Pressure Ulcer Prevention and Management Policy

Pressure Ulcer Prevention and Management Policy Subject: Pressure Ulcer Prevention and Management Policy Policy Number 3.0 Ratified By: Clinical Policy Approval Group Date Ratified: 12.12.2012 Version: 1.0 Policy Executive Owner: Bronagh Scott, Director of Nursing, patient experience Designation of Author: Jane Preece Tissue Viability Nurse Specialist Secondary Care Claire Davies Tissue Viability Team manager Primary Care Name of Assurance Committee: Quality committee Date Issued: January 2013 Review Date: January 2015 Target Audience: All health care staff within Whittington Health. Nursing homes and General Practice staff within Haringey and Islington. Prison service Key Words: Pressure ulcer, bed sore, pressure sore

Version Control Sheet Version Date Author Status Comment 1.0 April 2007 Jane Preece To be removed Whittington Hospital Pressure ulcer prevention and management guideline. 2.0 2010 Claire Davies To be removed Haringey and Islington NHS, PCT Pressure Ulcer prevention policy. New policy to replace both Community and Whittington Hospital policy/guideline

Contents: Paragraph Title Page Number Pressure Ulcer Prevention and management 1 quick reference guide 1.0 Introduction 2 2.0 Purpose 2 3.0 Duties 2 4.0 Pressure ulcer - Definition 5 5.0 Development of Policy 5 6.0 Pressure Ulceration 5 6.1 Primary causes 5 6.2 Common sites for Pressure Damage 6 7.0 Pressure ulcer prevention and treatment 6 7.1 Skin and Risk Assessment 6 8.0 Moisture lesions 9 9.0 Heel pressure ulcer prevention and management 9 10.0 Positioning 10 11.0 Pressure Relieving Devices 12 12.0 Maintain and Protect Skin integrity 13 13.0 Nutritional Status 14 14.0 Pressure ulcer treatment 14 15.0 Transfer within Whittington Health 14 16.0 Education 15 17.0 Reporting pressure ulcers 15 18.0 Useful contacts 16 17 References Relevant websites 17 1

APPENDIX Paragraph Title Page Number A Waterlow risk assessment tool 18 B Pressure Ulcer classification 19 C Pressure Ulcer classification Dark pigmented skin 20 D Differentiation of moisture and pressure ulcers 21 E Positioning using 30 Tilt 22 F Pressure relieving equipment product selection Guide 23 G Repositioning chart 24 H Pressure ulcer reporting system 25

Pressure ulcer prevention and management quick reference guide ASSESSMENT Assess all patients using Waterlow Risk Assessment Tool (appendix A) within 6 hours of admission to your clinical area or on first contact in the community Inspect the patient s skin & document condition on admission to clinical area or at first contact. Document daily or each visit patients skin condition Reassess all patients at least weekly or if condition changes. Community - All patients on long term usage of equipment to be assessed monthly Assess existing pressure damage using EPUAP classification (appendix B) Complete datix / incident form for all grade 2-4 pressure ulcers. Patients identified at elevated risk (Waterlow >15), and/or patients with pressure damage Complete Wound Assessment ACTION Documentation Positioning/ repositioning Regular repositioning Minimise friction & shearing damage use manual handling devices - Slide sheets Establish a repositioning schedule and document using repositioning chart (Appendix D). Pressure relieving devices Consider: Type of mattress Type of cushions Seating Restrict sitting to 2 hours Cushion Instigate appropriate wound management according to wound management guidelines REFERRAL Refer to local guidance on equipment (Appendix F) TVNS Physio OT Podiatry Continence advisor DOCUMENT Community - Implement Pressure ulcer pathway document Acute - Implement core care plan The GP must be informed of the pressure ulcer Community by DNS Acute On discharge summary 1

1. Introduction Pressure ulcers are common in healthcare settings and represent a significant burden of suffering for patients and carers and are costly to the NHS (1, 2). As the population ages and patterns of sickness change, the prevalence of pressure ulcers is likely to increase unless preventative action is taken (3). The presence of a pressure ulcer creates a number of difficulties psychologically, physically and clinically to the patient, carer and family. Pressure ulcer prevention and management should be patient centred and an integral part of patient care, which requires a multidisciplinary approach. The financial cost of treating pressure ulcers is substantial. Bennett et al (4) estimated the cost as 1.4 2.1 billion annually, 4% of NHS expenditure (5). Increasingly, there is the real risk of costs incurred by litigation, for failure to prevent or treat pressure damage effectively. Awards in the region of 100,000 have been given for negligent nursing or medical practice, which has lead to the development of pressure damage (6, 7) Whittington Health has a zero tolerance to pressure ulceration and it is everyone s responsibility to reduce the risk of a patient developing pressure ulceration whilst in there care. Definition: A pressure ulcer occurs over a bony prominence. It is an area of localised damage to the skin, and underlying tissue caused by pressure, shear, friction and/or a combination of these (8). 2. Purpose To provide guidance for all clinical staff on: strategies to prevent and reduce the risk of patients from developing pressure ulceration management of pressure ulceration if one should develop To ensure best practice at all times, assisting in reducing the number of pressure ulcer developed whist in Whittington Health s care. To outline Whittington Health strategy for reduction and prevention of avoidable pressure ulcers across the organisation The document takes into account national and international recommendations (8, 9, 10, 11). 2.1 Inclusion and exclusion The recommendations within this policy apply to all patient populations across Whittington Health, including infants and children, young people and pregnant women. 3. Duties Duties within the organisation All staff within Whittington Health have a responsibility and role in prevention of pressure ulcers. Specific roles and responsibility: 2

