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Assessment of pressure ulcer (PU) risk remains a challenge in clinical practice. The first part of this article (Martin and Holloway, 2024) discussed the evidence base underpinning the development of clinical guidelines for PUs alongside the creation of the bundle approach regarding PU prevention. This article, part two, presents the results of a clinical audit that explores compliance against a PU prevention bundle (the aSSKINg framework) in an adult community nursing setting in the south-east of England. The clinical audit was conducted between July-December 2021 and included records of 150 patients. Overall, compliance against the aSSKINg framework was poor, with only two criterion being met: equipment provision for chair and referral to the tissue viability team. Short-term recommendations are that mandatory PU training for staff in the management of PUs should be implemented, and the tissue viability nurse network should be increased. The long-term recommendation was the introduction of the aSSKINg framework as a template into the electronic patient record. [ABSTRACT FROM AUTHOR]

Pressure ulcers (PUs) represent a burden to the health economy and patients alike. Despite national and international guidelines regarding the management of risk, the incidence and prevalence across England remains high. Detecting early the risk of PUs is paramount, and requires using a valid risk assessment tool alongside clinical judgement and management of associated risk factors. There is a need to implement prevention strategies. Introducing care bundles for pressure ulcers, for example SKIN, SSKIN and most recently aSSKINg, is designed to guide clinicians and reduce variations in care. This article presents a review of the evidence on compliance with guidelines, frameworks, pathways or care bundles within primary and secondary care settings. This article focuses on the literature review that was conducted to inform a subsequent clinical audit of compliance with the aSSKINg framework in a Community NHS Foundation Trust in the South East of England. [ABSTRACT FROM AUTHOR]

Background: Falls are the most common safety incident reported by acute hospitals. In England national guidance recommends delivery of a multifactorial falls risk assessment (MFRA) and interventions tailored to address individual falls risk factors. However, there is variation in how these practices are implemented. This study aimed to explore the variation by examining what supports or constrains delivery of MFRAs and tailored interventions in acute hospitals. Methods: A realist review of literature was conducted with searches completed in three stages: (1) to construct hypotheses in the form of Context, Mechanism, Outcome configurations (CMOc) about how MFRAs and interventions are delivered, (2) to scope the breadth and depth of evidence available in Embase to test the CMOcs, and (3) following prioritisation of CMOcs, to refine search strategies for use in multiple databases. Citations were managed in EndNote; titles, abstracts, and full texts were screened, with 10% independently screened by two reviewers. Results: Two CMOcs were prioritised for testing labelled: Facilitation via MFRA tools, and Patient Participation in interventions. Analysis indicated that MFRA tools can prompt action, but the number and type of falls risk factors included in tools differ across organisations leading to variation in practice. Furthermore, the extent to which tools work as prompts is influenced by complex ward conditions such as changes in patient condition, bed swaps, and availability of falls prevention interventions. Patient participation in falls prevention interventions is more likely where patient directed messaging takes individual circumstances into account, e.g., not wanting to disturb nurses by using the call bell. However, interactions that elicit individual circumstances can be resource intensive and patients with cognitive impairment may not be able to participate despite appropriately directed messaging. Conclusions: Organisations should consider how tools can be developed in ways that better support consistent and comprehensive identification of patients' individual falls risk factors and the complex ward conditions that can disrupt how tools work as facilitators. Ward staff should be supported to deliver patient directed messaging that is informed by their individual circumstances to encourage participation in falls prevention interventions, where appropriate. Trial registration: PROSPERO: CRD42020184458. [ABSTRACT FROM AUTHOR]

The European Wound Management Association (EWMA) 2020 Level Seven curriculum recommends the provision of training on sharp debridement, primarily targeting specialist practitioners in wound care. Given the current lack of regulation for wound specialists in the UK, the quality and fidelity of training play a crucial role in health professionals' confidence when performing sharp debridement. Consequently, it is vital that training aids and methods accurately represent the realities of this procedure. Existing literature outlines training approaches using animal tissue or grapefruit models for sharp debridement. The University of Salford has developed a new simulation aid to teach tissue viability students about sharp debridement. This article details the development process and the creation of this innovative training aid designed to support sharp debridement education. The proposed simulation aid enables accurate representation of various wound tissue types requiring debridement in clinical settings, while eliminating the production of organic waste and the need for animal products, which may be objectionable to some learners. [ABSTRACT FROM AUTHOR]

