Pressure ulcer prevention policy - the Royal Cornwall Hospitals ...

Policy for the Prevention of Pressure UlcersV05May 2013Policy for the Prevention of Pressure UlcersPage 1 of 34

Table of Contents1. Introduction ................................................................................................................... 42. Purpose of this Policy/Procedure .................................................................................. 43. Scope ........................................................................................................................... 44. Definitions / Glossary .................................................................................................... 45. Ownership and Responsibilities .................................................................................... 46. Standards and Practice ................................................................................................ 56.1. Pressure Ulcer Prevention Principles of Practice .................................................. 56.3. Risk Assessment ................................................................................................... 66.48. Skin Assessment ............................................................................................. 106.51. Grading Pressure Damage .............................................................................. 116.54. Management of Pressure Ulcers ...................................................................... 116.58. Patient Information ........................................................................................... 126.63. Patient Repositioning ....................................................................................... 126.70. Care of Patients Nursed on Trolleys ................................................................ 136.76. Patient Nutrition ............................................................................................... 136.78. Patient Continence ........................................................................................... 136.80. Equipment Selection ........................................................................................ 146.88. Obtaining Equipment ....................................................................................... 146.96. Discharge of Patients Requiring Specialist Equipment .................................... 156.107. Cleaning & Decontamination of Equipment and Reporting Faults ................... 166.117. Reporting of Pressure Damage ........................................................................ 176.124. Audit/ Monitoring .............................................................................................. 186.126. Complaints and Legal ...................................................................................... 187. Dissemination and Implementation ............................................................................. 188. Monitoring compliance and effectiveness ................................................................... 189. Updating and Review .................................................................................................. 1910. Equality and Diversity .............................................................................................. 1910.2. Equality Impact Assessment ............................................................................ 19Appendix 1-Pressure Ulcer Prevention Clinical Pathway ................................................... 20Appendix 2- Pressure Relieving Equipment Selection Guidelines ..................................... 21Appendix 3- Range of Equipment Guide ........................................................................... 22Appendix 4- Serious Incident (SI) Reporting Process ........................................................ 23Appendix 5-Standard Operating Procedure (SOP)- RCHT Pressure Ulcer Prevention DataCollection ........................................................................................................................... 24Appendix 6- Complaints Response Process ...................................................................... 28Policy for the Prevention of Pressure UlcersPage 2 of 34

Appendix 7- Legal Claims Response Process ................................................................... 29Appendix 8. Governance Information ................................................................................ 30Appendix 9.Initial Equality Impact Assessment Screening Form ....................................... 32Policy for the Prevention of Pressure UlcersPage 3 of 34

1. Introduction1.1. This policy sets out the framework to guide evidence based care in theprevention and management of pressure ulcers.1.2. This version supersedes any previous versions of this policy.2. Purpose of this Policy/Procedure2.1. The purpose of this policy is to ensure that the Trust meets best practicestandards for the prevention and management of pressure ulcers in line with national,regional and local guidelines.2.2. Implementation of this policy will help to ensure that:• There is clear guidance to ensure that the prevention and management ofpressure ulcers is standardised across the Trust.• All staff act in accordance with this policy to prevent the development ofpressure ulcers or to prevent the deterioration of existing pressure damage.3. ScopeThis document is applicable to all staff regardless of grade or profession, working within aclinical setting, caring for patients with, or at risk of, pressure ulcers.4. Definitions / Glossary4.1. Pressure Ulcer – ‘Localised injury to the skin and/or underlying tissue usuallyover a bony prominence, as a result of pressure, or pressure in combination withshear. A number of contributing or confounding factors are also associated withpressure ulcers; the significance of these is yet to be elucidated.’ (EPUAP 2009)4.2. Unavoidable – ‘Unavoidable’ means that the person receiving care developed apressure ulcer even though the provider of the care has evaluated the personsclinical condition and pressure ulcer risk factors; planned and implementedinterventions consistent with the persons needs and goals, and recognised standardsof practice; monitored and evaluated the impact of the interventions and revised theapproaches as appropriate; or the individual person refused to adhere to preventionstrategies in spite of education of the consequences of non-adherence.5. Ownership and Responsibilities5.1. Role of all staff- to be responsible for acting to reduce the number of patientsdeveloping pressure ulcers and achieving “no avoidable pressure ulcers in NHScare” (Department of Health, 2009).5.1.1. All staff must act to achieve the Principles of Practice outlined inSection 6.5.1.2. All staff will be responsible for reporting pressure ulceration inaccordance with this policy.Policy for the Prevention of Pressure UlcersPage 4 of 34

5.2. Role of the Tissue Viability service- to advise and support staff in achieving theprinciples of practice through visible role modelling and clinical support in practiceand through education and training in the form of study days, self-directed learningresources, and practical workshops.5.3. Role of the Equipment Library- to supply equipment to protect patients’ skinintegrity whilst in hospital. Nursing staff will be responsible for requesting anddocumenting the use of equipment.6. Standards and Practice6.1. Pressure Ulcer Prevention Principles of Practice6.2. All staff must adhere to the following principles of practice to ensure care isdelivered in accordance with the best available evidence and every possible step istaken to reduce the risk of pressure ulcers occurring.• All patients will be assessed for their risk of pressure ulcer developmentand any existing pressure damage immediately, within four hours ofadmission to hospital, when their condition changes, and on transfer ordischarge. This will be documented in the patient’s record andcommunicated as part of the nursing handover using the Waterlow riskassessment tool for adults, the Glamorgan score for paediatrics and theMaternity Pressure Ulcer risk assessment for maternity patients.• All patients will have a skin assessment carried out immediately, withinfour hours of admission, and throughout their stay according to the clinicalpathway (Appendix 1). This will be documented on the Risk Assessmenttool on admission and the skin assessment tool throughout their stay.• Any pressure ulcers present on admission must be documented at the topof the Waterlow risk assessment tool and reported on the Safety Crossand on Datix.• Where a patient develops pressure ulceration during their hospital stay thismust be reported on the safety cross and as a clinical incident. If thepressure ulcer deteriorates during their stay the Datix must be updated.The risk and patient safety team can do this for staff. If a Grade 3 or 4pressure ulcer this is investigated as a Serious Incident and patients are tobe informed according to the Being Open policy• Pressure damage must be described on the wound assessment tool bystating the Grade of damage, the site of damage, the size of the damagedarea and the condition of the wound bed.• Where a patient is at risk of pressure damage a pressure ulcer preventioncare plan must be written in agreement with the patient.• Patients, carers and relatives must be made aware of the reason for theassessment and intervention, and provided with the Trust informationleaflet RCHT 153.Policy for the Prevention of Pressure UlcersPage 5 of 34

