Reducing the Risk of Pressure Ulcers in Acutely Unwell Patients

1.0  Terms of Reference

The aim of this report is to reduce the risk of the development of pressure ulcers in acutely unwell patients within a local National Health Service (NHS) Trust hospital. The report will recognise the stakeholders who are involved in pressure ulcer prevention and explore how interprofessional working can help to improve effective care of such patients and reduce their risk of pressure damage.

Executive Summary

1.1  This report advises that the foundation of pressure ulcer prevention is repositioning (National Pressure Ulcer Advisory Panel (NPUAP), 2016). It provides evidence to suggest that those patients most at risk of pressure ulcers are those with impaired mobility, impaired nutrition and poor posture (National Institute for Health and Care Excellence (NICE), 2014).

1.2  The report highlights that traditionally it was nurses who should determine interventions in order to prevent pressure ulcers (Soban et al., 2017). In spite of this, the report goes on to demonstrate the importance of other stakeholders within pressure ulcer prevention. Nonetheless, these stakeholders still rely on nurse referrals in order to be made aware of patients who are at risk of a pressure ulcers, therefore highlighting the importance of communication within the multi-disciplinary team (MDT).

1.3  The report identifies four stakeholders: Nursing staff; the Service User; Dieticians and Occupational Therapists. In addition, it discusses pressure ulcer prevention from the stakeholders perspective and how they could work collaboratively in order to ensure the best care.

1.4  The report suggests that easier recognition of those patients at risk of pressure ulcers may be beneficial for all stakeholders involved in their care. It also recommends that with a more honed use of Intentional Rounding tools, a patient’s position could be considered more regularly. Furthermore, the report also recommends additional education on pressure ulcer risk reduction for both staff and patients.

2.0  Introduction

2.1  Background

The purpose of this report is to consider how effective interprofessional working can help to reduce the amount of pressure ulcers seen in an acute hospital trust.

The National Pressure Ulcer Advisory Panel (NPUAP) (2016) define a pressure ulcer as a localised injury to the skin and/or underlying tissue, typically over a bony prominence. These are as a result of sustained pressure or sustained pressure together with shear. Pressure damage may also occur as a result of the use of medical devices which cause damage, for example, oxygen tubing (NPUAP, 2016).

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The National Institute for Health and Care Excellence (NICE) (2014) state that whilst all patients have a potential risk of developing a pressure ulcer, those patients that are seriously ill, have impaired mobility, impaired nutrition or poor posture pose the largest risk. In order for staff to identify those patients who are most at risk of developing a pressure ulcer, tools which provide a risk score, such as the Waterlow score (Waterlow, 2005) may be useful. However, these tools should not be used in isolation, they should be used together with clinical judgement (Payne, 2016).

The European Pressure Ulcer Advisory Panel (EPUAP), NPUAP and the Pan Pacific Pressure Injury Alliance (PPPIA) updated their Clinical Practice Guidelines for Prevention and Treatment of Pressure Ulcers in 2019 (EPUAP, NPUAP, PPPIA, 2019). Consequently, in January 2019, a local NHS Trust hospital amended their clinical guidelines for pressure ulcer prevention (Placement hospital, 2019). These guidelines recommend an evidence-based and multidisciplinary approach to pressure ulcer prevention and include the updated pressure classification system (Placement hospital, 2019). Whilst the trust has seen an improved performance in pressure ulcer numbers in the year 2017/18, it still aims to continue to improve on its achievements to date (Placement hospital, 2019).

 

2.2  Research

Evidence from research suggests that pressure ulcers may cause patients significant pain and distress which in turn may lead to anxiety and depression (Stinson, Ferguson and Porter-Armstrong, 2017). A mixed methods systematic review by Gorecki et al., (2011) obtained reports from patients regarding their pressure ulcer pain. Descriptions ranged from ‘sore and hurting’ to ‘torturing, terrible and exhausting’. This research suggests that pain from pressure ulcers may be debilitating, affecting the patient’s psychological wellbeing, which consequently may impact on their daily life.