Background. Cost-effectiveness analysis needs to be considered when introducing new tools and treatments to clinical services. The number of new assessment tools in mental health has rapidly expanded, including suicide risk assessment. Such suicide-based assessments, when linked to preventative interventions, are integral to high-quality mental health care for people with severe mental illness (SMI). We examined the cost implications of implementing Oxford Mental Illness and Suicide (OxMIS), an evidence-based, scalable suicide risk assessment tool that provides probabilistic estimates of suicide risk over 12 months for people with SMI in England. Methods. We developed a decision analytic model using secondary data to estimate the potential cost-effectiveness of incorporating OxMIS into clinical decision-making in secondary care as compared to usual care. Cost-effectiveness was measured in terms of costs per quality-adjusted life years (QALYs) gained. Uncertainty was addressed with deterministic and probabilistic sensitivity analysis. Results. Conducting suicide risk assessment with OxMIS was potentially cheaper than clinical risk assessment alone by £250 (95% confidence interval, -786;31) to £599 (-1,321;-156) (in 2020–2021 prices) per person with SMI and associated with a small increase in quality of life (0.01 [-0.03;0.05] to 0.01 QALY, [-0.04;0.07]). The estimated incremental costeffectiveness ratio of implementing OxMIS was cost saving. Using probabilistic sensitivity analysis, 99.96% of 10,000 simulations remained cost saving. Conclusion. Cost-effectiveness analysis can be conducted on risk prediction models. Implementing one such model that focuses on suicide risk in a high-risk population can lead to cost savings and improved health outcomes, especially if explicitly linked to preventative treatments. [ABSTRACT FROM AUTHOR]

The article discusses how past experiences, present practices, and future advancements shape researchers' approach to writing about the delivery of evidence-based care. Topics include the evolution of pressure ulcer care, the importance of evidence-based risk assessment tools like Purpose-T, and the challenges of delivering consistent care despite available research.

People with developmental disability have higher health care needs and lower life expectancy compared with the general population. Poor quality of care resulting from interpersonal and systemic discrimination may further entrench existing inequalities. We examined the prevalence of five avoidable in-hospital patient safety incidents (adverse drug reactions, hospital-acquired infections, pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis, and postoperative sepsis) for four developmental disability groups (people with intellectual disability, chromosomal abnormalities, pervasive developmental disorders, and congenital malformation syndrome) in the English National Health Service during the period April 2017-March 2019. We found that the likelihood of experiencing harm in disability groups was up to 2.7-fold higher than in patients without developmental disability. Patient safety incidents led to an excess length-of-stay in hospital of 3.6-15.4 days and an increased mortality risk of 1.4-15.0 percent. We show persisting quality differences in patients with developmental disability, requiring an explicit national policy focus on the needs of such patients to reduce inequalities, reach parity of care, and lower the burden on health system resources. [ABSTRACT FROM AUTHOR]

A specialist wound telehealth service was established to deliver equitable service with parity of access to wound care for all residents of 38 nursing homes in Sussex with wounds of any type (n=579). All patients were managed using a systematic telehealth approach that combined digital and in-patient consultations according to established protocols and care pathways. Data for a three-year period was analysed by hand to determine patient demographics, wound type and discharge outcomes for all patients with wounds. The results showed that the mean age of patients was 86 years, with the majority being female (80% healed and 66% deceased). Referral outcomes were referred onwards (n=92), healed (n=234) or deceased (n=253). The most prevalent wound type was pressure ulceration in both healed and deceased patient groups (60% and 59%, respectively), followed by lower limb wounds (20% and 26%, respectively). Mean time to healing or death were 103 days versus 86 days, respectively. The authors concluded that the collaborative use of a specialist wound telehealth service ensured that all residents received prompt, evidence-based wound care. Healing was achieved in this vulnerable patient population, despite the existence of numerous barriers to healing. Patients nearing end of life with a wound received palliative wound management. The time to healing in this group cannot be commented upon due to lack of comparative studies in this patient population. [ABSTRACT FROM AUTHOR]