• Patients, carers and relatives must be involved in decision makingregarding pressure area care and the use of devices to prevent and/ortreat pressure ulceration.• Communication with all members of the multi-disciplinary team involved incaring for the patient at risk of pressure damage is vital to ensure promptrecovery and optimum management of pressure areas across caresettings.• All patients at risk of pressure damage must have regular CARE roundsand skin assessments and immediate action must be taken if any signs ofpressure damage are identified. See Appendix 1 for clinical pathway forprevention of pressure ulcers.• Where necessary action will be taken to improve patients’ nutritionalstatus.• Where moisture may impact upon skin integrity and contribute to pressuredamage (i.e. incontinent patients) action must be taken to protect the skin.Skin breakdown from moisture is not classified as pressure damageunless pressure, shear and / or friction damage is also present.• Patients at risk of pressure damage must be advised to keep moving or berepositioned as determined by individual assessment and skin condition.This is incorporated within the principles of the SKIN bundle and will bedocumented in the patient records. S – surface. K – keep moving, I –incontinence, N – nutrition.• All patients assessed as at risk of pressure damage must be nursed onhigh density foam, pressure reducing mattresses.• Patients with a very high risk or with pressure ulcers grade 2 or abovemust be provided with an alternating pressure replacement mattress.• Specialist equipment will be available 24 hours a day, seven days a week• Patients at high risk of pressure ulceration should not sit out in a chair formore than two hours at a time and an appropriate pressure reducingcushion must be used.• All care provided to prevent pressure damage must be recorded in thepatient’s records and evaluated to determine the need for furtherintervention.• All health care professionals are required to attend education aboutpressure ulcer prevention and use of pressure relieving equipment.6.3. Risk Assessment6.4. For adults, excluding women in labour, the Waterlow Risk AssessmentCalculator must be used. This is to encourage a structured approach to theidentification of a patient’s risk of developing pressure ulcers. It should be used inPolicy for the Prevention of Pressure UlcersPage 6 of 34

conjunction with a nurse’s clinical judgement and experience. The Waterlow riskassessment tool forms part of the patient assessment documentation. Whenpossible it should be completed with involvement of the patient and/or carers toensure accurate collection of data (Anthony et al 2003).• Immediately, or within six hours of admission• On transfer of a patient to another clinical area/environment of care• Prior to discharge from hospital• If a patient’s condition changes• Weekly, if the Waterlow score is 10 – 14• Every three days if the Waterlow score is 15 – 19• Daily if the Waterlow score is 20 or greater.6.5. For maternity patients, the Maternity Risk Calculator must be used according tothe guidance provided as part of the Pregnancy and Birth Hand held record.(CHA2624)6.6. For paediatric patients, the Glamorgan Risk Assessment Scale must be used.(CHA2957)6.7. When assessing risk, the following factors must be considered (EPUAP 2009):• Activity and Mobility• Nutrition• Skin Condition• Perfusion and oxygenation of the tissues• Age• Build/weight for height• Continence• Tissue Malnutrition• Surgery• Neurological Deficit6.8. Activity and mobility6.9. Consider all individuals who are bedfast and/or chairfast to be at risk ofdeveloping pressure ulcers (EPUAP 2009).6.10. Chair bound patients have almost 50% of their weight on only 8% of their body,therefore the sacrum and buttocks are at increased risk of damage (Collins 1999).6.11. Restlessness and fidgeting may cause blistering and abrasions to the skin’ssurface.6.12. Traction or splints reduce one’s ability to reposition. In addition they may ruband cause damage to the surface of the skin and underlying tissues.6.13. When patients are sedated, unconscious or unable to move staff must takeresponsibility for protection from pressure damage.6.14. NutritionPolicy for the Prevention of Pressure UlcersPage 7 of 34

6.15. Reduced weight, impaired nutritional intake, dehydration and low serumalbumin levels may increase the risk of pressure ulcer development (Ferguson et al2000). However under nutrition is a reversible risk factor (EPUAP 2009).6.16. Nutritional indicators include anaemia, haemoglobin and serum albumin levels,measurement of nutritional intake (e.g. food charts) and weight. Weight loss mayresult in loss of fatty tissue and muscle wastage, which can increase pressure onbony prominences. Good nutrition and hydration is vital for maintenance of skinfunction and prevention of pressure damage. Protein is required for cell metabolismand the production of collagen, which gives the skin its strength.6.17. Carbohydrates and fats allow the body to use protein efficiently, generating newcells and reducing the risk of breakdown.6.18. Iron, zinc, vitamin A, C, B1, B2 and B6 are also required for collagen synthesis.6.19. Nutritional assessment using the MUST (Malnutrition Universal Screening Tool)tool must be carried out on all patients on admission and weekly thereafter. Forpatients who score as medium or high risk of malnutrition commence a nutritionalcare plan and refer to the dietician if necessary to ensure optimal nutritional supportfor patients (EPUAP 2009).6.20. Be aware that the MUST may not give a high score for obese patients who maybe at increased risk of developing pressure ulcers.6.21. Skin Condition6.22. All individuals with alterations to intact skin are at risk of developing pressuredamage. This includes dry skin, erythema, excessive moisture and non-blanchingerythema.6.23. Incontinent patients may have permanently moist skin. This reduces theirtolerance of pressure shear and friction. Moist skin is 5 times more likely to breakdown than healthy skin (Gibbon 2009).6.24. Patients with thin friable skin are at increased risk of blistering or abrasions.6.25. Dry skin is at risk of cracking when under pressure.6.26. Oedematous skin may have a reduced blood or lymphatic supply, resulting intoxins building up in the tissues. Oedema can leak onto the skin causing macerationand increasing the risk of breakdown.6.27. Discolouration may indicate poor blood supply or early pressure damage andpressure relief or a change of position is required.6.28. A break in the skin should only be recorded on the Waterlow score if it is due topressure damage.6.29. Perfusion and Oxygenation of the TissuesPolicy for the Prevention of Pressure UlcersPage 8 of 34

