discussion or Meeting must be held with partner agencies to present facts and adopt a staged and measured response in light of available information and, if necessary prepare an interim Adult Protection Plan. This must be undertaken within 48 hours of the VA1 being received by the DLM. 4. Responsibilities This procedure applies to all clinical staff who are involved in direct patient care. It is the responsibility of each professional group to ensure that this procedure is followed (see section 3). 5. Implementation and Training Training in the use of this procedure is being undertaking in the current POVA Level 2 and 3 training as well as during the wound healing training carried out by the Trust. This guidance can also be found on the POVA section of the Trust Intranet site and on posters where made available. 6. Equality This procedure has had an equality impact assessment and has shown there has been no adverse effect or discrimination made on any particular or individual group. 7. References Nice Guidelines - The prevention and treatment of pressure ulcers (2005) EPUAP - Guidelines Pressure Ulcer Classification Guidelines (2005) SWAP Forum - Inter-Agency Policy & Procedures for Responding to Alleged Abuse and Inappropriate Care of Vulnerable Adults in South Wales (2004). Version Number: 1 Page 4/13
Pressure Ulcer Report Form IR6 ABM University Health Board Appendix 2 To be completed by the Ward or Department involved in the incident IN BLOCK CAPITALS & Black ink Date: Patient/Client name: Date pressure ulcer identified in present environment Is the pressure ulcer new? (if the pressure ulcer is new also complete form IR3) If the pressure ulcer is not new, where was the patient/client cared for prior to admission to present environment? State location/ward/hospital where pressure ulcer FIRST identified (i.e.ward 2 POWH/patients home) Pressure ulcer risk assessment score i.e. Waterlow score (if other tool used please state name of tool & score) Was patient admitted to hospital as an emergency? List all equipment used for pressure relief (include make of foam mattress if used) Was there any delay in obtaining this equipment? If YES give description PRESSURE ULCER CLASSIFICATION (EUPAP) Grade 1 NON BLANCHING ERYTHEMA, unbroken red area that does not blanch when pressed Grade 2 BLISTER/ABRASION, partial thickness skin loss, involving epidermis, dermis or both Grade 3 SUPERFICIAL ULCER, full thickness skin loss, damage/necrosis to subcutaneous tissue Grade 4 DEEP ULCER, extensive destruction, damage to muscle, bone or supporting structures Site & Grade of pressure ulcer(s) Sacrum Buttock R Buttock L Heel R Heel L Other Grade Reason for admission to current care environment & main diagnosis: Does the patient have: Congestive heart failure yes/no Sepsis: yes/no Respiratory failure: yes/no Renal failure: yes/no This form must accompany (stapled to) the associated Trust Incident Report Form Version Number: 1 Page 5/13
VULNERABLE ADULT PROTECTION REFERRAL FORM Appendix 3 THIS FORM MUST BE COMPLETED IN ACCORDANCE WITH THE INTER-AGENCY POLICY AND PROCEDURES FOR RESPONDING TO ALLEGED ABUSE OR NEGLECT OF VULNERABLE ADULTS IN SOUTH WALES Social Services I.D. No. Date VA1 received by DLM.... SECTION 1 FOR COMPLETION BY THE PERSON MAKING THIS REFERRAL 1. ABOUT THE VULNERABLE ADULT (Subject of referral) Full Name: Address: Tel. No: Male Female Age : D:O:B: Ethnic Origin: Religion: Single Married Divorced Other Specify GP (if known) Personal Circumstances (Specify whether alleged victim resides in a Care Home, Hospital, domestic or other setting and whether they are subject to any legislative powers, e.g. under the Mental Health Act) 2. ABOUT THE ALLEGED ABUSE (The VA1 (a) Body Map form should be completed and attached to this form to record any injuries which are alleged to have resulted from abuse) Category of Abuse (tick all that apply) Physical Sexual Emotional/Psychological Financial/Material Neglect VA1 Body Map form completed and attached: Yes No Date and Time Alleged Abuse Took Place: Version Number: 1 Page 6/13
Place of Alleged Incident Circumstances of alleged abuse (continue on separate sheet if necessary) 3. WHAT ACTIONS HAVE BEEN TAKEN TO REDUCE OR REMOVE THE RISK/S TO THE VULNERABLE ADULT? 4. MENTAL CAPACITY AND CONSENT Does the vulnerable adult have the understanding to consent to this referral being made? Yes No Not sure If yes, do they agree to any actions which may subsequently follow by way of protection or investigation? Yes No Not sure Is the vulnerable adult aware that this referral has been made? Yes No Not sure The lack of consent does not necessarily mean that Adult Protection procedures will not be invoked. 5. ABOUT THE PERSON WHO IS ALLEGEDLY RESPONSIBLE FOR THE ABUSE (If unknown at present - state 'unknown at present') Name: Home Address: (work address if paid carer) Tel No: Mob No: Age D:O:B: Relationship to alleged victim (if any) Employing Agency &Title/Role (if any) Is alleged perpetrator a vulnerable adult? Yes No Not known Is alleged perpetrator aware of referral? Yes No Not known Version Number: 1 Page 7/13
If 'Yes' to either of the above, provide details: If more than one person is suspected of carrying out the alleged abuse, tick box and include details on a separate sheet of paper and attach to the VA1 6. ABOUT THE PEOPLE WHO WITNESSED THE ALLEGED INCIDENT(S) OR CONCERN(S) (i) Name: Contact Address: (work address if paid carer) Tel No: Mob No: D:O:B: Relationship to victim (if any): Is witness a vulnerable adult? Yes No Not Known Is witness aware of referral? Yes No Not Known (ii) Name: Contact Address: (work address if paid carer) Tel No: Mob No: D:O:B: Relationship to victim (if any): Is witness a vulnerable adult? Yes No Not Known Is witness aware of referral? Yes No Not Known NB. If more than 2 witnesses are identified, record details on separate piece of paper and attach to the VA1 7. ABOUT THE PERSON(S) REPORTING THE ALLEGED INCIDENT(S) OR CONCERN(S) (This relates to the first person to draw attention to the alleged abuse that is the subject of this disclosure, concern or direct referral) Name: Contact Address: Tel No: Version Number: 1 Page 8/13