The Chief Executive The chief executive has overall responsibility for the safety of patients in the organisation ensuring we meet all the statutory requirements. The Director of Nursing To ensure pressure ulcer reduction strategies maintain a high profile at board and senior nursing level The Tissue Viability Service The Tissue Viability Team is responsible for the provision of an effective Tissue Viability Service across Whittington Health responsible for the development and implementation of policies and guidelines which are evidence based and reflect best practice to support Pressure ulcer prevention and reduction provide expert advice on Pressure ulcer prevention and treatment provide education to all Health Professional development of strategies to continuously reduce incidence of pressure ulcer Promote a Zero tolerance to pressure ulcer development Review incidence data, observe trends and work with teams locally to reduce occurrence of pressure ulcers Ensure pressure ulcer prevention equipment and resources are available and fit for purpose Ensure pressure relieving equipment contract meets the needs of the Organisation Responsible for the everyday running of the Pressure relieving equipment contract (Whittington Hospital) Assist with the development of audit tools Assist with audits and development of Organisational action plans in response to the audits Work with specialised areas Emergency department, Theatres to develop strategies for pressure ulcer prevention Ensure all Grade 3 and 4 pressure ulcers are investigated using the Root Cause analysis (RCA) and action plans developed Report to Director of Nursing and clinical division all concerns Provide information for reports on pressure ulcer prevention The clinical governance and risk management To ensure Whittington Health report and investigate all pressure ulcers in accordance with department of health requirements. To ensure system are in place for collection of accurate data, which is disseminated across the organisation Heads of Nursing Ensure pressure ulcer reduction maintains a high profile within the clinical division Review trends in pressure ulcer development Address local issues to assist in reduction of pressure ulceration across Whittington Health Ensure all pressure ulcer prevention strategies are implemented across the division 3

Matrons and Service manager leads To share information on incidence of pressure ulceration across clinical areas and address issues to reduce pressure ulceration To review all pressure ulcers incident in there clinical area observing for trends and ensure local action is taken To facilitate the completion of Root Cause Analysis investigation for all Grade 3 and 4 pressure ulcers developed within there clinical areas and action plans are completed Ward Managers/ Team leaders All staff attend training on pressure ulcer prevention All staff follow pressure ulcer prevention policy and guidance Complete the Essence of care Pressure ulcer prevention audit according to Whittington Health guidelines and implement actions across there clinical area Nominate a Link nurse for Tissue Viability and ensure support to enable them to fulfil the role All pressure ulcers are reported and investigated as per Whittington Health policy Inform Tissue Viability Service of any service needs or problems Pressure ulcer incidence data is visible Pressure ulcer safety Cross/calendar completed (Whittington Hospital) All patients with Grade 3 and 4 pressure are reported and referred to Tissue Viability Service Completion of Safety Thermometer data Tissue Viability Link Nurses Assist with the implementation of pressure ulcer prevention policy Ensure pressure ulcer incidence data is displayed Ensure completion of weekly Waterlow incident form (Whittington Hospital) and sent to Tissue Viability Service Participate in audit as requested by Tissue Viability team Attend meetings and study days Ensure all resources are available within the clinical area Provide local induction and training on pressure ulcer prevention Medical staff To be familiar and adhere to the Pressure ulcer prevention policy That all pressure ulcers are assessed, graded and documented within patient s case notes. Any skin changes/ damage reported to the nursing team Allied Health professionals To adhere to the policy Ensure all relevant staff are trained in pressure ulcer prevention Any skin damages/ changes noted reported to the nursing team All clinical staff nurses, midwifes, student nurses, health care assistance Read and understand the policy Ensure receive training on pressure ulcer prevention Adhere to the policy Ensure patients are assessed and appropriate plan of care is developed and implemented Any pressure ulcer identified reported Pressure relieving equipment contractors and providers ArjoHuntleigh technician, community equipment store All equipment provided is clean and in an working order prior to delivery to clinical area/patients Follow Whittington Health procedures for decontamination of all pressure relieving equipment 4