6.30. Factors affecting perfusion include diabetes, cardiovascular instability,norepinephrine use, low blood pressure, reduced ankle brachial pressure index anduse of oxygen (EPUAP 2009).6.31. Age6.32. As the skin ages the amount of collagen and elastin in the dermis reduces. Thisresults in thinning of skin, loss of tensile strength and increased risk of breakdown(Wounds UK 2008).6.33. Build/weight for height6.34. Distribution of weight requires consideration and bariatric patients may be atrisk of pressure damage. Where excess weigh occurs on specific areas of the bodythere may be an increased risk of deep pressure damage secondary to friction.6.35. If weight is below average the amount of tissue covering bony prominences isreduced, resulting in a concentration of pressure onto a smaller area.6.36. Continence6.37. Moisture on the surface of the skin can result in maceration and the skin is lessable to resist damage (Cutting and White 2002). Urine and faecal fluid causechanges in the skin’s pH and reduces its tensile strength, this can then make it moresusceptible to pressure ulceration (see skin condition above).6.38. Tissue Malnutrition6.39. Some conditions can reduce blood flow through the arteries and capillaries.This can result in poor perfusion of the tissue. The addition of pressure whencirculation is already poor can increase the risk of damage.6.40. Surgery6.41. Immobility during and after surgery may result in pressure damage. The longerthe surgery, the greater the risk of pressure damage (Clinch 1996). Some patientsmay need to be cared for in certain positions post operatively, (e.g upright) limitingthe extent to which they can be repositioned.6.42. Anaesthetics and analgesia can prevent patients from experiencing painassociated with pressure damage. It is important to inform them that they may be atrisk and closely monitor skin condition.6.43. Patients undergoing surgery will have a raised Waterlow score for 48 hours postoperatively however this may be for longer if their post-operative recovery is slow.6.44. Neurological Deficit6.45. Damage to the nerves can prevent patients being aware that they areexperiencing pressure damage.6.46. Other factors requiring consideration are:Policy for the Prevention of Pressure UlcersPage 9 of 34

• Acute, chronic or terminal illness• Co-morbidity, (e.g. pain, infection, medication)• Body temperature• Posture• Psychosocial issues• Exposure to pressure, shear or friction prior to admission6.47. When a patient is identified as at risk of pressure ulceration action is required toreduce or manage the risks to prevent tissue damage occurring. The followingsections focus upon risk management and the prevention of tissue damage.6.48. Skin Assessment6.49. The key principles of skin assessment are as follows:• All patients to have a top to toe skin assessment immediately or within sixhours of admission to hospital. Following a lower limb fracture,assessment must be undertaken within one hour of admission. This is tobe recorded on the Waterlow assessment page in the patient profile bycircling YES or NO and recording the skin condition in the specificpressure damage box at the bottom of the page.• All patients to have a repeat skin assessment following transfer to a newclinical area or to theatre. This is to be recorded on the skin assessmentsheet which is found on the back of the CARE round documentation.(CHA3061)• Following admission, all patients at risk of pressure damage, Waterlow 10-14, require a daily skin assessment.• For all patients at high risk of pressure damage, Waterlow 15-19, a twicedaily skin assessment is required.• For all patients at very high risk of pressure damage, Waterlow 20+, athree times daily skin assessment is required.• All ongoing skin assessments must be recorded on the skin assessmentsheet which is found on the back of the CARE round documentation.• A daily skin assessment should be viewed as a minimum standard.6.50. Maintaining healthy skin: The following principles should be considered inmaintaining healthy skin:• Keep the skin clean and dry, but do not let it dry out.• Avoid excessive moisture from urine, faeces, wound exudates, saliva andperspiration, as this can increase the risk of friction and shearing, reduceskin integrity and lead to maceration.• Cleanse the skin with a soap substitute.Policy for the Prevention of Pressure UlcersPage 10 of 34

• Use emollients on a regular basis to prevent skin dehydration.• Avoid using talcum powder and excessive rubbing of the skin.• Use skin barrier products topically to protect the skin from excessivemoisture and potential irritants.• Ensure that the patient has adequate nutritional and fluid intake.6.51. Grading Pressure Damage6.52. Pressure damage is graded according to severity and depth as follows:Grade oneGrade twoGrade threeGrade fourNon blanching erythemaRed discolouration of the skin that does not blanch whenpressedBlistering or abrasionPartial thickness skin loss involving the epidermis and possiblythe dermisFull thickness skin loss (visible fat)Full thickness skin loss involving the epidermis, dermis andsub-cutaneous layer, but not extending into the fasciaDeep ulcerExtensive destruction of fascia, muscle and bone, with orwithout skin lossTissue necrosisBlue/purple/black colouration of the skin6.53. Note: Hard necrosis and or blue/purple discolouration of the skin may indicatedeep tissue damage and must be treated as grade 4 pressure damage unlessidentified as otherwise. If the grade remains difficult to determine the tissue viabilityteam must be contacted for advice and a period of watchful waiting may be required.6.54. Management of Pressure Ulcers6.55. The most important factor in management of pressure damage is pressurerelief. Repositioning and use of pressure reducing/relieving equipment is key.6.56. When pressure damage does occur the position, grade and appearance of theulcer needs to be assessed and documented, and care planned to reduce the risk ofany deterioration in skin condition. A holistic assessment is required with specificconsideration given to repositioning, nutrition, continence, mobility, psychosocialissues and pain (EPUAP 1998).6.57. Any breaks in the skin should be treated as wounds and dressed to protectedthem from infection and promote healing. Debridement should only be carried if thetissue is well perfused, otherwise necrotic tissue should be left dry. The DressingPolicy for the Prevention of Pressure UlcersPage 11 of 34