Occupation: Relationship to Adult (alleged victim): Date/Time Reported Referral made: In person By Telephone Other Means If by Other Means, 8 WHO WAS THE REPORT FIRST MADE TO? Social Services Health Police CSSIW Other Agency Name: Agency: Date & Time reported : 9. DOES THE REFERRER WISH TO REMAIN ANONYMOUS? NB any request for anonymity must be considered in light of the Public Interest Disclosure Act 1998. However, if a qualified member of staff is reporting they may be bound by their professional code to support an investigation. Yes No If 'Yes' state reasons (if willing to provide these) 10. DETAILS OF PERSON COMPLETING THIS FORM Name (print): Designation: Agency: Contact Tel No: Mob No: Time/Date VA1 referral completed: Signature of person completing this referral form: NB. Details of this referral must be reported to your line manager/duty line manager without delay. If your line manager is unavailable, this should not delay the submission of this form. Version Number: 1 Page 9/13
SECTION 2: FOR COMPLETION BY LINE MANAGER/SUPERVISOR ONLY 11. ADDITIONAL INFORMATION AND COMMENTS Line Managers are reminded that they have a responsibility to: Evaluate reliability of source of information Consider the wishes of alleged victim, their mental capacity and the provision of informed consent in relation to this VA1 referral Confirm the alleged victim is informed of the reasons for any referral to the Police and that they understand the consequences of taking such action Collate any available information Record decisions and actions taken to date Submit VA1 referral without delay 12. DETAILS OF LINE MANAGER/SUPERVISOR Name of Line Manager (print): Designation: Contact Tel No: Mob No: Time/Date Notified: VA1 faxed to Agency DLM: Signature of Line Manager: CONSIDERATIONS GOVERNING THE USE OF E-MAIL AND FAX FOR THE TRANSFER OF CONFIDENTIAL OR SENSITIVE INFORMATION: Confidential and sensitive information must not be sent by e-mail over the internet unless encrypted. If transferring this information via a fax, this must be sent to a known recipient who must be notified in advance so that they may make arrangements to receive and collect the information. Version Number: 1 Page 10/13
South Wales Adult Protection Forum VA1 (a) Body Map ABM University Health Board VA1 Referral Form Supplement Name of Vulnerable Adult: Date of birth: Social Services I.D. No.(if known) Date referral made to DLM: VA1(a) Body Map is to be used in conjunction with the VA1Referral form by practitioners to record the location, size and number of injuries which may have been caused as a result of abuse or inappropriate care (as a precursor to medical/police photography). Where used, the completed VA1(a) Body Map should be submitted with the VA1 Referral form. Please draw on the body map in black ink, using the following key to indicate the different types of injury (shading or alphabetic code), and provide brief details for each injury, e.g. measurements of wound, colour of bruise, etc using arrows (a ruler is provided to assist with measurement): A - Pressure ulcers B - Bruising C - Cuts, wounds D - excoriation, red areas (not broken down) E-Scalds, burns F-Other-specify Version Number: 1 Page 11/13
Body Map notes: ABM University Health Board Note any other details, such as anything the vulnerable adult discloses on examination (verbatim), or information received from any other source regarding injuries. Please use the space below to make any close-up drawings of body parts/injuries highlighting where they appear on the above body map, e.g. injury to ears, genitalia, fingers etc. Name/designation of person completing Body Map form: Contact details of person completing Body Map Form: Date/time of completion: (NB. When used, completed VA1(a) Body Map form should be attached to completed VA1 Referral form) Version Number: 1 Page 12/13
Nice Clinical Guidelines (2005) Appendix 4 Patients at risk of developing pressure ulcers should receive a Pressure Ulcer risk assessment in the first episode of care (within 6 hours) or on first home visit by community staff. The pressure ulcer grade should be recorded using the European Pressure Ulcer Advisory Panel Classification System (see above). Patients should receive initial and ongoing pressure ulcer assessment. This should be supported by medical photography (the Trust recommends body-mapping and wound assessment charts as a precursor to photography). All those who are vulnerable to pressure ulcers should as a minimum be placed on a high specification foam mattress. For patients undergoing surgery, as a minimum provision a high specification foam theatre mattress or other pressure redistributing surface should be used. All pressure ulcers graded 2 and above should be documented as a clinical incident. Patients with a grade 1-2 pressure ulcer should as a minimum provision be placed on a high specification foam/mattress with pressure reducing properties and be closely observed for skin changes. Patients with a grade 3-4 pressure ulcer should as a minimum provision be placed on a high specification foam mattress with an alternating pressure overlay or a sophisticated continuous low pressure system (for example, low airloss, air flotation, viscous fluid) The optimum wound healing environment should be created by using modern dressings (for example, hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, soft silicones). Version Number: 1 Page 13/13