All equipment to be provided according to contracts. Facilities support staff Porter, housekeeping Procedures for delivery of pressure relieving equipment and cleaning are followed 3.1 Consultation and Communication with Stakeholders This policy has been produced in conjunction with relevant stakeholders and they have been provided the opportunity to participate in the consultation process. 3.2 Approval of Policy The Clinical Policy Approval Group 4.0 Pressure Ulcer: A Definition A pressure ulcer occurs over a bony prominence. It is an area of localised damage to the skin, and underlying tissue caused by pressure, shear, friction and/or a combination of these (8). 5.0 Development of the Policy 5.1 Prioritisation of Work This policy has been updated so it can be referred to by all staff working across Whittington Health 5.2 Responsibility for Document Development Tissue Viability Service. 5.3 Equality Impact Assessment Under the Race Relation (Amendment) Act 2000 the ICO is required to undertake equality impact assessments on all policies/guidelines and practices. This obligation has been expanded to include equality and human rights with regard to disability, age, gender and religion. The Equality Impact Assessment Tool (appendix 2) is designed to help the author to consider the needs and assess the impact of this policy/guideline and practice. 6.0 Pressure ulceration Pressure ulceration occurs when the skin and underlying tissues are compressed for a period of time, between the bone and the surface, on which the patient is sitting or lying. Blood cannot circulate causing a lack of oxygen and nutrients to the tissue cells. Furthermore, the lymphatic system cannot function properly to remove waste products. If the pressure continues, the cells die and the area of dead tissue that results is pressure damage. The amount of time this takes will vary, but may develop in as little as two hours in patients at greatest risk. Pressure 6.1 Primary Causes: The blood pressure at the arterial end of the capillaries is approximately 32 mmhg, while at the venous end this drops to 10 mmhg. The average mean capillary pressure equals about 17 mmhg and any external pressures exceeding this will cause capillary obstruction. Tissues that are dependent on these capillaries are deprived of their blood supply. Eventually the ischaemic tissues will die. 5

Shearing forces This may occur when the skin rubs against the bed sheets or other surfaces, e.g. when a patient slips down the bed or is dragged up the bed or chair. This gliding of internal tissue layers causes blood vessels to stretch and kink, thus obstructing blood supply to the skin area attached. Friction This is a component of shearing. Areas caused by friction wounds are more susceptible to damage from pressure and shearing forces. Therefore, to prevent shearing and friction forces, appropriate moving and handling techniques and equipment (e.g. sliding sheets and hoists) should be employed in order to ensure the patient is clear of the support surface. Moisture Skin should not be left wet (e.g. perspiration, incontinence, amniotic fluid) as it can become macerated making it more susceptible to shear and friction. 6.2 Common Sites of Pressure Damage: Pressure ulcers can occur on any area of the body usually over a bony prominence. Figure 1. 7.0 PRESSURE ULCER PREVENTION AND MANAGEMENT Skin and Risk Assessment: To identify individuals vulnerable to or at elevated risk of pressure ulcers. 7.1 Assessment: Initial and ongoing assessment of risk of pressure ulcers is the responsibility of registered healthcare professionals. It should involve both formal and informal (skin inspection) procedures. All members of the multi-disciplinary team have a responsibility to assess a patient s risk of developing a pressure ulcer and to report and document the risk assessment as appropriate. 6

Formal using Waterlow risk assessment tool (Appendix A) (7) or tools designed for clinical area (Paediatric, maternity) The primary assessment is the responsibility of the registered nurse/midwife delivering care to the patient. All patients should be assessed using the appropriate ICO Waterlow risk assessment documentation for there clinical area. 7.11 Frequency of assessment All patients should be formally assessed, (except midwifery refer to local guidelines) See Table 1. Table 1. Frequency of assessment In patient beds In Emergency Department On admission, within 6 hours On transfer between clinical areas When the condition changes Weekly post-operatively post-procedure Community First visit On transfer between clinical areas When the condition changes Initially weekly Monthly for those patients with no active nursing need but on long term usage of equipment Patients using pressure relieving mattress Weekly on DNS caseload and nursing/ care home Monthly for those under the DNS with no active nursing need but on long term usage of equipment. Whilst they have an epidural insitu Note: risk assessment tools should be used as an aide memoire and should not replace clinical judgement (12) 7.12 Skin Assessment Skin inspection should occur regularly. Assess patients skin condition immediately on admission to your clinical area or at first visit by DNS All bony prominence should be examined. For example Sacrum, heels, hips, ankles, elbows, occipital and buttocks (Figure 1) Patients and carers who are willing or able should be taught to assess their own skin and take ongoing responsibility as appropriate. Patient and carers will be provided with the Whittington Health pressure ulcer prevention leaflet Please see Whittington Health: Preventing pressure ulcer patient information leaflet 7

The condition of the skin persistent erythema, non-blanching hyperaemia (redness which does not disappear on relief of pressure) blisters, discolouration, localised heat, localised oedema and localised induration (9). Identifying discolouration on patients with dark skin may be difficult and care should be taken not to rely solely on visual inspection (9, 13). Points to consider when assessing darkly pigmented skin (Appendix C) Any existing or acquired pressure ulcers should be categorised using the European Pressure Ulcer Advisory Panel Classification System (EPUAP) (Appendix B) (8). Where pressure damage is present, a comprehensive wound assessment will be completed using the documentation for your clinical area. A tracing of the wound should be made and, where possible, a photograph should be taken. Note: Pressure ulcers should not be reverse/down categorised e.g. a grade 4 does not become a grade 2. Should be documented as Healing category 4 7.2 Other relevant assessments These should be carried out in accordance with local guidance and using tools established in your clinical area. Assess the patients: Nutritional status and hydration requirements. Patient handling assessment Pain assessment Continence assessment Mental health/capacity assessment 7.3 Documentation Record details of the assessments in the patient s assessment documentation, using the nursing model appropriate to your clinical area. Ensure the date and time of the assessment is recorded and the information is signed by the assessing clinician. Name and status should be written in block capitals. Care provided will be evaluated and progress documented in the patient s case notes for each episode of care, incorporating progress in the condition of any pressure ulcer(s). 7.4 Care Plan Devise and implement a plan of care to reflect the patient s individual needs for the prevention and/or treatment of pressure ulcers. All patients deemed at risk of pressure ulcer development (Waterlow >15), will have a written pressure ulcer prevention plan incorporating: Positioning and repositioning schedule Pressure relieving equipment Nutritional requirements Pain management Continence management A wound assessment chart with plan of care should be completed for all patients with pressure ulcers. 8