Trauma in older people leads to substantial morbidity and mortality. The National Hip Fracture Database (NHFD) has driven improved practice with units compared to identify outliers. In 2013, our unit was an outlier for mortality post hip fracture (30-day mortality 12.2% vs. 8.3% nationally). This triggered external review. In 2019 the unit was highlighted as an exemplar in the UK. We describe the process that moved us from outlier to outstanding. After the initial review process, we made changes to our healthcare system, with regular reassessment of progress and care quality. Examples include a dedicated hip fracture unit, strong leadership (Nursing, Orthopaedic, Geriatrician, Anaesthetic), consultant-led in-depth monthly mortality reviews, changes to admission pathways and delirium prevention. Improvements were seen in all aspects of hip fracture care in 2019 compared with 2012. Thirty-day case-mixed adjusted mortality halved (12.2–6.1%), with substantial reductions in reoperations and pressure sores. Length of stay reduced by 5.9 days. In 2019 our unit's performance was significantly above the national average for all six indicators assessed by NHFD: prompt orthogeriatric review (97% vs. 91% national average), prompt surgery (85% vs. 68%); NICE compliant surgery (85% vs. 74%); prompt mobilisation (93% vs. 81%); not delirious postoperatively (77% vs. 69%); return to original residence (78% vs. 71%). The NHFD highlighted our Unit as one of nine (from 175 total) highly performing UK trusts. We summarise our service development and improvement work undertaken to achieve 'outstanding' status, which provides a valuable template to units managing trauma in older people. [ABSTRACT FROM AUTHOR]

Background: Parafricta bootees are made of low friction material intended to prevent heel pressure ulcers (PU). Aims: To compare, in hospitalised patients, whether the bootees, added to standard care (SC), prevent heel PU compared with SC alone. Methods: Patients with Waterlow score ≥20 and no heel PUs at baseline were randomly allocated to either bootees plus SC, or SC alone. Target sample size was 450 patients. Patients' heels were clinically assessed for heel PUs at day 3 and day 14. Results: Slow recruitment stopped the study early. In 31 recruited patients there were zero incident heel PUs (intervention group, 0%) versus 1 (SC group, 6%) at day 3 and no new heel pressure ulcers at Day 14. Conclusion: This study failed to reach sufficient statistical power to assess the efficacy of the bootees in preventing heel PUs. No adverse events were related to the bootees. Only 1 patient in the SC group developed a heel PU. [ABSTRACT FROM AUTHOR]

Patients continue to develop skin damage and pressure ulcers (PUs). The aim of this audit was to explore the prevalence of PUs and the adherence to the fundamental elements of the aSSKINg framework across hospitals in England. A cross-sectional survey was conducted on 10,144 patients from 36 hospitals representing 18 NHS trusts. The PU status of all patients was determined by two independent nurses who assessed the skin and ensured data capture was completed. The overall prevalence of PUs recorded, in terms or proportion of patients with 1 or more PUs, was 9.04% (95% confidence interval (CI) 8.48% to 9.60%). There were 689 (64.0%) PU allocated a category (i.e., 1,2,3,4, unstageable (US) or deep tissue injury (DTI)) were superficial, involving only the skin (categories 1 and 2). A further 218 (20.3%) were in an evolving category, i.e. US or DTI. There were 7086 patients (69.8%) that had a risk assessment completed within six hours, 6576 (81.4%) patients considered to be at risk had a care plan in place, but only 5216 patients (51.3%) had a planned repositioning regimen in place. This audit has identified areas of care that require improvement to prevent PU occurrence, including patient education and keeping patients moving and repositioning. There continues to be over-prescription of equipment, with patients being allocated higher specification equipment than their risk score identifies and no clinical reason apparent. [ABSTRACT FROM AUTHOR]

An editorial is presented on the brief history of pressure ulcer measurement in England. The article discusses that the Pressure ulcers (PU) have long been recognized as a challenge to healthcare, are a cause of significant pain and distress for patients and are costly for healthcare providers in term of finances and use of human resource; and describes the predominant methods that have been used to capture the prevalence of PUs in England over the last 20 years.