Research by Clarkson et al., (2016) looked at whether MDT working is promoted as best practice for pressure ulcer prevention and whether it is being practiced effectively. Their research suggested that Occupational Therapists and Health Care Assistants had a more positive attitude to pressure ulcer prevention than nurses. The research concluded that whilst pressure ulcer prevention has historically been seen as a nursing issue, some pressure ulcer causes may help to be prevented by working with the Therapy Service Team (Clarkson et al., 2016).

NPUAP (2016) advise that the foundation of pressure ulcer prevention is pressure relief through repositioning. This includes the use of equipment such as pressure-reducing mattresses, chair cushions and heel cushions. NPUAP (2016) do not endorse a specific time interval for repositioning, but the frequency should be individually agreed whilst considering the patients tissue tolerance, their skin condition, their level of activity and mobility and their general medical condition.

 

2.3  Statistics

Despite the guidelines from NPUAP (2016) and EPUAP (2014) pressure ulcers remain to have a significant financial impact on the health service, with treatment costing considerably more than prevention (Stinson, Ferguson and Porter-Armstrong, 2017). The cost of pressure ulcer care to the NHS has been estimated as between £1.4 billion and £2.1 billion annually (Dealey, Posnett and Walker, 2012), emphasising the importance of pressure ulcer prevention.

 

 

3.0 Main Body

3.1  Stakeholders

There are many stakeholders involved in the reduction of pressure ulcers, however, for the purposes of this report, Nursing staff, Service Users, Dieticians and Occupational Therapists have been discussed.

3.1.1      Specialist Nurses, Nurses and Nursing Assistants

Traditionally, the prevention of pressure ulcers has been determined by nursing interventions (Soban et al., 2017). Individualised care plans, as recommended in NICE (2014) guidelines, are developed and documented by nurses on the patient’s admission which encompass skin assessments, mobility, any comorbidities and whether there is any need for additional equipment, for example, pressure relieving mattresses. It is after these assessments that nurses are accountable and responsible for referrals to be made to appropriate stakeholders for further review (NMC, 2019).

NPUAP (2016) suggest that the foundation of pressure ulcer prevention is repositioning, with the frequency of the repositioning being individually determined after considering the patients tissue tolerance, activity level and mobility. Local NHS trust guidance states that a pressure ulcer assessment, adapted from Waterlow (2005) must be completed within six hours of admission on the ward or when there is a change in the patient’s condition (Placement hospital, 2019). During the admission process, the nurse initiates either a high or low risk Intentional Rounding schedule, to be completed electronically either one or two hourly by nursing staff.

Intentional Rounding tools were initially developed in the United States; however, the United Kingdom implemented them as part of the recommendations from the Francis Inquiry (2013) with the aim of improving patient outcomes (Sims et al., 2018). Intentional Rounding is a system of routinely checking on patients at regular intervals (Morgan et al., 2016) and include positioning as a key element (Sims et al., 2018). This activity could enable tasks such as changing position to be anticipated and addressed, therefore each patient could be reviewed for their risk of pressure ulcers with each rounding task completed.

In the local NHS hospital trust Intentional Rounding is a task that is often seen as being delegated to Nursing Assistants. Research has suggested that nursing support workers are commonly used for this task, ensuring that any relevant care requirements are then reported back to the Registered Nurse (Roche et al., 2017). In spite of this, further research suggests that it is in fact registered nurses who score significantly higher on a pressure ulcer prevention questionnaire than nursing assistants. Furthermore, it is those staff who had attended additional training that score the highest (Meyer et al., 2019). This suggests that staff education is an important factor in the success of Intentional Rounding (Sims et al., 2019), indeed, it should not just be seen as a tick box exercise completed from observing patients from afar. In spite of the study by Meyer et al., (2019), there is still limited research to support the fact that Intentional Rounding reduces the incidence of pressure ulcers (Harris et al., 2017). This implies that the success of Intentional Rounding schedules relies for the most part on the compliance and engagement of the staff conducting them (Morgan et al., 2016).