Please see Whittington Health: Community Pressure ulcer risk assessment pathway Core care plan for pressure ulcer prevention Waterlow assessment tool Acute Adult Waterlow assessment Maternity risk assessment documentation Paediatric risk assessment document Wound assessment chart and care plan Core care plan for pressure ulcer prevention 8.0 Moisture Lesions Moisture associated skin damage affects 50% of patients with incontinence. There is often confusion between pressure damage and moisture lesions. Moisture lesion Pressure Ulcer The aetiology of moisture lesions is complex and multifactorial The Stratum Cornea provides a protective barrier and with aging thins Incontinence or frequent cleansing the barrier reduces and permeability increases The PH of the skin becomes more alkaline and tissue damage occurs Friction and shearing forces increases the skin damage It is important that moisture lesions are identified and treated appropriately and not confused with pressure damage see section 6.1 for management. Differentiation between Pressure ulcers and Moisture Lesions see Appendix D 9.0 Heel ulcer prevention and management The Incidence of pressure ulcer on the heels is high and need careful consideration and management as can lead to prolonged intervention amputation, infection and death. The heels should be assessed regularly refer to assessment section 7.12 9

9.1 Prevention of heel pressure Patients should be encouraged to mobilise and wear good fitting footwear. When patients are in bed or elevating the legs the heels should be free floating. This can be achieved by the use of: Heel lifts, heel protectors, troughs and pillows placed lengthways. Antiemoblism stockings should be removed twice daily for a maximum of 30 minutes and skin inspected. The patient should be informed of when, how and frequency of removal of any compression, antiembolism stockings and importance of skin inspection. 9.2 Assessment of heel pressure ulcers Black heels - an area of black necrotic eschar or shell on heel should be treated as grade 4 pressure ulcers and referred to the TVS. 9.3 Management of necrotic heel pressure ulcers Heel pressure ulcers with eschar do not require aggressive debridement initially if there is no oedema, erythema, sponginess or exudate or clinical signs of infection, then keep the area dry and await autodebridement. Continue to assess and monitor. If there is oedema, erythema, with clinical signs of infection then the eschar should be removed by debridement Refer to TVS. An ankle brachial pressure index (ABPI) should be performed on all patients with black heels to determine if there is any arterial insufficiency. 9.4 Referral All patients with diabetes should be referred to Multidisciplinary Diabetic foot team (Podiatry, diabetes consultant) Consideration should be given for the need for vascular surgical referral for patients with an ABPI <0.8mmHg and >1.3mmHg. 10.0 Positioning Patients with an elevated risk and/or pressure ulcers should be encouraged to actively mobilise (10). The patient should be advised to stand hourly and rest, lying on their side for short periods in the day Where possible patients should be taught to reposition themselves and redistribute their weight and carers should be shown how to assist. Patients who are at risk of pressure damage or have pressure damage should be repositioned and the frequency of repositioning determined by the results of skin inspection and individual needs, not by a ritualistic schedule (9, 10,12). Repositioning should take into consideration other relevant matters, including the patient s medical condition, their comfort, the overall plan of care, the support surface (9,10) and attendance of formal and informal carer s 10

Patients should be positioned in such a way as to minimise the impact on bony prominences (e.g. 30 tilt) and pressure ulcer (10) (Appendix E) Patient should be positioned appropriately to reduce the effect of shear and friction forces A re-positioning schedule will be agreed with the patient and documented. A repositioning chart or turning clock (Appendix F) will be used as deemed necessary for individual patients e.g. poor concordance, Waterlow >21 10.1 Seating Individuals are at a higher risk of pressure ulcer development when sitting out of bed due to: inability to reposition incorrect / inappropriate chair or seating facility inability to redistribute weight Patients at risk from pressure damage, who cannot relieve their own pressure independently, should restrict chair sitting to a maximum of 2 hours at any one time. After sitting the patient requires 2 hours bed rest (side lying) Patients with pressure ulcers on the sacrum/coccyx or ischial should be advised or have sitting limited to two times a day in periods of < 2 hours (9,11) Modify sitting-time schedules and re-evaluate the seating surface and the individual s posture if the ulcer worsens or fails to improve. Some patients may need referral for specialist seating assessment by physiotherapist or occupational therapist Pressure redistribution cushions should be considered 10.2 Patient handling Skin damage can be minimised by using correct positioning, transferring and repositioning techniques and the use of aids. For example: hoists, sliding sheets, pillows, bed cradles and other aids. Complete the patient handling risk assessment within 24 hours of admission or on first visit within the community Write a plan of care to meet patient handling needs Patients should be encouraged to move independently where possible. If assistance is required, safer handling techniques should be employed. Refer to manual handling policy Slide sheets help to eliminate friction and should be used to assist/move patients with mobility needs. When hoisting patients, hoist slings must be the correct size and properly fitted. Hoist slings should not be left under patients. The use of four section electric profiling beds can contribute to reducing pressure, friction and shearing forces. If the bed is used to its full potential. Raise the end of the bed (reverse trendlenberg) Use the auto contour mechanism (raises the foot end, when head end is raised) Use the knee-break facility Use appropriate manual handling techniques and equipment Remove slings, slide sheets or other parts of the handling equipment after moving the patient. Do not use sheets to move patients Please see Whittington Health Guideline: Manual handling policies 11