Selection Guideline in the Wound Care Guidelines can be used to support clinicaldecision making.6.58. Patient Information6.59. It is essential to ensure patients, relatives and carers are aware of the risk ofpressure damage. Patient information should include:• What is a pressure ulcer• Who is at risk• What to do to prevent damage• What to look for• When and how to report changes in skin condition• Repositioning• Where to go for further information6.60. All clinical areas should keep copies of the Trust information leaflet available forpatients and carers. This can be obtained from the publications department, LeafletNo. 153.6.61. Additional resources available to patients and carers and staff include NICE,NHS Direct and the ‘Your Turn’ website – www.your-turn.org.uk6.62. Where possible patients should be involved in decision making regarding theircare, these include repositioning times, and use of pressure relieving equipment.(EPUAP 1998; NICE 2005).6.63. Patient Repositioning6.64. All patients at risk of pressure damage should be repositioned if it is safe to doso. Medical condition, comfort and over all care (e.g. physiotherapy) need to beconsidered and incorporated into a turning plan (Bonomini 2003).6.65. Timing of repositioning is determined by individual assessment of the patient’srisk and the skin’s response to pressure.6.66. Repositioning should be done in a way that does not put pressure on bonyprominences. Tilting the patient 30º and placing a pillow in the small of the back torelieve pressure on the sacrum and ischial tuberosities can be effective. Pillows canalso be used lengthways along the calf to raise the heels, protecting them from thesurface below.6.67. The use of an electronic profiling bed can assist in repositioning without turning.Reduce shear factors by maintaining the head position at the lowest positionpossible. The use of the knee break will also help to break heel pressure.6.68. It is an important part of recovery to allow patients to sit out in a chair, howeverwhere the patient is at risk of damage, or has a pressure ulcer, a pressure reducingcushion should be used and sitting out limited to two hours at a time. The patient’sseating position may influence the development of a pressure ulcer, therefore thecorrect size chair should be used and the patient observed to ensure he/she iscomfortable and not at risk of sliding (Collins 1999).Policy for the Prevention of Pressure UlcersPage 12 of 34

6.69. The patient’s position must be recorded on the Skin Assessment Tool at everyassessment of skin condition or when he/she is repositioned.6.70. Care of Patients Nursed on Trolleys6.71. If a patient is lying on a trolley for more than 1 hour the trolley must have apressure reducing high density foam surface.6.72. If patients have a Waterlow score of 10 or above they must not be on trolleys formore than 4 hours.6.73. Patients with existing pressure damage must be placed on a bed with thecorrect mattress as soon as possible after admission.6.74. The flow chart below provides guidelines for the prevention of pressuredamage:Patient has a pressureulcer grade 2 or abovePatient at high or veryhigh risk or has grade 1damagePatient is at risk but skinintactPlace on a bed with analternating pressuremattress as soon aspossibleEncourage repositioningat least hourly, monitorskin, transfer to a bedwithin 4 hours.Reassess skin every 4hoursEncourage repositioning.Reassess skin andWaterlowNo bed availablerepositionat least hourlyand prioritise finding a bedIf skin condition deteriorates, transfer to a bed andalternating mattress6.75. NICE (2005) recommend that all patients with grade 2 or above pressuredamage should be nursed on alternating pressure mattresses, therefore trolleys arenot recommended for these patients.6.76. Patient Nutrition6.77. All patients should be assessed on admission and reassessed throughout theirstay, for the nutritional risk using the MUST tool. All nutritional care requirementsshould be implemented according to the patient’s level of risk and a care plan mustbe in place.6.78. Patient ContinencePolicy for the Prevention of Pressure UlcersPage 13 of 34

6.79. All patients should be assessed on admission and throughout their stay for theircontinence status. Care must be planned according to the risk of skin damage andtheir level of incontinence. See section 8, ‘Skin Assessment’.6.80. Equipment Selection6.81. Guidelines for equipment selection based on individual patient assessment canbe found in Appendix 2. Types of equipment are listed in Appendix 6.6.82. All patients will be provided with a pressure reducing high density foam or viscoelasticfoam mattress.6.83. An alternating pressure mattress is required when:• The patient is assessed as being very high risk via the Waterlow and/orholistic factors• When the patient is unable to reposition independently or with assistance• When the patient has a pressure ulcer grade 2 or above•• The following factors also need to be considered:•• Patient comfort• The patient’s ability to reposition on the mattress• Patient choice• Site of pressure damage6.84. When patients with or at high risk of pressure damage sit out in the chair apressure reducing cushion is needed.6.85. All staff are responsible for attending training on specific pressure relievingequipment and the equipment library staff will inform the wards of training dates.6.86. The Range of Equipment Guide (Appendix 3) outlines all equipment availablefrom the equipment library.6.87. Heels- Placing a pillow from the ankle to below the knee allows the heel to befree from pressure, and is an acceptable method of relieving the pressure. Heeltroughs, heel pads or Heelift boots can also be used to protect the heels (see Heelpressure ulcer prevention, equipment selection guide appendix 3).6.88. Obtaining Equipment6.89. Pressure reducing and alternating pressure mattresses are available from theequipment library and can be obtained by contacting extension 3049 or bleep 2951,between 08:00 and 16:00. Outside these hours when a mattress is required,reassess all patients in your clinical area to determine whether anyone can bestepped down to a high density foam mattress.6.90. If not, contact the porters on extension 3700 as they have a list of availableequipment. If there is none available, please contact the other wards to check foravailability. The Repose overlay mattress is available in clinical areas for out of hoursPolicy for the Prevention of Pressure UlcersPage 14 of 34

