Pressure Ulcer Prevention and
Management Policy
Type: Strategy / Policy
Developed in response to:
Contributes to CQC Regulation
Trust requirements Best Practice
Consulted With
Rabina Tindale
Lorraine Grothier
Clive Gibson
Professionally Approved By
Lyn Hinton
Register No: 10132
Status: Public
9, 11
Post/Committee/Group
Associate Director for Nursing
Consultant Nurse Tissue Viability,
Provide Community Services
Adult Safeguarding Named Nurse.
Lyn Hinton, Acting Chief Nurse
Version Number
Issuing Directorate
Ratified by:
Ratified on:
Executive Management Board Sign Off Date
Implementation Date
Next Review Date
Author/Contact for Information
Policy to be followed by (target staff)
Distribution Method
Related Trust Policies (to be read in conjunction
with)
Document Review History
Version Number Authored / Reviewed by
1.0
Anne Marie Brown
2.0
Lindsay Young
Date
Oct 2015
Oct 2015
Oct 2015
Dec 2015
2.0
Corporate
Document Ratification Group
27 January 2016
February 2016
29th January 2016
January 2019
Lindsay Young Tissue Viability Clinical Nurse
Specialist Mid-Essex Hospitals NHS Trust
All healthcare professionals
Intranet and Website
Mandatory Training Policy (Training Needs
Analysis) 08092
Being Open Policy 08063
Safeguarding Vulnerable Adults Policy 08034
Clinical record keeping standards policy 08086
Discharge Policy 11037
Date
27th January 2011
29th January 2016
1
Index
1.
Purpose
2.
Background
3.
Scope
4.
Definitions
5.
Staffing & Management Responsibilities
6.
Staff Training
7.
Pressure Ulcer Risk Assessment
8.
Use of Support Surfaces for Pressure Ulcer Prevention
9.
Reporting process for Pressure Ulcers
10.
Inherited Pressure Ulcer reporting process
11.
Hospital Acquired Pressure Ulcer Reporting Process
12.
Patient Care on Identifying a Pressure Ulcer
13.
Communication of Risk
14.
Support for Staff Following an Event
15.
Discharge from Hospital
16.
Equality and Diversity
17.
Audit & Monitoring
18.
Review
19.
Communication & Implementation
20.
References & Further Reading
Appendix 1 - Unavoidable Pressure Ulcer Definition – Page 11
Appendix 2 – Waterlow Risk Assessment – Page 12
Appendix 3 – Dynamic Mattress Ordering Process – Page 13
Appendix 4 – MEHT Pressure Ulcer Process – Page 14
Appendix 5 – Root Cause Analysis – Page 15
Appendix 6 – Pressure Ulcer Panel Review - Page 16
2
1.0
Purpose
1.1
The purpose of this policy is to provide information and guidance to registered nurses,
healthcare assistants, allied health professionals and medical staff who work within
in-patient wards and departments, to ensure a consistent and safe approach across
the Trust in the assessment, prevention and management of Pressure Ulcers.
1.2
The policy aims to raise awareness amongst staff about the risk of the development
of Pressure Ulcers and the appropriate management of these risks including the risk
assessment process and incident reporting and to facilitate the implementation of best
practice.
.
1.3
Specifically the policy provides guidance on:
•
•
•
The actions staff should take to ensure that patients admitted to the trust with
existing pressure ulcers are adequately assessed and if necessary referred to the
appropriate services.
The actions staff should take to identify all patients at risk of developing pressure
ulcers on admission and at changes in their medical condition.
The actions staff should take to ensure the appropriate and timely care of patients
following the identification of a pressure ulcer.
1.4
Where pressure ulcers do occur the contributing factors within the hospital should be
investigated and adequately controlled.
2.0
Background
2.1
Pressure ulcers are caused when an area of skin and/or the tissues below are
damaged as a result of being placed under sufficient pressure or distortion to impair
its blood supply. Typically they occur in a person confined to a bed or a chair most of
the time by an illness; as a result they are sometimes referred to as 'bedsores', or
'pressure sores'.
2.2
All people are potentially at risk of developing a pressure ulcer. However, they are
more likely to occur in people who are seriously ill, have a neurological condition,
impaired mobility, poor posture or a deformity, compromised skin or who are
malnourished.
2.3
Pressure ulcers represent a major burden of sickness and reduced quality of life for
people and their carers. They can be debilitating for the patient, with the most
vulnerable people being those aged over 75. Pressure ulcers can be serious and lead
to life-threatening complications such as blood poisoning or gangrene. Pressure
ulcers are graded with increasing severity from category 1–4, according to the
European Pressure Ulcer Advisory Panel classification system.