10.3 Pain Patients who are in pain will be reluctant to reposition and relieve pressure (1). Patient s pain should be assessed individually using local pain assessment tools and aids. A plan of care will be developed with the patient so the pain is controlled and patient is informed of the need for adequate analgesia. 11.0 Pressure Relieving Devices: Pressure relieving mattresses, cushions and devices do not replace the need for patient repositioning. 11.1 Mattresses Pressure relieving support surfaces aim to reduce the magnitude and/or duration of pressure between the individual and support surface. Choice of pressure relieving support surface should be made by a registered nurse who is trained and competent in pressure ulcer risk assessment, prevention and management. Decisions on type of surface should be based on: Social assessment and support Pressure ulcer risk assessment Category (Grade) of pressure ulcer Ability to reposition Length of time spent out of bed Comfort Patient weight and height General health Acceptability by the individual Requirement for bed side rails (cot sides) For general guidance on equipment selection refer to Appendix F. Refer to local product selection guides for specific information for clinical area. 11.2 Cushions All patients who sit out of bed and at a high risk of development of pressure ulcer should be provided with a pressure relieving cushion or chair with integrated pressure relieving properties in the seating area. A specialist seating maybe necessary refer to physiotherapist or occupational therapist 11.3 Safe use of equipment Ensure mattress does not elevate the individual to an unsafe height in relation to side rails Ensure the individual is within the recommended weight range for the equipment Children and alternating pressure mattresses small children can sink into gaps created by deflated cells risk of discomfort and reduced efficacy 11.4 Accessing Equipment Acute ArjoHuntleigh Whittington Hospital bed store 0207288 5167 Monday Friday 08.00 17.00 Out of Hours refer to Out of Hours Community Islington - Integrated Community Equipment Store (ICES), through the DNS 02033161111 Haringey Haringey Integrated Equipment Store (HICES) through the DNS 02030742306 12

procedure ArjoHuntleigh on 08457 342000 All equipment should be cancelled and returned to the store as soon as it is finished with for maintenance and decontamination. Remember: when re-assessing patients risk think does the patient still require this mattress 11.5 Audit and maintenance of equipment Equipment can deteriorate due to age and usage, therefore all pressure relieving equipment should be checked and maintained in good working order according to manufactures guidelines Refer to local guidance on maintenance and decontamination 11.51 Foam Mattress and cushion audit Audits should be carried out regularly and all pieces of equipment should be checked between patients for: Condition of the cover no stains, splits, tears Acute Yearly foam mattress and cushion audit Ward staff to check in between patients Community Yearly foam mattress and cushion audit Equipment with motors should be serviced yearly via HICES Please see Whittington Health Guideline: Acute Pressure relieving equipment resource folder Community Infection Control Policy and ICES catalogue, HICES catalogue 12.0 Maintain and Protect Skin Integrity: An individual s skin may be exposed to a variety of moist substances, which may make it more susceptible to injury. When handling patients, all health professionals should take care not to damage a patient s skin. Neither rings (other than wedding bands) nor watches should be worn when turning or repositioning patients, and nails should be kept short and nail varnish removed. The skin should be kept well hydrated. If the patient is at high risk of skin damage or incontinent they should be advised to use an emollient soap substitute (e.g. aqueous cream, emulsifying wax) to wash and apply moisturisers regularly. The patient s skin should be thoroughly dried using a patting motion, particularly over vulnerable areas. Do not use a rubbing motion or massage when drying patients as this causes friction forces and is associated with tissue damage (13). Talcum powder should not be used because of its tendency to cake, thereby increasing friction, clogs the pores and increase risk of infection (13) and skin damage Incontinence should be managed effectively 12.1 Incontinence management Assess the patient and develop a plan of care Barrier creams should be used with caution as they clog the pores in the pad and effect efficacy Referral to continence advisor should be considered 13