3.1.2      Service Users

The impact of pressure ulcers on a service user’s quality of life include pain, depression, sepsis, gangrene and sometimes death (McGinnis et al., 2014). Pressure Ulcer pain can be debilitating, with service users describing it as the most bothersome problem, reporting that the pain is “endless” (Gorecki et al., 2011). Pain can reduce both physical and social activities and the individual can find it difficult to get into a comfortable position. Furthermore, individuals have also described pain at a potential pressure ulcer site as a precursor to a pressure ulcer developing (McGinnis et al., 2014). This suggests that an early assessment of the skin’s condition is paramount in order to observe any skin changes before any damage occurs.

The principal patient-related risk factors for the development of pressure ulcers are activity and mobility (Woodhouse et al., 2015). Individuals with reduced mobility may rely on healthcare professionals to reposition them, with positions being maintained with the use of pillows and/or cushions (Woodhouse et al., 2015). In contrast to guidelines from NPUAP (2016), NICE guidelines (2014) suggest that adults at risk of pressure ulcers should be repositioned at least every six hours, with ‘high risk’ adults to be repositioned every four hours. NICE Guidelines (2014) also encourage those adults who are high risk to change their position by themselves at least four hourly if they are able to do so. Repositioning is a critical part of prevention of pressure ulcers, and staff should take responsibility to educate both service users and their families to fully participate in this activity, encouraging small position shifts when they are able (Miles, Nowicki and Fulbrook, 2014).

3.1.3      Dieticians

In the local NHS trust, in order for Dieticians to become involved in the care of patients, they rely on receiving a referral from nursing staff after the patient’s admission (Placement hospital, 2019).

Nutritional deficiency and insufficient dietary intake are significant risk factors for pressure ulcer development (Saghaleini et al., 2018). Tissue viability and preservation of skin require an adequate nutritional intake. Factors which can influence a service users’ nutritional status include issues with swallowing, declining cognition, mobility issues and lack of appetite may affect the level of tissue tolerance (Saghaleini et al., 2018). The nutritional status of the service user should be part of the assessment of pressure ulcer risk (NICE, 2014).

The Association of UK Dietitians (2019) describe one role of a dietician is to try and prevent and manage pressure ulcers by optimising the patient’s nutrition status. They suggest that pressure ulcers may occur in overweight or underweight service users, with the skin requiring a good supply of fluid and nutrients to maintain good circulation and to keep it supple. A balanced diet and a healthy body weight will help to reduce the risk of developing a pressure ulcer (The Association of UK Dietitians, 2019).

The British Association for Parenteral and Enteral Nutrition (BAPEN), 2016 launched a screening tool in the UK in 2003, the ‘Malnutrition Universal Screening Tool’ (‘MUST’). This tool is completed by nursing staff and identifies those who may be at nutritional risk. The Services Users identified, together with those who score ‘at risk’ for pressure damage on the Waterlow score (2005) should then be referred to the dietetics team (BAPEN, 2016). NICE (2012) recommend that all hospital inpatients should be screened for malnutrition using a validated screening tool, for example, ‘MUST’.

The dietetics team will also work alongside other members of the MDT. Discussions with doctors and pharmacists may highlight any of the service users’ medications which may be causing a reduction in appetite, and the Speech and Language Therapists (SALT) could be spoken to if there are any swallowing impairments which may impact on nutritional intake. Occupational Therapists can assist by giving equipment aids to those who cannot feed themselves (Jaul, 2010).

Research suggests that nutritional supplementation, which assists in providing additional calories and protein, may help to prevent the development of pressure ulcers, with these being given either orally or through enteral feeding (Jaul, 2010). Benefits and risks of enteral feeding should be discussed with other members of the Multidisciplinary Team, the service user and their family members.

3.1.4      Occupational Therapists 

In the local NHS trust Occupational Therapists rely on a referral from the nursing team to become involved in patient’s care (Placement hospital, 2019).