6.103. Equipment is provided for the treatment of pressure ulcers. It is the nursinghomes responsibility to provide equipment for prevention unless there are specialcircumstances such as end of life care.6.104. Discuss requirements with the Discharge Liaison Nurses who will liaise withthe Community Tissue Viability team regarding funding. Complete the relevantcontinuing health care needs form.6.105. The Community TV team will then organise the equipment whereappropriate: equipment should not be ordered via the CELS system for thesepatients.6.106. Ensure that discharge planning is started early to allow for timely provision ofequipment. At least 24 hr notice is required in order to put equipment in place forpatient discharge to home. The Occupational Therapist or Discharge Liaison Nursewill confirm when the equipment is in place, to then enable the discharge to proceed.6.107. Cleaning & Decontamination of Equipment and ReportingFaults6.108. Reporting Faults- All mattresses must be checked between patients forcover, foam, and operational faults. Any equipment not fit for use must be dealt withas detailed in the table below in section 19.2.6.109. Static foam mattresses that are no longer fit for use must be condemnedwhen:• The cover is damaged and fluids permeate through to the foam• The foam has “bottomed out” and the base of the bed can be felt throughthe mattress.6.110. Alternating pressure mattresses should be set up in accordance with themanufacturer’s instructions for use. When a mattress fails to work correctly ensure:• It is correctly attached to the mains and switched on• It is not in static mode• The setting are adjusted in accordance with patient need• The CPR is not activated6.111. Cleaning & Decontamination- All pressure relieving equipment should becleaned prior to returning to the equipment library following the TrustDecontamination Policy and the guidelines below.6.112. Decontamination of pressure reducing/relieving equipment is carried outthrough cleaning or disinfection depending on the extent to which the equipment isexposed to bacteria which are likely to cause infection.6.113. Clean all mattresses between patients with mild detergent and warm water,paying particular attention to the mattress folds and loose flaps. Rinse and drythoroughly.Policy for the Prevention of Pressure UlcersPage 16 of 34

6.114. If soiled with body fluids, a chlorine releasing agent such as sodiumhypochlorite and di-isochlorocyanurate (NaDcc) e.g. Actichlor, can be used to cleanthe mattress in line with RCHT Decontamination Policy.6.115. http://cww.cornwall.nhs.uk/DocLibrary/default.asp.6.116. Please follow the guidance in the table below for specific cleaning anddisposal of mattresses.Mattress Normal Working Hours Out of HoursSTATIC- Clean, notcondemned, nolonger requiredALTERNATING-Clean, not faulty,no longer requiredALTERNATING-FaultySTATIC- Dirty/condemnedALTERNATING-ContaminatedClean mattress as per policy. Attach‘clean’ label and send mattress toEquipment Library via the PortersClean mattress as per policy. Place inclear plastic bag. Label as ‘clean’ andreturn to the Equipment Library via thePortersClean as above. Contact the EquipmentLibrary to report the fault (x 3049) andreturn to the library with a ‘fault’ labelattachedPlace mattress in a large clear bag(available to order via EROS). Label ascondemned and leave message for theEquipment Library (x3049). Label ascondemned and leave the mattress onthe ward for the Equipment Library tocheck as soon as possible.Replacement mattresses can berequested via the PortersClean mattress as per policy. Place inlarge clear bag. Label as contaminatedand contact the Equipment Library staff(x3049). Return to the EquipmentLibrary via the PortersAs per normalworking hoursAs per normalworking hoursAs per normalworking hoursAs per normalworking hours. Acondemnedmattress shouldno be left on award for morethan 72 hoursonce reported.As per normalworking hours6.117. Reporting of Pressure Damage6.118. When a pressure ulcer occurs or deteriorates, re-assessment of the patientand the grade, position and appearance of pressure damage must be documented.A new care plan should reflect intervention to heal existing ulceration and preventfurther damage.6.119. All pressure ulcers should be reported as follows:6.120. Grade 1 & 2 – on Safety Cross and Datix. Root cause analysis to becompleted as part of Datix investigation.6.121. Grade 3 and 4 – on Safety Cross and Datix. A Serious Incident (SI) is to becompleted on all hospital acquired Grade 3 and 4 pressure ulcers. See Appendix 4for SI process.Policy for the Prevention of Pressure UlcersPage 17 of 34

6.122. When reporting pressure ulcers on the DATIX system the report mustinclude:• Patient details• Grade of pressure damage• Site of pressure damage• Hospital or non-hospital acquired damage• Equipment in use• Action taken to manage the increased risk6.123. Where skin damage occurs in a vulnerable adult the ‘Reporting Skin Damagein a Vulnerable Adult as Safeguarding Alert’ guidance should be followed. This canbe found in the Safeguarding Adult folder kept in the clinical areas.6.124. Audit/ Monitoring6.125. The following audit activity will be undertaken. The results will be reportedthrough the RCHT Quality Action group. This is detailed in the Standard OperatingProcedure (SOP) in Appendix 5.Audit / Outcomes Frequency Method Persons ResponsiblePressure Ulcer Monthly Data obtained from Tissue Viability TeamIncidenceDATIX.SKIN bundle and riskassessment and careplanning complianceMonthly Quality CareindicatorsWard sisters / chargenurses / matronsAlternating and Staticmattress auditsAnnuallyAll availablemattresseschecked within theTrustEquipment LibraryManager6.126. Complaints and Legal6.127. All complaints relating to pressure ulcers will be investigated by theDivisional teams with support from the Tissue Viability team. See Appendix 6 for thecomplaint response process.6.128. There is a very robust legal process that must be followed in the event of aclaim against the Trust. (See Appendix 7)7. Dissemination and Implementation7.1. This policy, once ratified, will be stored electronically on the Trust’s DocumentLibrary.7.2. The Senior Nursing teams across the Divisions will be made aware of theupdated policy and will be responsible for the dissemination of the information within.8. Monitoring compliance and effectivenessPolicy for the Prevention of Pressure UlcersPage 18 of 34

Element to bemonitoredLeadToolFrequencyReportingarrangementsIncidence reportingHeather NewtonMonthlyDivisional Nurses will receive report monthlyDivisional teams will report via the Divisional Quality andLearning group action plans and SI and CI outcomesGovernance Committee will receive exception reportsActing onrecommendationsand Lead(s)Change inpractice andlessons to besharedDivisional Nurses will be responsible for leading theactions/changes required to improve complianceChanges will be monitored and reported monthly as part of thereport. Divisional Nurses will discuss findings and actions at thePressure ulcer quality action group monthly.9. Updating and Review9.1. This is managed via the document library. Review will be undertaken every twoyears unless best practice dictates otherwise.10. Equality and Diversity10.1. This document complies with the Royal Cornwall Hospitals NHS Trust serviceEquality and Diversity statement.10.2. Equality Impact Assessment10.3. The Initial Equality Impact Assessment Screening Form is at Appendix 2.Policy for the Prevention of Pressure UlcersPage 19 of 34