2.4
A review of death and severe harm incidents reported to the National Reporting and
Learning System found that pressure ulcers were the largest proportion of patient
safety incidents in 2011/2012, accounting for 19% of all reports. It has been
acknowledged that a significant proportion of pressure ulcers are avoidable.
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3.0
Scope
3.1
This policy relates to all patients admitted to the trust at risk of developing pressure
ulcer, those with pre-existing pressure ulcers and those who develop pressure ulcers
whilst an in patient at the trust.
3.2
All staff working within the Trust are expected to adhere to this policy.
4.0
Definitions
4.1
Pressure Ulcer
A pressure ulcer is localised injury to the skin and/or underlying tissue over a bony
prominence, as a result of pressure, or pressure in combination with sheer and/or
friction. A number of contributing or confounding factors are also associated with
pressure ulcers, the significance of these are yet to be elucidated (NPUAP).
4.2
Avoidable pressure ulcer
Avoidable pressure damage is defined as pressure damage which could have been
avoided if all preventative actions possible had been put in place. See East of
England Definitions.
4.3
Unavoidable Pressure Ulcer
Unavoidable means that the individual developed a pressure ulcer even though the
individuals condition and pressure ulcer risk had been evaluated; goals and
recognised standards of practice that are consistent with individual needs has been
implemented; the impact of these interventions had been monitored, evaluated and
recorded; and the approaches had revised as appropriate.
http://nhs.stopthepressure.co.uk/Path/docs/Definition%20unavoidable%20PU.
4.4
Hospital acquired pressure ulcer
A pressure ulcer which is acquired within the Trust, this was not evident on admission
and developed after 72 hours following admission.
4.5
Community acquired/Inherited Pressure Ulcer
A pressure ulcer that is evident on admission to hospital and was acquired outside of
the Trust, or developed within 72 hours of admission to the trust.
4.6
Active dynamic mattress
A support surface which provides pressure redistribution via cyclic changes in loading
and unloading. These may be programmed to benefit tissue pressure redistribution.
4.7
Static Mattress
A high specification medical mattress which consists of a high specification foam with
pressure redistributing properties and is covered with a durable launder able cover.
5.0
Staffing and Management Responsibilities
(Staff responsibilities following an incident can be found in section 9)
5.1
Chief Nursing Officer and Chief Medical Officer
5.1.1 The Chief Nursing Officer and Chief Medical Officer are the nominated Executive
Directors with responsibility for patient safety and will act on behalf of the Chief
Executive to ensure processes are in place to manage the risks associated with
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pressure ulcer prevention and management including implementing and monitoring
this policy.
5.1.2 The Chief Nursing Officer is the nominated Executive Director with responsibility for
Health and Safety of persons on premises and will act on behalf of the Chief
Executive to ensure processes are in place to manage the risks associated with
pressure ulcer prevention and management including implementing and monitoring
this policy.
5.2
Lead Nurse – Tissue Viability
5.2.1 Leading the implementation and development of the patient pressure ulcer policy
throughout the trust. Ensuring policies are adhered to through consultation and audit.
5.2.2 To provide clinical expertise in the implementation and monitoring of the pressure ulcer
prevention strategy to reduce the number of hospital acquired pressure ulcers.
5.2.3 To be responsible for the multi-professional staff education on pressure ulcer
prevention and management to ensure implementation of the agreed pathways of care
and to reduce the incidence of hospital acquired pressure ulcers.
5.2.4 Analyse pressure ulcer data, identifying trends, demonstrating the need for
improvement and working with the clinical teams to achieve this. Presenting pressure
ulcer data to the monthly Pressure Ulcer Steering Group and providing quarterly
reports to the Clinical Governance Group.
5.2.5 Provide guidance regarding the management of complex patients with pressure ulcer
related problems and provide specialist assessment and advice on the appropriate
management of patients including effective risk prevention strategies and
implementation of pressure relieving equipment.
5.3
Heads of Nursing, Matrons, Clinical Operational Managers (COM), Ward Sisters
and other Supervisors
5.3.1 To ensure that steps are taken to implement the requirements of Trust policies and
management guidelines.
5.3.2 To ensure all staff receives training in pressure ulcer prevention and safe use of
pressure relieving equipment in accordance with the Trust’s Training Needs Analysis
and in the use of any equipment required to comply with this policy. To follow up all
incidents associated with pressure ulcers to identify their cause and review the control
measures in place.