Wounds may negatively affect a person’s ability to participate in their usual routines, this may impact on self-care, work, social activities and sleep, therefore impacting on a person’s quality of life (Amini, 2018). The Occupational Therapist’s role is to improve people’s ability to function as independently as possible (Royal College of Occupational Therapists, 2019). Within pressure ulcer prevention this could include providing modifications to the environment whilst the wound is healing and providing adaptive equipment to assist with the activities of daily living. An Occupational Therapist can also help to position the body in order to alleviate points of pressure, for example, distribution of weight and postural alignment. They may also provide education to service users in skin care techniques, including moisture control and prevention of dry skin, plus suggesting transfer techniques to minimise the risk of tearing the skin (Amini, 2018).

Members of Allied Health Professionals, such as Occupational Therapists, could have a great potential to be largely involved in prevention of pressure ulcers. However, in spite of this, research has shown some difficulties are still being found. Worsley et al., (2018) observed that some Occupational Therapists had experienced situations whereby they had moved patients from their bed to the chair to encourage movement, but consequently had been asked not to sit patients out due to a lack of nursing staff who can return the patient back to bed. Worsley et al., (2018) also reported a lack of communication with regard to pressure ulcer prevention, some Occupational Therapists did not feel confident to discuss pressure ulcer prevention with the nurses because they thought they had more knowledge than them.

3.1.5      Interprofessional working

The Interprofessional working relationship between Nursing staff, Dieticians and Occupational Therapists should enable goals to be established and prevention plans to be prepared. These should then be evaluated regularly (EPUAP, NPUAP, PPPIA, 2019).

In order to support effective interprofessional working for pressure ulcer prevention, early recognition of an at-risk patient, via a risk assessment, should be carried out with prompt referrals to the appropriate teams (NICE, 2014). Patients who are at-risk of pressure ulcers should be made easily recognisable to all members of the MDT, which should then remind all staff to reposition patients. The importance of repositioning, together with advice regarding a healthy diet, should be communicated to all staff on the ward.

The identified stakeholders all have a role in the reduction of pressure ulcers within the local health trust (Placement hospital, 2019). Therefore, it could be said that collaborative working is necessary to ensure the best possible care.

 

5.0. Conclusion

 

NICE guidelines (2014) have stated that the risk of pressure ulcers for patients is greatest when they have impaired mobility, impaired nutrition and poor posture, therefore it could be concluded that input from the Occupational Therapist and Dietician are invaluable to prevent pressure ulcers developing. However, it is currently the nurse’s responsibility to make these patients known to these members of the multi-disciplinary team. It is only then that they provide their input regarding equipment, nutrition and education.

With NPUAP (2016) suggesting that repositioning is the foundation of pressure ulcer prevention, Intentional Rounding tools present an ideal opportunity for nursing staff to provide an ongoing assessment of their patients position and comfort after the initial admission process has taken place, allowing for referrals to other members of the MDT, not only on admission, but throughout the patients stay in hospital.

Communication between the members of the MDT could possibly still be improved. Worsley et al., (2018) suggests that education is lacking within teams as to who’s responsibility pressure ulcer prevention is. Furthermore, Soban et al., (2017) suggest that traditionally pressure ulcer prevention is determined by nursing interventions. However, whilst it may be the nurse who refers the patient to other members of the MDT, maybe if patients were easily recognisable as being at risk, both by a visual prompt at the bedside and by ensuring it is on the handover sheet, then referrals could take place not only on the admission of the patient, but any time that is necessary. Perhaps this may then go towards prompter pressure ulcer prevention for the patient.

6.0 Recommendations

6.1  Education and training for staff

SPECIFIC

Continue to include pressure ulcer prevention education for all healthcare professionals within annual training sessions, specifying the role of the MDT within this training. Ensure that the completion of Intentional Rounding tools is part of this training.

MEASURABLE 

The training is within the annual training skills programme, plus ongoing training by staff on the ward.

ACHIEVABLE 

Intentional Rounding can be part of training scenarios. Tissue Viability Specialist nurses could provide further training and workshops for all members of the MDT.