Appendix 1-Pressure Ulcer Prevention Clinical PathwayASSESSMENTNew Patient to RCHTImmediately and within 4 hours:- Pressure Ulcer Risk Assessment- Skin AssessmentOn transfer to new clinical area, if conditionchanges or on discharge-- Pressure Ulcer Risk Assessment- Skin AssessmentAT RISK: 10-14 HIGH RISK: 15-19 VERY HIGH RISK: >20OR if patient has Grade 2, 3or 4 pressure ulcerACTIONSSurface- Static MattressSkin Assessment- DailyKeep Moving- Encouragepatient to reposition/mobiliseIncontinence- Assesscontinence status and plancare accordinglyInformation- Provide patientleafletNutrition- AssessNutritional Status and plancare accordinglySurface- Static MattressSkin Assessment- TwicedailyKeep Moving- Reposition 2,4, or 6 hourly dependingon skin toleranceIncontinence- Assesscontinence status andprotect skinInformation- Provide patientleafletNutrition- AssessNutritional Status and plancare accordinglySurface- Dynamic AirMattressSkin Assessment- Threetimes dailyKeep Moving- Reposition 2,4, or 6 hourly dependingon skin toleranceIncontinence- Assesscontinence status andprotect skinInformation- Provide patientleafletNutrition- AssessNutritional Status and plancare accordinglyRE-ASSESSMENTRisk Assessment- Weeklyunless condition changesSkin Assessment- DailyRisk Assessment- 3 x weeklyunless condition changesSkin Assessment- 2 x dailyRisk Assessment- DailySkin Assessment- 3 x dailyPolicy for the Prevention of Pressure UlcersPage 20 of 34

Appendix 2- Pressure Relieving Equipment Selection GuidelinesIf patients are at risk or have pressure ulcers the following guidelines should be used to select appropriate equipment.If patients have heel pressure ulcers, heel troughs, heel boots or gel pads should be considered with or without dynamic mattresses, depending on clinicalneed. Use bed cradles to relieve pressure of bed clothes on heels.Where patients have a manual handling need electric profiling bed frames should be used.PATIENTS AT RISK PATIENTS AT HIGH RISK PATIENTS AT VERY HIGH RISKNo damage/Grade 1 Grade 2 – 4 No damage/Grade 1 Grade 2 – 4 No damage/Grade 1 Grade 2 - 4High specification Dynamic replacement High specification Dynamic replacement Dynamic replacement Dynamic replacementfoam mattress mattress foam mattress mattress mattress mattressReposition according Reposition according Reposition according Reposition according Reposition according Reposition accordingto clinical need to clinical need to clinical need to clinical need to clinical need to clinical needFoam cushion Foam cushion Memory foam or Memory foam or Memory foam or Gel cushion if patientGel cushion Gel cushion can reposition orAlternating pressurecushionLimit time sat outElectric bed frame Electric bed frame Electric bed framePolicy for the Prevention of Pressure UlcersPage 21 of 34

Appendix 3- Range of Equipment GuideHIGHSPECIFICATIONFOAM MATTRESSPENTAFLEXWEIGHT SUPPORT39 STONE (248kg)TRANSWAVESUPREMEWEIGHT SUPPORT39 STONE (248kg)MEMAFLEXMEMORY FOAMWEIGHT SUPPORT39 STONE (248kg)PERMAFLEXPLUSSUPPORT 39STONE (248)OUT OF HOURS /SHORT TERM USESTATIC OVERLAYREPOSEOVERLAYMATTRESS21 STONE (139KG)DYNAMIC HIGHRISKREPLACEMENTMATTRESSNIMBUS 3WEIGHT SUPPORT39 STONE (248kg)QUATTRO ACUTEWEIGHT SUPPORT39 STONE (248kg)PHASE IIIWEIGHT SUPPORT36 STONE (229kg)FOAM CUSHION GEL CUSHION HEELPROTECTORSMEMAFLEXWEIGHT SUPPORT20 STONE (127kg)FLO-TECHWEIGHT SUPPORT20 STONE(127kg)SOFTFORM GELSACSDYNAFLEX REPOSE HEELWEDGES ANDBOOTSHEEL TROUGHSHEEL LIFTSUSPENSIONBOOTSPolicy for the Prevention of Pressure UlcersPage 22 of 34

Appendix 4- Serious Incident (SI) Reporting ProcessProcess for reporting Serious Incidents (SI’s):Hospital Acquired Grade 3 and 4 Pressure UlcersA patient develops a grade 3 or 4 pressure ulcer followingadmission to hospitalIncident reported on Datix and TV team informed byrisk and safety teamTV team confirms Grade of of pressure ulcer. If Grade 3 or 4 hospital acquired, the patient isoffered an apology and the investigation process is discussed.An entry is made in the patient’s records to evidence compliance with the Being Open policy.Incident is declared as a Serious IncidentOnce SI is declared, risk and safety team send the 72 hour form, SI tool and Being Opentemplate letter to the relevant Divisional Nurse who will allocate and Investigating Officer.72 hour form to be competed at this stage.Completed SI report to be returned to risk team within 15days, with outcomes and action planTV Consultant Nurse to review SI report and finalise prior tosending to executive lead for sign offReport uploaded toDivisional SI actionplan log on the shareddriveReport sent to PCTSI themes shared withPressure Ulcer QualityAction Group andMatrons to ensureshared learningPolicy for the Prevention of Pressure UlcersPage 23 of 34

Appendix 5-Standard Operating Procedure (SOP)- RCHTPressure Ulcer Prevention Data CollectionIT IS THE RESPONSIBILITY OF ALL USERS OF THIS SOP TO ENSURE THAT THECORRECT VERSION IS BEING USEDStaff must ensure that they are adequately trained in the process and must make sure thatall copies of superseded versions are promptly withdrawn from use unless notifiedotherwise by the SOP Controller.If you are reading this in printed form, check that the version number and date below is themost recent one as shown:SOP Reference:Version Number:Author:Implementation date of current version:Approved by: Name/Position:Signature:Date:Name/Position:Signature:Date:V2Heather Newton31 st January 2013This SOP will normally be reviewed every 2 years unless changes that require otherwiseVersion History LogThis area should detail the version history for this document. It should detail the keyelements of the changes to the versions.VersionV1 March2012V2January2013DateImplementedMarch 2012Details of significant changesJanuary 2013 Data collection methodology has changed.Changes made to reflect Incidence monitoringData collection changed to reflect the need tocount number of pressure ulcers as well asnumber of patients.Regional Quality Improvement Framework now inplace detailing specific organisationalrequirements. SOP updated to reflect Governancepathway, Divisional structures for reporting andlearning from incidents and complaintsPolicy for the Prevention of Pressure UlcersPage 24 of 34