5.4
All Employees
5.4.1 All Employees have an individual responsibility and accountability for the provision of
safe and competent practice and are expected to adhere to Trust policies and follow
the guidelines to prevent risks to themselves and others.
5.5
Organisational Groups
5.5.1 Clinical Governance Group is responsible for receiving a quarterly report from the
Lead Nurse for Tissue Viability on all matters relating to the Trust’s Pressure Ulcer
Prevention Strategy together with appropriate risk control measures to eliminate or
5
reduce any identified risks. The group will take any action it feels appropriate in the
light of that received report.
5.5.2 Pressure Ulcer Steering and Panel Group is accountable to the Patient Safety and
Quality Committee via the Clinical Governance Group. The Pressure Ulcer Steering
Group is responsible for the promotion of the Pressure Ulcer Prevention agenda in
line with national and local guidelines. The group is also responsible for the on-going
monitoring of all pressure ulcers reported within MEHT. This includes ensuring that
the outcomes of incidents and lessons learnt are shared effectively. The Pressure
Ulcer Panel is a sub group of the Pressure Ulcer Steering Group and is responsible
for providing a multi-professional investigation of hospital acquired pressure ulcer
incidents grade 2,3 and 4. The panel review incidents using a Pressure Ulcer Root
Cause Analysis investigation to identify the root causes with the intent of reducing the
likelihood of recurrence.
6.0
Staff Training
All registered nursing and healthcare support workers will receive pressure ulcer
prevention training on induction. Pressure ulcer prevention updates will be available
via e-learning or planned sessions and will be undertaken every 2 years.
7.0
Pressure Ulcer Risk Assessment
7.1
All patients will receive an Anderson Pressure Ulcer Risk Assessment within 60
minutes of arrival to the emergency department.
7.2
Once a patient is admitted to MEHT they will have a Waterlow Pressure Ulcer Risk
Assessment undertaken within 6 hours of admission. This will be repeated at every
transfer to a different ward area and at any change in the patient’s condition. (see
Appendix 2)
7.3
A visual inspection of the patient’s skin will be performed and a body map will be
completed and accurately documented in the nursing documentation on admission
and at transfer to a new ward. The body map will be updated if a new injury to the
skin or pressure ulcer occurs.
8.0
Use of support surfaces for pressure ulcer prevention
8.1
All inpatients will be nursed as a minimum on a high specification foam mattress.
8.2
Where a patient is deemed to be at high risk of developing pressure ulcers following a
formal risk assessment they will be nursed on an Active Dynamic Mattress, (see
appendix 3) for ordering process of mattresses.
8.3
A&E trollies will have a high specification foam mattress on them. Where a patient is
deemed at high risk of developing pressure ulcers or has pressure ulcers they will be
transferred to an appropriate bed and as a minimum a high specification foam
mattress until an active dynamic is obtained.
9.0
Reporting process for pressure ulcers
9.1
All grades of pressure ulcer, 1, 2, 3 and 4 identified upon admission or that occur
within 72 hours of admission will be reported using the electronic reporting system
Datix upon identification. These will be reported under the category “Pressure Ulcer”
6
and sub category “Inherited Pressure Ulcer” followed by the grade. (See appendix 4)
9.2
All grades of pressure ulcer, 1, 2, 3 and 4 which occur within MEHT after 72 hours of
admission will be reported using Datix electronic incident report. These will be
reported under the category “Pressure Ulcer” and sub category “Hospital Acquired
Pressure Ulcer” followed by the grade.
9.3
All patients with pressure ulcers will be referred to Medical Photography. The Medical
Photography department will attach medical images to the Datix report. Patients who
have pressure ulcers will have medical photography performed prior to discharge or
transfer to a different healthcare provider.
10.0 Inherited pressure ulcer investigation process
10.1 Following identification of an inherited pressure ulcer a Datix will be submitted by the
ward staff.
10.2 The ward sister or a deputy will be nominated as the investigator.
10.3 Consideration must be given to the history of the pressure ulcer and any omissions of
care/neglect and any safeguarding concerns reported to the MEHT safeguarding
team.
10.4 Grade 3 and 4 pressure ulcers will have a Pre 72 hour alert completed by the Tissue
Viability (TV) team. The alert will be sent by the TV team to the last known provider of
care for investigation.
11.0 Hospital Acquired Pressure Ulcer investigation process
11.1 Following the identification of a Hospital Acquired Pressure Ulcer a Datix will be
submitted by the ward staff.
