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 4

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 8

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. 9

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:

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Date of Admission

WEB ref.: Age:

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Directorate: Current ward:

Ward

Ward(s) during first 72 hours post admission:

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Ward(s) post 72 hours admission period:

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Site and Grade of Pressure Ulcer

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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

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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