1 Purpose1.1 This RCHT Pressure Ulcer Prevention SOP will guide the process of collecting datafrom Incident reporting, the Safety Cross and patients’ notes. Compliance with thisdata set is required as part of the NHS Safety Thermometer and the South WestQuality and Patient Safety Improvement Programme (SWQPSIP).1.2 This SOP reflects the commitment by the RCHT to monitoring pressure ulcerincidence with the overall aim to eliminate avoidable pressure ulcers and take azero tolerance approach.1.3 The objective is to achieve a level of understanding at ward level of why the data isrequired, how it is to be collected and when it is to be collected. This will provideassurance that the data collected is valid, robust and meaningful; in order to reduceall avoidable pressures ulcers in our care.2 Who Should Use This SOP?2.1 This SOP will be used by the Clinical teams who will be collecting the data. ClinicalMatrons and Divisional Nurses will also have an understanding of the implicationsand the relevance of the data to improving quality, patient’s safety, and harm freecare.2.2 The Tissue Viability team will use the data collected to analyse and report findingsand required actions to the Senior Nursing and Executive teams.3 When This SOP Should Be Used3.1 This SOP may be subject to change and it is therefore the responsibility of all usersto ensure that the most up to date version is being used.3.2 Pressure Ulcer Incidence data will be collected using information from the Incidentreporting system (Datix)3.3 Pressure Ulcer Incidence (Quantitative data)When a patient develops a hospital acquired pressure ulcer this is to be reported asa clinical incident on the Incident reporting system (Datix)The ward sisters and charge nurses together with the Clinical matrons areresponsible for ensuring that this information is correct on the systemIncidence data is to be collected and analysed by the Tissue Viability ConsultantNurse at the end of each month.Outcomes will be reported to the Divisional teams and Governance committee asfollows-Total number of patients with pressure ulcers both hospital and non-hospitalacquired-Total number of pressure ulcers reported-The incidence (rate) of patients with hospital acquired pressure ulcers based onpatient activity per 1000 bed days (SWQPSIP target)Policy for the Prevention of Pressure UlcersPage 25 of 34

-Pressure ulcers by Grade and Site (CQC and SHA targets)Any hospital acquired Grade 2 pressure ulcers will be investigated using a Rootcause analysis methodology.Any hospital acquired Grade 3 and 4 pressure ulcers will be reported as SeriousIncidents and investigated accord to Trust policy.Pressure Ulcer Risk Assessment, Care Planning and Skin Bundle compliance(Qualitative data)This data is to be collected by the ward teams on a monthly basis using the Qualitycare indicators This will include pressure ulcer risk assessment, care planning, skinassessment and compliance with the SKIN bundle all of which are required as partof the SWQPSIP programme.Safety Cross – pressure ulcersThe safety cross is to be completed at ward level to identify patients that developpressure ulcers or are admitted with pressure ulcers. If there are no patients withpressure damage then this is reflected on the cross. At the end of the month theward sister / charge nurse uses this information to reflect on the quality of careprovided and the days between pressure ulcer incidents. This information is alsoused when collecting safety thermometer data.Safety Thermometer – pressure ulcersThis data will be collected from all in patient areas on one day each month by theward / dept teams. The worse new and the worse old pressure ulcers will bereported by Grade. Old are defined as being present on admission and occurringwithin 72 hours of admission with new being those that developed 72hours afteradmission.Electronic data will be sent to a National database.4 Procedure(s)4.1 Procedure for the collection of pressure ulcer qualitative data using the SafetyCross.A new safety cross sheet is to be used per month. Complete ward, month and yearon the formComplete the sheet on a daily basis. If no new pressure ulcers have developedplease mark as an incident free day.When a new pressure ulcer develops record the incident by marking a red cross onthe relevant date on the safety cross sheet. Complete the back of the form.If a patient is admitted with pressure damage mark with a blue cross. Complete theback of the form.Complete the information on the back of the sheet relevant to the specific pressureulcer incident as follows:Policy for the Prevention of Pressure UlcersPage 26 of 34

1. Date of incident which corresponds with X on the safety cross2. Patient ID –required to ensure relevant investigations are undertaken on theright patient3. Grade of pressure ulcer –required for more detailed analysis4. Site of pressure damage - required for more detailed analysis5. Datix reference number – required to remind staff that ALL pressure ulcersare to be Datixed as an incident.At the end of each month ward staff are to reflect on the number of incidents andimplement actions to reduce the number of incidents for the following month.4.2 Procedure for the collection of pressure ulcer qualitative data using the clinical careindicators. All wards and departments to collect quality data using the clinical careindicator metrics. This includes qualitative data relating to pressure ulcer riskassessment and care planning, skin assessment and skin bundle. 10 sets of patient records to be reviewed and evidence of compliancerecorded on a central data basePolicy for the Prevention of Pressure UlcersPage 27 of 34

Appendix 6- Complaints Response ProcessLetter of complaint receivedwhich involves thedevelopment of a hospitalacquired pressure ulcerComplaint vetted by Patient SupportCo-ordinators and details are checked topidentify if reported on Datix and/or if an SIinvestigation is in process or completedIf high risk, ie grade 3 or4, refer to SI processComplaint letter and other relevantpaperwork is sent to the divisionalInvestigating Officer and cc’d to the TVConsultant NurseDivisions investigate andrespond to complaintTV Consultant Nurse or TV CNSinvestigates and providesresponse where relevantTV Consultant Nurse or TV CNSreviews complaint responseIf further issues are highlighted,response is sent back to the divisionsfor outcomes to be shared for learningand service improvements to be madeDraft CEO response is written and/ormeeting with complainant is held toresolve issues where possiblePolicy for the Prevention of Pressure UlcersPage 28 of 34