11.2 The ward sister or a deputy will be nominated as the investigator.
11.3 Consideration will be given to the safeguarding process and any safeguarding
concerns reported to the MEHT safeguarding team.
11.4 A member of TV will assist staff to validate the grade of the pressure ulcer in the ward
area/dept.
11.5 For grades 2, 3 and 4 a Root Cause Analysis (RCA) investigation will be carried out
by the ward sister or deputy within 72 hours of the incident occurring. The RCA will be
attached as a document to the Datix. (See appendix 5)
11.6 A panel review will be convened which as a minimum will include the ward sister
or/and the deputy, the Lead Tissue Viability Nurse (TVN), the Matron for the division
where the incident has occurred. Other members of the Multi-Disciplinary Team
(MDT) as well as any ward staff will be encouraged to attend the panel review so that
learning may be shared.A decision will be made at the panel review whether the
pressure ulcer incident was avoidable or unavoidable.
11.7 The TVN will complete a panel review summary (see appendix 6) which will be
attached to the Datix and Governance will be alerted as to the outcome.
7
11.8 The incident will be raised as a Serious Incident (SI) by the Governance Department.
12.
Patient Care on Identifying a Pressure Ulcer
12.1 Following a formal Waterlow pressure ulcer risk assessment and visual skin
inspection, if pressure related tissue damage is evident a management plan must be
identified in the nursing and clinical documentation.
12.2 All pressure related tissue damage will be indicated on the body map within the
nursing documentation, this will include the grade of the pressure ulcer and
dimensions.
12.3 A mobility and Moving and Handling assessment will be performed and where the
patient is unable to reposition themself independently a repositioning plan and turning
regime will be clearly documented within the nursing documentation.
12.4 A patient who has a grade 3 or 4 pressure ulcer should have a referral to the dietician
department at MEHT.
12.5 A wound assessment will be carried out by the registered nurse and a management
plan documented in the patients clinical notes. A referral to the TV team should be
made where a complex wound is evident.
12.6 A patient with a grade 3 pressure ulcer or above should be nurse on an active
dynamic mattress unless contra indicated.
13.0 Communication of Risk
13.1 To ensure effective communication of risk of a patient developing pressure ulcers the
Waterlow score and any tissue damage will be handed over at shift change.
13.2 A manual handling plan will be available for anyone needing to assist a patient with
repositioning.
14.0 Support for Staff Following an Event
14.1
Any member of staff involved in a slip, trip or fall event can obtain immediate advice
and support from their line manager or the Governance team. For further information
on supporting staff refer to the Support for Staff Involved in a Traumatic Incident,
Complaints, and Claims policies.
15.0 Discharge from hospital
15.1 Medical photography should be taken for all patients with pressure ulcers prior to
discharge.
15.2 Referral should be made to district nursing team for wound management prior to
discharge.
15.3 The pressure ulcer including location, grade and dimensions will be documented on
the nursing and medical discharge summary.
15.4 Consideration will be given for ongoing equipment needs upon discharge and
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equipment will be in place prior to discharge home.
16.0
Equality and Diversity
16.1
The Trust is committed to the provision of a service that is fair, accessible and meets
the needs of all individuals
17.0
Audit and Monitoring
17.1 Monitoring
17.1.1 The Associate Chief Nurse, Lead Nurse for Tissue Viability and the Pressure Ulcer
Steering Group will monitor incident frequencies and near misses in relation to
Pressure Ulcers. Incident report will be regularly reviewed by the Pressure Ulcer
Steering Group and Clinical Governance Group.
17.2 An annual audit of compliance with this policy will be undertaken by the Lead Nurse
for Tissue Viability with support from the Clinical Audit Team.
17.2.2 This audit will assess the requirement to undertake appropriate risk assessments
for the prevention and management of pressure ulcers involving patients and the
development of appropriate care plans.
17.2.3 The findings of the audit will be reported to the Pressure Ulcer Steering Group and
subsequently to the Clinical Governance Group. Where deficiencies are identified,
actions with named leads and timescales will be developed and progress with
implementation monitored at subsequent Pressure Ulcer Steering Group meetings
18.0
Review
18.1 The policy will be reviewed on a two yearly basis unless earlier revision is required as
the result of any changes in legislation, the Trust’s assessment processes or
technological improvements.
19.0
Communication & Implementation
19.1
The policy will be made available on the Trust’s intranet and website. The Health and
Safety Team and Professional Development Team will be responsible for issuing
copies to all Directorate Leads and Ward Sisters for dissemination within their
departments.