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Preventive care was recently identified as a Government priority, which is likely to affect pressure ulcer (PU) preventive care in the NHS. Contemporary economic analyses of PU prevention interventions are undermined by factors including methodological challenges and poor inter-rater reliability of PU risk assessment tools. Healthcare demands on the NHS created by PU prevention remain unclear, although the burden is high, with litigation costs rising continuously. The poorly understood economics of PU prevention may create variation in practice. Patient expectations of PU prevention may be influenced by mainstream media, national awareness campaigns and the varied information and advice offered by professionals. Patient expectations and low levels of functional health literacy may create confusion and unrealistic expectations. This article critically examines the impact of recent changes in Government priorities related to PU prevention, considering the effects of healthcare demand, economics and patient expectations. [ABSTRACT FROM AUTHOR]

Objective: To explore health disparity in on‐campus undergraduate nurse education through the analysis of teaching and teaching material exploring pressure injuries. Background: As a discipline, nursing espouses ideologies of inclusion, equity and valuing diversity. However, little is known about how these ideologies translate into clinical care. Pressure injury prevention is a routine aspect of nursing care; yet, there is evidence of inequity in relation to clinical care and patient assessment, as people with darker skin tones have a higher prevalence of severe pressure injuries before detection of damage occurs. Despite limited literature being available surrounding the topic of pressure injuries and skin tone diversity, it remains the responsibility of nurse educators to address contemporary issues and health disparity within the nursing curriculum. Design: A multiple method collective case study. The STROBE checklist was followed in reporting this study. Methods: Documentary and observational data of lectures regarding pressure injuries were collected during 2017 and 2018 from five Higher Education Institutes in England delivering approved nursing undergraduate programmes. Results: Documentary analysis confirmed all Higher Education Institutes overwhelmingly directed teaching and learning activities about pressure injury towards people with Caucasian skin tones. Observation of teaching indicated all teaching sessions only contained brief, separate and superficial information on people with pressure injuries and darker skin tones. There was no discursive language or awareness of colour or colour blindness. Conclusion: Radical critique of all teaching and learning activities needs to occur, to help explore, improve and meaningfully and authentically include diversity and inclusivity in nurse education, and in particular, how people across the skin tone spectrum are included and represented in teaching and learning activities. Relevance to clinical practice: Critical examination of current teaching practice is crucial to address disparity and ensure care for people with darker skin tones is optimised.Nurse educators have a responsibility to educate for the care needs of all, as the quality of nurse education has a direct impact on care delivery and health disparity.This paper highlights the importance of addressing skin tone diversity and offers the opportunity for reflective practice, not just in formal education, but in clinical settings by preceptors and senior staff. [ABSTRACT FROM AUTHOR]

On 27 July, Journal of Wound Care and the University of Huddersfield streamed the first of 10 live webinars on their Wounds Week channel (www.woundsweek.com). All sessions are now available to watch on-demand. With 10 highly apposite topics, Wounds Week gives a chance for the wound care community to come together in these difficult times and engage in key education, free of charge. Each session had live question and answer sessions; participants asked questions of the experts, making them a key part of the event. The registration process takes just a minute. There's nothing to install or set up—simply register and fill out your details. Follow on twitter at #WoundsWeek [ABSTRACT FROM AUTHOR]