Please see Whittington Health: Continence assessment Continence Policy 13.0 Nutritional Status The link between impaired nutrition and pressure ulcer development and delayed healing is unclear. Although decreased calorie intake, dehydration and low serum albumin is linked with decreased tolerance of the skin from pressure, friction and shearing forces therefore reduced wound repair (15, 16). 13.1 Assessment All patients should be screened on admission, at first visit and reassessed regularly using ICO assessment tools and receive a well balanced diet in accordance with their wishes. All patient should have their Body Mass index (BMI) calculated on admission or first visit where possible and repeated weekly when an in patient, monthly on DNS caseload if practicable. If patient has a poor intake a food chart should be commenced (in-patient) Patients with pressure ulcers need monitoring of haemoglobin and serum albumin levels Patient s with pressure ulcer/s should be referred to the dietician for further assessment 13.2 Intervention Refer for specialist advise as required Provide patient advise on well-balanced diet and protein-energy foods (16) Ensure 2 litres of fluid per day. 14.0 Pressure ulcer treatment Modern dressings should be used to create an optimal wound healing environment. Refer to Whittington Health wound management guidelines and formulary. Complete the wound assessment document and develop a plan of care. Patients with Category 3, 4 and /or necrotic pressure ulcers should be referred to Tissue Viability Service. Patients with Category 2 pressure damage which is non healing (after 6 weeks in community) should be referred to TVS for further advise Referral for general surgery and/or plastic surgical intervention should be considered on an individual patient basis. If a pressure ulcer is non healing osteomyelitis should be considered. Radiography (x-ray, MRI scan) should be considered in discussion with other health professionals (GP, Consultant) Please see Whittington Health Guideline: Wound Management guidelines and formulary 15.0 Transfer within/ from Whittington Health Acute Referral form to be completed for visit by DNS Referral to DNS for pressure relieving Community Transfer letter to be faxed to receiving area Communicate verbally with the receiving 14

equipment at least 5 days before discharge Supply of wound management products for 5 days Give patient written information leaflet Pressure ulcer information to be written on Discharge letter to GP area if e.g. issues of non concordance social and family concerns DNS to inform GP 16.0 Education All staff should be familiar with the Pressure ulcer prevention and management policy. They should attend the Tissue Viability study day in accordance with their personnel development plan (PDP). All staff will have pressure ulcer prevention, risk assessment and planning of care within local induction programmes A record of individual practitioners education and training will be maintained my the practitioners manager 16.1 Health care assistance (HCA) Health care assistant can undertake the following, once they have received training and deemed competent which will be recorded within their KSF. Assessment of risk of pressure ulcer development Manage a Grade 1 pressure ulcer In the acute setting only- manage a grade 2 pressure ulcer following assessment and management plan by a RN HCA will document clearly and escalate any deterioration to RN Grade 2 pressure ulcers will be assessed regularly by DN 17.0 Reporting of pressure ulcers All health care professionals are responsible for reporting pressure ulcers. A Datix/ incident form will be completed for all identified category 2-4 pressure ulcers The TVS should be informed of all grade 3 and 4 pressure ulcers Care homes will report all grade 2 4 pressure ulcers to CQC and commissioners Category 3 and 4 pressure ulcer require a full root cause analysis investigation and are reportable to the DH refer to Appendix G GP will be informed the patient has a pressure ulcer by DN and on discharge letter 17.1 Safeguarding adults and skin damage Skin damage has a number of causes, some relating to the individual patient such as poor medical condition and others relating to external factors such as poor nursing care, lack of resources e.g. equipment, staffing. It is recognised that not all skin damage can be prevented and therefore the risk factors in each case should be reviewed on an individual basis before a safeguarding referral is considered. Not all pressure ulcers in vulnerable adults are the result of neglect. If there are concerns that observed pressure damage maybe the result of neglect or omissions care please refers to Whittington Health Safeguarding Adults and Skin Damage Protocol. 15

Please see Whittington Health Guideline: Safeguarding Adults and pressure ulcers Protocol 18.0 Useful Contacts: Acute Community Haringey Islington Tissue Viability 02072883369 Tissue Viability 02033168393 Bed store 02072885167 Equipment library 02033161111 02030742306 (ArjoHuntleigh) ArjoHuntleigh 08457 342000 16

References 1. Franks P.J, Winterburg H., Moffatt C. (1999) Quality of life in patients suffering from pressure ulceration: a case controlled study. Ostomy and Wound Management 45. 56. 2. Allman R.M., Goode P.S., Burst N., Bartolucci A.A., Thomas D.R. (1999) Pressure ulcers: hospital complications and disease severity: impact on hospital costs and length of stay. Advanced Wound Care. 12. (1). 22-30. 3. Waterlow J. (2005) Waterlow Pressure Ulcer Risk Assessment. www.judy-waterlow.co.uk 4. Bennett G., Dealey C., and Posnett J. (2004) Cost of pressure ulcers in the UK. Age/Ageing. 33. (3). 230-235. 5. Touche Ross (1993) The Cost of Pressure Sores. Touche-Ross and company, London. 6. Silver, J. (1987) Letters. Care, Science & Practice; 5:3 30 7. Tingle J. (1997) Pressure Sores: counting the legal cost of nursing neglect. British Journal of Nursing 6 (13) 757-758 8. EPUAP & NPUAP (2009) Prevention of pressure ulcers: Quick Reference Guide. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Washington DC. USA. http://www.epuap.org/guidelines/final_quick_prevention.pdf 9. NICE (2003) Pressure ulcer risk assessment and prevention, including the use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. National Institute for Health and Clinical Excellence. London. www.nice.org.uk/page.aspx?o=20052 10. NICE (2005) Pressure ulcers: the management of pressure ulcers in primary and secondary care. National Institute for Health and Clinical Excellence. London. http://www.nice.org.uk/nicemedia/pdf/cg029fullguideline.pdf 11. TVS (2003) Seating and Pressure Ulcers: Clinical Practice Guideline. Tissue Viability Society. www.tvs.org.uk 12. NICE (2001) Pressure ulcer risk assessment and prevention. Inherited Clinical Guideline B. National Institute for Clinical Excellence, London 13. DH (2003) Essence of Care Patient-focus benchmarks for clinical governance: Food & Nutrition. Department of Health. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4 127915.pdf 14. Royal College of Nursing (2000) Pressure ulcer risk assessment and prevention, clinical practice guidelines. RCN, London 15. Bergstrom N, Braden B (1992) A prospective study of pressure sore risk among institutionalized elderly. Journal of American Geriatrics Society, 40 (8) 747 758. Cited in NICE (2005) Management of pressure ulcers in primary and secondary care. www.nice.org.uk 16. EPUAP (2003) Nutritional guidelines for pressure ulcer prevention and treatment. www.epuap.org Relevant websites: www.nice.org.uk www.epuap.org.uk www.rcn.org.uk 17