19.2
The approved policy will be notified in the Trust’s Staff Focus that is sent via e-mail to
all staff.
20.0
References & Further Reading
Department of Health (2015) Quality standard (QS) 89 prevention of pressure ulcers
European Pressure Ulcer Advisory Panel (2009).Classification of pressure damage.
Healey F. (2006) Root Cause Analysis for Tissue Viability Incidents. Journal of Tissue
Viability 16(1): 12-15.
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National Patient Safety Agency (2003) RCA Toolkit. www.nhs.uk/rca.
NHS Institute for Innovation and Improvement (2009) High Impact Actions for Nursing and
Midwifery. University of Warwick.
National Health Service England, Serious Incident Framework, March 2015
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Appendices – 1 to 6
11
12
13
Pressure Ulcer Identification & Actions Protocol
Criteria: All inpatient Pressure Ulcers (PU) where wounds are identified and agreed to be pressure ulcers to follow this protocol.
Other wounds (such as skin tears, leg ulcers, moisture damage) are excluded.
Inherited PU- identified within 72 hours of admission
to hospital.
Grade 1 & 2 –
• Body Map
• Datix
• Request Medical
Photograph of site
(to be completed
by Ward)
Grade 3 & 4 –
• Body Map
• Datix
• Request Medical
Photograph of site
(to be completed
by Ward)
Hospital Acquired PU- identified after 72 hours of admission to hospital
Grade 1 –
• Body map
• Datix
(Within 6 hours)
• Request Medical
Photograph of site (to be
completed by Ward)
Grade 2 –
• Body map
• Datix
(Within 6 hours)
• Request Medical
Photograph of site (to be
completed by Ward)
Grade 3 & 4 –
• Body Map
• Datix
(Within 6 hours)
• Request Medical
Photograph of site (to be
completed by Ward)
Sister/Charge Nurse to complete Root Cause Analysis and attach to Datix within 72 hours.
Complete the Pressure
Ulcer Alert form and
attach to Datix within 24
hours and send via
[email protected] to
appropriate
Organisation (to be
completed by Tissue
Viability Team)
Speciality Matron to arrange RCA panel review. Panel to be held within 10 days.
Attendees to include:
Tissue Viability Nurse (TVN)
Ward Sister/relevant nursing staff
Ward Physiotherapist/Occupational Therapist
Speciality Matron (Panel Chair)
Consultant or member of the medical team
Ward Pharmacist.
Panel Review outcome to be completed by TVN and attached to Datix and Governance alerted.
(Consideration against the Serious Incident (SI) Framework and report as an SI if criteria reached).
Outcome of Panel Review and related themes from aggregated LEAP to be presented to the next:
• Tissue Viability Steering Group.
• Directorate Governance Group.
Aggregated LEAP to be reviewed monthly at the Directorate Governance meetings until actions have been
completed.
CONCISE RCA TEMPLATE for PRESSURE ULCERS
RCA Framework for Pressure Ulcer Panel ‘Patient Presentation’ Grades 2 / 3 and 4
Overview
Name:
Incident date:
Click here to enter
text.
Click here to enter
text.
Date of Admission
WEB ref.:
Age:
Click here to enter text.
Click here to enter
text.
Click here to enter
text.
Directorate:
Current ward:
Ward
Ward(s) during first 72 hours post admission:
Click here to enter text.
Ward(s) post 72 hours admission period:
Click here to enter text.
Site and Grade of Pressure Ulcer
Click here to enter text.
Click here to enter
text.
Click here to enter
text.
Click here to enter text.
Significant medical History (including other co-morbidities present relevant to pressure)
Click here to enter text.
Yes☐
No☐
Vulnerable Adults Concerns
Additional Information if required:Click here to enter text.
Timeline Summary (eg pressure area care given, skin, inspection identification of pressure damage and
actions taken, dressings used to facilitate healing)
Date / time
Detailed summary
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
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Root Cause Analysis Panel Review for Grade 2, 3 and 4 Hospital
Acquired Pressure Ulcers
WEB
Date:
Time:
Chair:
Present
Agreement on avoidable / non avoidable
Summary of how the outcome & conclusions have been reached.
The panel considered all aspects of the patients care during the inpatient
admission at MEHT, including the patient’s general health, assessment of the
skin, mobility, nutrition, repositioning and support surfaces used.
Root cause
Duty of candour
(Who will share the information with the patient/family and how this will be
shared)
Tissue Viability Steering Group agreement on avoidable /non avoidable
Date:
16