Background: The costs to healthcare systems of pressure ulcer (PU) prevention and management programmes remain high, and although PU risk assessment tools exist, they generally have poor predictive value. It has been demonstrated that PU are preceded by subtle tissue changes that are invisible to the naked eye before skin breakdown occurs. One such change is an increase in sub-epidermal moisture (SEM) which can be identified by biocapacitance. Aim: To investigate the effect of skin barrier cream on biocapacitance readings made with the SEM Scanner 200 (BBI LLC (CA, USA). Methods: SEM Scanner 200 delta readings were recorded on the heels and sacrums of healthy volunteers with and without barrier cream. This was a two part investigation. In part one participants had barrier cream applied to one heel (right) and not to the other (left). In part two participants were allocated into one of two groups-full application or partial application of barrier cream. Results: No difference in SEM delta values was observed in participants between the right and left heel. With sacral application there was a significant rise in SEM Scanner 200 readings when barrier cream was only applied to a small area compared to those with full coverage though this rapidly resolved with time and skin cleaning. Conclusions: Even distribution of barrier creams over scanned areas did not affect SEM readings though uneven application might adversely affect readings. [ABSTRACT FROM AUTHOR]

The article focuses on challenges and opportunities in tissue viability, particularly addressing financial concerns and the shift towards a population health approach. Topics discussed include the impact of tax cuts on healthcare, the importance of integrating mental health into wound care, and upcoming conferences and resources for healthcare professionals in the field.

An estimated 14 million adults experience incontinence in England alone, and this population is at a very high risk of developing incontinence-associated dermatitis (IAD). The risk associated with developing IAD is further increased among older adults, due to the effects of the ageing process, which leave the skin thinner and more fragile. Understanding the causative factors of IAD in addition to understanding the impact of IAD on the skin enable the clinician to make informed choices regarding treatment, management and prevention. Additionally, understanding the association between IAD and pressure ulcers is a critical component of IAD management, as IAD and pressure ulcers often coexist or develop alongside each other. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the effect of Care Quality Commission external inspections of acute trusts on adverse event rates in the English National Health Service. Methods: Interrupted time-series analysis including all acute NHS trusts in England (n = 155) using two control groups (new versus historical inspection regime and trusts not inspected). Multilevel random-coefficient modelling of (1) rates of falls with harm and (2) pressure ulcers, from April 2012 to June 2016, was undertaken using the new, resource-intensive regime of Care Quality Commission inspections as an intervention. Data used in the model included dates and type of inspection, patient safety indicators, demographic characteristics and financial risk of hospitals. Results: In one year, Care Quality Commission inspected 66 acute trusts (42% of all English trusts) using their new regime and 46 (30%) using their previous one. Prior to inspections being announced, rates of falls with harm and pressure ulcers were improving in both intervention and control hospitals. The announcement of an inspection did not affect either indicator. After inspections, rates of falls with harm improved more slowly, and pressure ulcer rates no longer improved for trusts inspected using both regimes. Conclusions: Neither form of external inspection was associated with positive, clinically significant effects on adverse event rates. Any improvement happening before the announced Care Quality Commission inspections slowed after the inspection. [ABSTRACT FROM AUTHOR]

Aims and objectives: To explore how the context of care influences the development of community‐acquired pressure ulcers from the perspective of nurses working in home healthcare settings, to identify and categorise the factors perceived as contributing to the development of these ulcers using the Model for Examining Safety and Quality Concerns in Home Healthcare, and to explore how these risks are managed in practice. Background: Pressure ulcer reduction is a priority in both hospital and community settings. Evidence suggests the factors affecting safety and performance in community settings are not the same as in hospital. However, research pertaining to pressure ulcer risk management has predominantly been undertaken in hospital settings. Design: The study was framed by a qualitative exploratory design. Methods: Semistructured interviews were conducted with a purposive sample of 19 registered nurses recruited from an independent regional tissue viability network and five community nursing provider organisations in London. Results: The experiences and perceptions of participants mapped onto the components of the Model for Examining Safety and Quality Concerns in Home HealthCare: patient characteristics, provider characteristics, nature of home healthcare tasks, social and community environment, medical devices and new technology, physical environment, and external environment. Four strategies to address identified risks were established: behavioural interventions, technical interventions, safeguarding interventions and initiatives to promote better integration between health, local authorities and families. Conclusion: Understanding the complex interplay between people and other elements of the healthcare system is critical to the prevention, management and investigation of pressure ulcers. This study has illuminated these elements from the perspective of nurses working in community settings. Relevance to clinical practice: Further consideration should be given to the importance of place when both developing risk management strategies for pressure ulcer prevention and learning the lessons from failure. [ABSTRACT FROM AUTHOR]