Appendix A WATERLOW RISK ASSESSMENT Name: Guidance on scores: 10+ AT RISK 15+ HIGH RISK 20+ VERY HIGH RISK HOSP No: Date Time BUILD / WEIGHT FOR HEIGHT Average BMI 20 24.9 0 Above Average BMI 25 29.9 1 Obese BMI >30 2 Below Average BMI <20 3 SEX and AGE Male 1 Female 2 14 49 1 50 64 2 65 74 3 75 80 4 81+ 5 SKIN TYPE and VISUAL RISK AREAS Healthy 0 Tissue paper 1 Dry 1 Oedematous 1 Clammy/ pyrexia 1 Discoloured Grade 1 2 Broken / Spot Grade 2-4 3 MOBILITY Fully 0 Restless / Fidgety 1 Apathetic 2 Restricted 3 Bed bound e.g. Traction 4 Chair bound 5 CONTINENCE Complete / Catheterised 0 Urine incontinence 1 Faecal incontinence 2 Urinary & faecal incontinence 3 Persistent diarrhoea 3 NUTRITIONAL RISK Section A Has the patient had unplanned weight loss in past 3 6 months or recently YES Go to section B NO Go to section C Unsure Go to section C & Score 2 Section B Weight loss score 0 3 kg 1 3 6 kg 2 > 6 kg 3 Section C Patient appetite Poor appetite 1 Refusing to eat 2 NBM/IV fluids/enteral feed/ IV nutrition 3 TISSUE MALNUTRITION Terminal Cachexia 8 Multiple organ failure 8 Single organ failure 5 Peripheral Vascular Disease 5 Anaemia (Hb <8) 2 Smoking 1 NEUROLOGICAL DEFICIT Diabetes 6 MS. CVA. Paraplegia 4-6 MAJOR SURGERY / TRAUMA Orthopaedic 5 * Below waist spinal 5 On table >2 hours 5 ** On table for > 6 hours 8 ** MEDICATION Cytotoxics, long term high dose Steroids or anti-inflammatory 4 Sedated & Paralysing Agent 3 Epidural 4 SCORE SIGNATURE JOB TITLE 18

Appendix B Category 1 EUROPEAN PRESSURE ULCER ADVISORY PANEL PRESSURE ULCER CLASSIFICATION Non-blanchable erythema of intact skin. Discolouration of skin, warmth, oedema, induration or hardness may also be used as indicators particularly on individuals with darker skin. Category 2 Category 3 Category 4 Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion or blister Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss NECROSIS Unable to grade whilst necrotic, should be recorded as a probable Category 3 or 4 Pressure ulcers should not be reverse graded. Document as a healing grade 4 or grade 3 etc. 19

Appendix C Pressure ulcer categorisation in patient with Dark Pigmented Skin It is difficult to identify Category 1 pressure damage in dark pigmented skin. Observe for the following signs and symptoms: Patient complains of pain, numbness, discomfort over bony prominence Localised oedema Purplish/bluish localised area Localised induration Localised heat/ warmth this is replaced with coolness once damage occurs 20

Appendix D Differentiation between Pressure ulcer and Moisture lesions Moisture lesion Pressure ulcer History of faecal and/or urinary Will usually be circular and symmetrical incontinence Irregular and asymmetrical shape Over bony prominence Lesions will be over fatty parts of buttocks and thighs, not isolated to bony prominence May take butterfly wing shape if spans out from sacrum Lesions may extend into perineal area May have necrotic or thick sloughy tissue present Superficial Partial to full thickness A linear shaped lesion in the natal cleft is likely to be a moisture lesion No necrotic tissue Do not Grade/ categorise Categorise using EPUAP 21