Appendix 7- Legal Claims Response ProcessLegal Team receives a requestfor records from a solicitor orequivalent under the DataProtection ActLegal Department obtains patientnotes and reviews concerns raisedin solicitor’s letterLegal Department run a check onany Datix, SI Investigations orcomplaints related to this enquiry.(This information is all disclosable)Legal Departmentmatches claim withpatient records to checkvalidity of claimNotes sent tosolicitorLetter of claim receivedby the Trust. Notes arerequested backThe Trust has fourmonths in which toThe Trust has fourmonths in which torespondTV Consultant Nurseinformed of claim andworks with Legal Team toinvestigateThe Trust informs theNHS LA for theirDivisional Teaminvolved whereThe Trust formulates aresponse which aims todefend where possibleDefendedSuccessful ClaimClient not happyClient no longerpursues the claimProceedings areissuedThoroughinvestigationinvolving interviewsof all staff involvedPolicy for the Prevention of Pressure UlcersPage 29 of 34

Appendix 8. Governance InformationDocument TitlePolicy for the Prevention of Pressure UlcersDate Issued/Approved: 17 th May 13Date Valid From: 17 th May 13Date Valid To: !7 th May 16Directorate / Department responsible(author/owner):Contact details: 01872 252673Heather Newton, Tissue Viability NurseConsultantBrief summary of contentsThis policy sets out the framework to guideevidence based care in the prevention andmanagement of pressure ulcers.Suggested Keywords:Target AudienceExecutive Director responsible forPolicy:Ulcer, Pressure, Tissue viability,RCHT PCT CFTMedical DirectorDate revised: 20 Feb 13This document replaces (exact title ofprevious version):Pressure ulcer prevention policyApproval route (names ofcommittees)/consultation:Pressure Ulcer Action GroupDivisional Manager confirmingapproval processesAndrew MacCallumName and Post Title of additionalsignatoriesSignature of Executive Director givingapprovalPublication Location (refer to Policyon Policies – Approvals andRatification):Document Library Folder/Sub FolderNot Required{Original Copy Signed}Internet & IntranetClinical/DermatologyLinks to key external standards CQC Outcome 4Related Documents:Training Need Identified? Intranet Only Tissue Viability Referral Pathway NICE Guidance Prevention andTreatment of Pressure Ulcers CG29NoPolicy for the Prevention of Pressure UlcersPage 30 of 34

Version Control TableDateVersionNo20 Feb 13 V5.0Summary of ChangesV4.0 Previous changes not known.Addition of preventative flow chart and updateof SOP to reflect data collection processes.Changes to time frame for risk assessmentfrom 6 hours to 4 hours.Update of cleaning and disposal ofmattressesChanges Made by(Name and Job Title)Heather Newton,Tissue Viability NurseConsultantAll or part of this document can be released under the Freedom of InformationAct 2000This document is to be retained for 10 years from the date of expiry.This document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy on Document Production. It should not be altered in any way without theexpress permission of the author or their Line Manager.Policy for the Prevention of Pressure UlcersPage 31 of 34

Appendix 9.Initial Equality Impact Assessment Screening FormName of service, strategy, policy or project (hereafter referred to as policy) to beassessed: Policy for the Prevention of Pressure UlcersDirectorate and service area: Tissue Is this a new or existing Procedure?ViabilityExistingName of individual completingTelephone: 01872 252673assessment: Heather Newton1. Policy Aim* To promote best practice in the prevention and managementofpressure ulcers2. Policy Objectives* To support the reduction of prevalence and incidence ofhospitalacquired pressure damage through assessment,implementation and evaluation of patient care.3. Policy – intended-Prevalence of pressure ulcers will reduceOutcomes*-Incidence of pressure ulcers will reduce-Staff will provide pressure area care in accordance with thebest available evidence-Equipment to reduce or relieve pressure will be available4. How will you measurethe outcome?5. Who is intended tobenefit from the Policy?-To meet policy standards-Monthly Incidence audit-Annual audit of alternating and static mattresses-Audit of pressure ulcer assessment and care planningthrough Quality care indicators-All patients admitted to RCHT who are at risk of pressuredamage or are admitted with a pressure ulcer-All staff caring for patient with, or at risk of pressuredamage-Informed workforce-Patients risks of developing pressure ulcers are reduced-Patients are managed according to best practice6a. Is consultationrequired with theworkforce, equalitygroups, local interestgroups etc. around thispolicy?-Not required as update of existing policyb. If yes, have thesegroups been consulted?c. Please list any groupswho have been consultedabout this procedure.*Please see GlossaryPolicy for the Prevention of Pressure UlcersPage 32 of 34

7. The ImpactPlease complete the following table using ticks. You should refer to the EA guidance notesfor areas of possible impact and also the Glossary if needed. Where you think that the policy could have a positive impact on any of the equalitygroup(s) like promoting equality and equal opportunities or improving relationswithin equality groups, tick the ‘Positive impact’ box. Where you think that the policy could have a negative impact on any of the equalitygroup(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box. Where you think that the policy has no impact on any of the equality group(s) listedbelow i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.Equality Positive Negative No Reasons for decisionGroup Impact Impact ImpactAge Yes No Older person’s skin is at greaterrisk of pressure damage and so willbe assessed and protectedaccording to the best availableevidenceDisability Yes No Increased staff awareness of riskto patients with reduced mobilityReligion orbeliefYesGenderTransgenderPregnancy/MaternityRaceSexualOrientationMarriage / CivilPartnershipYesYesYesYesYesYesYou will need to continue to a full Equality Impact Assessment if the following havebeen highlighted: A negative impact and No consultation (this excludes any policies which have been identified as notrequiring consultation).8. If there is no evidence that the policypromotes equality, equal opportunitiesor improved relations - could it beadapted so that it does? How?Full statement of commitment to policy ofequal opportunities is included in the policyPlease sign and date this form.Policy for the Prevention of Pressure UlcersPage 33 of 34

Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, ChyveanHouse, Penventinnie Lane, Truro, Cornwall, TR1 3LJA summary of the results will be published on the Trust’s web site.Signed ________________________________________Date _________________________________________Policy for the Prevention of Pressure UlcersPage 34 of 34