Background: Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population. Aim: To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care. Design: A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms. Setting and participants: Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014. Results: A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcareassociated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death. Conclusion: Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk. [ABSTRACT FROM AUTHOR]

Background Pressure ulcers are areas of localised damage to the skin and underlying tissue; and can cause pain, immobility, and delay recovery, impacting on health-related quality of life. The individuals who are most at risk of developing a pressure ulcer are those who are seriously ill, elderly, have impaired mobility and/or poor nutrition; thus, many nursing home residents are at risk. Objectives To understand the context of pressure ulcer prevention in nursing homes and to explore the potential barriers and facilitators to evidence-informed practices. Methods Semi-structured interviews were conducted with nursing home nurses, healthcare assistants and managers, National Health Service community-based wound specialist nurses (known in the UK as tissue viability nurses) and a nurse manager in the North West of England. The interview guide was developed using the Theoretical Domains Framework to explore the barriers and facilitators to pressure ulcer prevention in nursing home residents. Data were analysed using a framework analysis and domains were identified as salient based on their frequency and the potential strength of their impact. Findings 25 participants (nursing home: 2 managers, 7 healthcare assistants, 11 qualified nurses; National Health Service community services: 4 tissue viability nurses, 1 manager) were interviewed. Depending upon the behaviours reported and the context, the same domain could be classified as both a barrier and a facilitator. We identified seven domains as relevant in the prevention of pressure ulcers in nursing home residents mapping to four “barrier” domains and six “facilitator” domains. The four “barrier” domains were knowledge , physical skills , social influences and environmental context and resources and the six “facilitator” domains were interpersonal skills , environmental context and resources , social influences , beliefs about capabilities , beliefs about consequences and social/professional role and identity ). Knowledge and insight into these barriers and facilitators provide a theoretical understanding of the complexities in preventing pressure ulcers with reference to the staff capabilities, opportunities and motivation related to pressure ulcer prevention. Conclusion Pressure ulcer prevention in nursing home residents is complex and is influenced by several factors. The findings will inform a theory and evidence-based intervention to aid the prevention of pressure ulcers in nursing home settings. [ABSTRACT FROM AUTHOR]

This article reports on the monitoring of healing rates of full-thickness pressure ulcers at one care provider in the Midlands. This was an agreed measure that was part of the Commissioning for Quality and Innovation (CQUIN) incentive scheme for the CCG. It was an attempt to provide data to support the anecdotal reports that pressure ulcer healing rates had improved after the implementation of a pressure ulcer reduction scheme called the Midlands and East Pressure Ulcer Ambition in 2012. The healing times for full-thickness pressure ulcers were recorded at 40 and 80 days after being reported by the community care provider (a community interest company [CIC], providing NHS funded services). There were 138 patients included in the data collected over a one-year period in 2015. A total of 34% of the patients were healed or healing at 40 days. A total of 55% of patients were healed or healing at 80 days. Of the 138 patients who had a full-thickness pressure ulcer, 56 died (41%), 15% had deteriorating or static wounds at 40 days and 9% at 80 days. This demonstrates that the majority of full-thickness pressure ulcers progress to healing unless the patient is at the end of life. There should be a continued emphasis on preventing as many pressure ulcers as possible to reduce avoidable harm to patients. [ABSTRACT FROM AUTHOR]

The article focuses on the different teams within the National Health Service England (NHSE) that are working on the prevention and management of pressure ulcers (PU), including the National Wound Care Strategy Programme and the National Patient Safety Team. Topics include the impact of PUs on patients' quality of life, the launch of a Patient Safety Incident Response Framework by NHSE to improve patient safety and the response planning processes in a patient safety incident.

