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The home front on pressure ulcers

Tissue viability specialist nurses at Guy’s and St Thomas’ trust in London are training care home staffand community carers to prevent and manage pressure ulcers. The successful Zero Pressure campaign stresses immediate response to any sign of skin reddening.

One of the best things about Leonie Bell’s job is seeing a problem that someone has had, sometimes for years, and being able to do something about it – often beyond patient expectations.

A tissue viability specialist nurse at Guy’s and St Thomas’ NHS Foundation Trust in London, her delight in treating pressure ulcers – and transforming lives – shines through.

‘I’ve loved wounds forever,’ she says. ‘Some people have wounds and think that’s it, there’s nothing they can do about it. But we can manage it, improve the symptoms, and improve people’s lives. And if we can ultimately heal that wound – well, that’s just really satisfying.’

Pressure ulcers have moved up the agenda with NHS campaigns such as Stop the Pressure – an initiative begun in the East Midlands, now rolled out across NHS England – and targets on reducing incidence (see box). Good progress has been made in hospitals, but there has been less focus on community settings.

Pressure ulcer profile

Nearly 700,000 people in England are affected by pressure ulcers each year, in hospitals, in care homes and in their own homes.

Figures from NHS England suggest that 186,617 people develop a pressure ulcer in hospital each year.

Each pressure ulcer adds around £4,000 to care costs.

Between 80% and 95% of pressure ulcers are believed to be avoidable.

Patients who are unwell, have incontinence issues, are not eating or drinking properly, and who have reduced mobility are at higher risk of developing pressure ulcers.

According to NHS Improving Quality, avoidable pressure ulcers are a key indicator of the quality of nursing care. (www.nhsiq.nhs.uk/improvement-programmes/patient-safety/pressure-ulcers.aspx)

Yet, according to Stop the Pressure (nhs.stopthepressure.co.uk/care-homes.html), about one in five people in nursing and residential homes will be affected by pressure ulcers.

That’s why Ms Bell (pictured) and the tissue viability team are going into care homes to train staff in how to prevent and manage pressure ulcers among their residents – with impressive results.

The team’s Zero Pressure campaign began in April 2014 in response to a CQUIN (Commissioning for Quality and Innovation) target to tackle pressure ulcers, explains Guy’s and St Thomas’ tissue viability nurse manager Claire Acton.

‘Our pressure ulcer incidence [in hospitals] was already quite low, but we recognised that there was a bit of a gap in nursing homes,’ she says. ‘We have 14 care homes in the two boroughs we cover [Lambeth and Southwark] and we put two tissue viability nurses into each of them to do training with staff.

‘By September this year, nine out of the 14 had 365 pressure ulcer-free days, and three had gone for more than 600 days without a pressure ulcer, which is fantastic.’

Leonie Bell assists Felicia Badejo with an examination at Uplands Care Home

Picture credit: David Gee

The training involved teaching staffat the homes to ‘react to red’ – any skin reddening that might lead to damage – and introduced the safety cross to note numbers of pressure ulcer-free days. The tissue viability nurses also provide ongoing support and can advise if staff are concerned about what to do.

The response from the care homes has been brilliant, Ms Acton says. ‘We’ve embraced them into the trust ethos, which is to celebrate success, so when they reach 100 pressure ulcer-free days, we bring them in, give them a certificate, and again for 200 days, and 365 days. The care homes like it because they can demonstrate that they have good quality care.’

Ms Bell presents Ololade Nadi with Uplands Care Home’s certificate for achieving 200 days free of pressure ulcers

Picture credit: David Gee
Questions for carers

Ms Acton says that it is hard to quantify exactly how much incidence of pressure ulcers has fallen as a result of Zero Pressure. Tissue viability nurses from the trust also work in the community in people’s own homes.

‘We’ve offered similar training to care agencies to raise awareness,’ explains Ms Acton. ‘We want carers to ask themselves a number of questions, such as “is it red, are they immobile, what’s their nutrition like?” If anything ticks more than two boxes, they should refer on to a health professional.’

By the end of October, more than 1,000 care agency staff had been trained. Keeping it simple and focused is the key, Ms Acton says. ‘It’s not about pressure ulcers; it’s about looking at skin and if it’s red, doing something about it.’

Ms Bell also finds that care home staffhave been keen to take part in the training, and confidence in preventing and managing pressure ulcers has grown, particularly among unregistered staff. ‘These are the people who are doing the skin care on a daily basis,’ she says. ‘The feedback we’ve had is that they feel more empowered to check skin, and to refer on if required.’

Having pressure ulcer champions in the home also helps to give the issue a higher profile.

Improving quality

At Uplands Care Home in Streatham, London, staff are celebrating more than a year free from pressure ulcers among the residents, and unit manager Loraine Cumberbatch is delighted. ‘It’s had a real impact on care at the home,’ she says. ‘We’re heading for 400 days without a pressure ulcer. I think we’re really improving quality of care.

‘The training has helped our staff to have the confidence to notice the signs of pressure ulcers and to seek help. They feel empowered and know they can approach the tissue viability nurses for support.’

At a national level, the Stop the Pressure campaign work continues to be led by Ruth May, nurse director at Monitor. A spokeswoman for NHS England says one of the priorities of the Stop the Pressure programme board is supporting care homes: ‘We have a collaborative programme working with some care home providers sharing best practice and are also sharing the learning from similar care home projects across the country.’

Ms Bell says that she still gets a buzz from seeing the human results, not just of her training of others, but also of her own hands-on care.

‘There was one man who had had leg ulcers for years, and it took time, but they could all be cured,’ she recalls. ‘It had such an impact on him. His pain had subsided, he was able to sit in his chair again for quite a long time, and he got back some of his quality of life. Of course that’s great for the patient, but for a nurse, that’s really rewarding’.

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