REALISTIC  

It is feasible to include this within the annual training programme.

TIME RELATED 

Can be implemented straight away.

6.2  Patient Education

SPECIFIC  

Ensure patients are educated on the importance of movement to prevent pressure ulcers.

MEASURABLE 

When Intentional Rounding is completed by staff on the ward, reminders to move could be given to the patient.

ACHIEVABLE 

Incorporated within the Intentional Rounding tools.

REALISTIC  

Staff to be trained in annual training sessions and passed on to colleagues and reminders in handover.

TIME RELATED 

Can be implemented straight away.

 

6.3 ‘At risk of pressure ulcers’ sticker to be used above bed 

SPECIFIC  

A sticker could be placed above the bed to ensure all staff who come into contact with patient are aware of their pressure ulcer risk.

MEASURABLE 

Nurses or Nursing Assistants can ensure the sticker is in place once patient is identified as high risk.

ACHIEVABLE 

Small financial implication in producing stickers but should reduce financial implications in the long run.

REALISTIC  

Stickers are used already for patients who are risk of falls, therefore this should not be an issue to produce for pressure ulcer risk.

TIME RELATED 

Could be implemented once stickers have been produced. Funding could be sought from hospital budget.

6.4 ‘At risk of pressure ulcers’ to be highlighted within handover 

SPECIFIC 

Ensure that handover sheets include whether a patient is at risk of pressure ulcers.

MEASURABLE 

Nurses to include this within handover template and highlighted to next shift.

ACHIEVABLE 

Incorporated within handover.

REALISTIC  

Handovers are already in circulation.

TIME RELATED 

Can be implemented straight away.

7.0. References

Amini, D. (2018) ‘Role of Occupational Therapy in Wound Management’, The American Journal of Occupational Therapy, Volume 72, pp. 1-9.

BAPEN (2016) Screening & ‘MUST’. Available at: https://www.bapen.org.uk/screening-and-must/must(Accessed: 27 April 2019).

Clarkson, P. et al. (2016) ‘A multidisciplinary approach to pressure ulcer prevention: exploring healthcare professionals’ knowledge and attitudes to pressure ulcer prevention in the community’, Physiotherapy, 102(1), pp. 256-257.

Dealey, C., Posnett, J. and Walker, A. (2012), ‘The cost of pressure ulcers in the United Kingdom’, Journal of Wound Care, 21(6), pp. 261-266.

EPUAP (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Available at: http://www.epuap.org/wp-content/uploads/2016/10/quick-reference-guide-digital-npuap-epuap-pppia-jan2016.pdf(Accessed: 19 April 2019).

EPUAP, NPUAP and PPPIA (2019) Prevention and Treatment of Pressure Ulcers/Injuries: Methodology Protocol for the Clinical Practice Guideline (Third Edition). Available at: http://www.internationalguideline.com/static//pdfs/Methodology-Protocol-Guideline-vDec2018.pdf (Accessed: 27 April 2019).

Gorecki, C. et al. (2011) ‘Patient-Reported Pressure Ulcer Pain: A Mixed-Methods Systematic Review’, Journal of Pain and Symptom Management, 42(3), pp. 443-459.

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National Pressure Ulcer Advisory Panel (2016) NPUAP Pressure Injury Stages. Available at: https://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/(Accessed 19 April 2019).

National Institute of Health and Care Excellence (2012) Nutritional support in adults. Available at: https://www.nice.org.uk/guidance/qs24/chapter/quality-statement-1-screening-for-the-risk-of-malnutrition#quality-statement-1-screening-for-the-risk-of-malnutrition(Accessed: 27 April 2019).

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Woodhouse, M. et al. (2015), ‘The physiological response of soft tissue to periodic repositioning as a strategy for pressure ulcer prevention’, Clinical Biomechanics, 30(2), pp. 166-174.

Worlsey, P. et al. (2017) ‘Identifying barriers and facilitators to participation in pressure ulcer prevention in allied healthcare professionals: a mixed methods evaluation’, Physiotherapy, 103(3), pp. 304-310.