Wound infection is proving to be a challenge for health care professionals. The associated complications and cost of wound infection is immense and can lead to death in extreme cases. Current management of wound infection is largely subjective and relies on the knowledge of the health care professional to identify and initiate treatment. In response, we have developed an infection prediction and assessment tool. The Wound Infection Risk- Assessment and Evaluation tool (WIRE) and its management strategy is a tool with the aim to bring objectivity to infection prediction, assessment and management. A local audit carried out indicated a high infection prediction rate. More work is being done to improve its effectiveness. [ABSTRACT FROM AUTHOR]

Purpose Local serious case reviews (SCRs) (now Safeguarding Adults Reviews (SARs)) may be held in England when a vulnerable adult dies or is harmed or at risk of being so, and local agencies may not have responded to the abuse or neglect. The purpose of this paper is to present findings from a documentary analysis of these reviews to ascertain what recommendations are made about pressure ulcer prevention and treatment at home, setting these in the context of safeguarding, and assessing what lessons may be learned by considering them as a group. This analysis is presented at a time of increased interest of the risks of pressure ulcers among frail and very ill populations; and debates about the interface of neglect and safeguarding systems.Design/methodology/approach Identification of SCRs from England where the person who died or who was harmed had been suffering from pressure ulcers or their synonyms in their home; termed home acquired pressure ulcers. Narrative and textual analysis of documents summarising the reports was undertaken to explore the reviews’ observations and recommendations. The main circumstances, recommendations and common themes were identified.Findings The authors located 18 relevant SCRs, one of which was a case summary and two SARs covering pressure ulcers that had been acquired or worsened when the individual was living at home. Most of these inquired into the individual’s circumstances, their acceptance of care and support, the actions of others in their family or professionals, and the events leading up to the death or harm. Failures to have followed guidance were noted among professionals, and problems within wider health and care systems were identified. Recommendations include calls for greater training on pressure ulcers for home care workers, but also greater risk communication and better adherence to clinical guidelines. A small number focus on neglect by family members, others on self-neglect, including some vulnerable adults’ lack of capacity to care for themselves or to access help. In some SCRs the presence of a pressure ulcer is only mentioned circumstantially.Research limitations/implications The value of this documentary analysis is that it draws on case examples and scrutiny at local level. Future research could consider the related findings of SARs as they emerge, similar documents from the rest of the UK, and international perspectivesPractical implications This analysis highlights the multitude of complex social and health situations that gives rise to pressure ulcers among people living at home. Several SCRs observe problems in the wider communications with and between health and care providers. Nonetheless poor care quality and negligence are reported in some SCRs. Cases of self-neglect give rise to challenging practice situations. While practices and policies about poor quality care and safeguarding in the form of prevention of wilful neglect are emerging, they often relate to hospital and care home settings. Preventing and treating pressure ulcers may be part of safeguarding in its broadest sense but raises the question of whether training, expertise and support on this subject or wider self-neglect and neglect by others are sufficiently robust for home care workers and community-based professionals.Originality/value The value of having a set of SCRs is that they lend themselves to analysis and comparison. This analysis is the first to focus on home acquired pressure ulcers and to address wider considerations related to safeguarding policy and practice. Pressure ulcers feature in several SCRs either as contextual information about the vulnerable adults’ health-status or as indications of poor care. The potential value of examining home acquired pressure ulcers as a key line of enquiry is that they are “visible” in the system, with consensus about what they are, how to measure them and what is optimal care and treatment. In the new Care Act 2014 context, they may still feature in safeguarding inquiries as symptoms of failings in systems or of personal culpability for poor care. Learning from them may be of interest to other parts of the UK. [ABSTRACT FROM AUTHOR]