Appendix E 30 TILT (Byrant 1992) 22

Appendix F PRESSURE RELIEVING EQUIPMENT PRODUCT SELECTION GUIDE Waterlow score Risk level Skin Condition Mobility Pressure redistributing equipment 10-17 At Risk No damage Mobile Foam mattress 17-25 High Risk No damage or Grade 1 2 Restricted Foam mattress replacement 17 25 High risk Grade 2 3 Bed/ Chair bound Restricted > 25 Very High No damage Mobile or can turn self in bed > 25 Very high Grade 2-4 Restricted. Bed/chair bound Overlay or mattress replacement alternating pressure Foam mattress replacement Mattress replacement Patients with pressure ulcers or at high risk of pressure ulcer development must only sit out for maximum 2 hours at anyone time and mist be provided with a pressure redistributing cushion 23

Appendix G Patient Name: Hospital No: REPOSITIONING CHART Ward: Date: Identify patients with pressure areas that are at risk Ensure patient s Waterlow assessment is up to date Every patient with a pressure ulcer must have a wound assessment chart and care plan Assess reposition plan daily Complete European pressure ulcer advisory panel EPUAP Scale when a pressure ulcer is discovered and at least every 8 hours (for at risk patients) NB Do not reverse grade e.g. improving grade 4 is graded as healing grade 4 not a grade 2 Reposition plan is: turn patient hourly and sit out for hour (s) only Time *Position Intact or EPUAP Grade Signature & print name 01.00 02.00 03.00 04.00 05.00 06.00 07.00 08.00 09.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00 21.00 22.00 23.00 24.00 *KEY M = patient mobilising P = lying prone L = left side B = lying on their back R = right side C = to sit out in an arm chair T = having therapy (Physio, OT) I = gone for investigation (e.g. imaging dept) TH = in theatre department F = refused repositioning (failed) 24

Appendix H Pressure ulcer reporting system Pressure Ulcer reporting PU 2, 3, 4 Report to GP DATIX/ Incident form Completed by the identifier 2 3 & 4 SI report DH Risk Management Level one investigation Root caus e anal ysis Completed within 40 days Hold meeting with team PU SI Panel Action plan NHS London EC 25

Tool to Develop Monitoring Arrangements for Policies What key element(s) need(s) monitoring as per local approved policy or guidance? Who will lead on this aspect of monitoring? Name the lead and what is the role of the multidisciplinary team or others if any. What tool will be used to monitor/check/observe/asses s/inspect/ authenticate that everything is working according to this key element from the approved policy? How often is the need to monitor each element? How often is the need complete a report? How often is the need to share the report? What committee will the completed report go to? Element to be monitored Lead Tool Frequency Reporting arrangements 1. All pressure ulcer prevention strategy as outlined within Essence of Care key elements Tissue Viability lead community and Whittington Hospital will co-ordinate and provide monitoring tools. Whittington Health Essence of Care monitoring tool, Monitoring - Every 3 months Report - Quarterly Report to Director of Nursing 2. Pressure relieving equipment and devises are available, effective in working order Ward managers will undertake the audits Tissue Viability leads Mattress audit tool Monitoring - Yearly for foam mattresses and beds Secondary care Health and Safety committee Pressure relieving equipment contract Secondary care Tissue Viability Secondary care and Steven Packer Key performance indicator within contract Monitoring Quarterly 3. All grade 2 4 pressure ulcers are reported and investigated Deputy director of Nursing and Pressure ulcer SI Panel committee (PUSIP) Safety thermometer, Pressure ulcer log. Monitoring Monthly Report Quarterly Monthly - Director of Nursing Quarterly - Quality committee 4. Education and training Tissue Viability Lead. Education department administrator to provide data. Attendance lists and ESR Twice yearly To be included in twice yearly in report to Quality committee A full report will be provided yearly to the quality committee on all elements of the policy. 26

Plan for Dissemination and implementation plan of new Procedural Documents To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Acknowledgement: University Hospitals of Leicester NHS Trust Title of document: Pressure ulcer prevention and management Date finalised: Previous document already being used? Yes (Please delete as appropriate) Dissemination lead: Print name and contact details Jane Preece and Claire Davies Jane.preece@nh s.net Claire.davies1@ nhs.net If yes, in what format and where? Proposed action to retrieve out-of-date copies of the document: Single documents for community and Hospital intranet general guidelines. Tissue Viability web page. Hard copies on Whittington Hospital site Lead will collect from all clinical areas. Lead will remove from Tissue Viability webpage To be disseminated to: How will it be disseminated/implem ented, who will do it and when? Paper or Electroni c Comments All clinical staff On the intranet Electroni c Launch at Stop Pressure ulcer day Distributed and communicated at link nurse meetings Is a training programme required? Who is responsible for the training programme? No Tissue Viability Service Training all ready in place on Pressure ulcer prevention 27

Appendix I Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Impact (= relevance) 1 Low 2 Medium 3 High Race 1 Evidence for impact assessment (monitoring, statistics, consultation, research, etc Evidential gaps (what info do you need but don t have) Action to take to fill evidential gap Other issues Disability 1 Gender 1 Age 1 Sexual Orientation 1 Religion and belief 1 Once the initial screening has been completed, a full assessment is only required if: The impact is potentially discriminatory under equality or anti-discrimination legislation Any of the key equality groups are identified as being potentially disadvantaged or negatively impacted by the policy or service The impact is assessed to be of high significance. If you have identified a potential discriminatory impact of this procedural document, please refer it to relevant Head of Department, together with any suggestions as to the action required to avoid/reduce this impact. 28