Purpose Serious Case Reviews (SCRs, now Safeguarding Adults Reviews (SARs)) may be held at local level in England when a vulnerable adult dies or is harmed, and abuse or neglect is suspected, and there is cause for concern about multi-agency safeguarding practice. There has been no analysis of SCRs focussing on pressure ulcers. The purpose of this paper is to present findings from a documentary analysis of SCRs/SARs to investigate what recommendations are made about pressure ulcer prevention and treatment in a care home setting in the context of safeguarding. This analysis is presented in cognisance of the prevalence and risks of pressure ulcers among care home residents; and debates about the interface of care quality and safeguarding systems.Design/methodology/approach Identification of SCRs and SARs from England where the person who died or who was harmed had a pressure ulcer or its synonym. Narrative and textual analysis of documents summarising the reports was used to explore the Reviews’ observations and recommendations. The main themes were identified.Findings The authors located 18 relevant SCRs and 1 SAR covering pressure ulcer care in a care home setting. Most of these inquiries into practice, service communications and the events leading up to the death or harm of care home residents with pressure ulcers observed that there were failings in the care home, but also in the wider health and care systems. Overall, the reports reveal specific failings in multi-agency communication and in quality of care. Pressure ulcers featured in several SCRs, but it is problems and inadequacies with care and treatment that moved them to the safeguarding arena. The value of examining pressure ulcers as a key line of inquiry is that they are “visible” in the system, with consensus about what they are, how to measure them and what constitutes optimal care and treatment. In the new Care Act 2014 context they may continue to feature in safeguarding enquiries and investigations as they may be possible symptoms of system failures.Research limitations/implications Reviews vary in content, structure and accessibility making it hard to compare their approach, findings and recommendations. There are risks in drawing too many conclusions from the corpus of Reviews since these are not published in full and contexts have subsequently changed. However, this is the first analysis of these documents to take pressure ulcers as the focus and it offers valuable insights into care home practices amid other systems and professional activity.Practical implications This analysis highlights that it is not inevitably poor quality care in a care home that gives rise to pressure ulcers among residents. Several SCRs note problems in wider communications with healthcare providers and their engagement. Nonetheless, poor care quality and negligence were reported in some cases. Various policies have commented on the potential overlap between the raising of concerns about poor quality care and about safeguarding. These were highlighted prior to the Care Act 2014 although current policy views problems with pressure ulcers more as care quality and clinical concerns.Social implications The value of this documentary analysis is that it rests on real case examples and scrutiny at local level. Future research could consider the findings of SARs, similar documents from the rest of the UK, and international perspectives.Originality/value The value of having a set of documents about adult safeguarding is that they lend themselves to analysis and comparison. This first analysis to focus on pressure ulcers addresses wider considerations related to safeguarding policy and practice. [ABSTRACT FROM AUTHOR]

The National Stop the Pressure Programme (NSTPP) is an important Quality Improvement (QI) programme to support the delivery of improved patient care in relation to pressure ulcers. Within the NSTPP, good progress has been made in developing key approaches to deliver an improved profile to avoid patient harm in England. It is key that the new approaches are now consistently implemented to achieve the desired changes in practice. This article gives an overview of all recent pressure ulcer-related initiatives that have taken place across England and discusses the current focus of the NSTPP. [ABSTRACT FROM AUTHOR]

Pressure ulcer avoidance in the context of care has the potential to improve the quality and longevity of lives for those living in residential and non-residential care home settings. This paper reports on an educational intervention in the North East of England, which focused on the initial benchmarking of self-reported knowledge levels of healthcare workers, who regularly work with people living within this context. Using a longitudinal study design, a series of three questionnaires were used to collate data from research participants. The study revealed a disparity between what healthcare workers perceived their knowledge to be versus what it was, in terms of application to practice at the front line of patient care. The study reveals that confidence levels in dealing with pressure ulceration had been significantly altered by the training session that was being implemented. It also raised concerns on the methodological approaches being used in the education and training of care staff, which should ideally lead them to be proactive with patients in their care. The study provides an insight into the need for a strategic and targeted approach to pressure ulceration avoidance education, which is tailored to individual learning needs through supervision and mentorship as part of clinical education.

ABSTRACT Background Pressure ulcer prevention is an important safety issue, often underrated and an extremely painful event harming patients. Critically ill patients are one of the highest risk groups in hospital. The impact of pressure ulcers are wide ranging, and they can result in increased critical care and the hospital length of stay, significant interference with functional recovery and rehabilitation and increase cost. Aims This quality improvement project had four aims: (1) to establish a critical care network pressure ulcer prevention group; (2) to establish baseline pressure ulcer prevention practices; (3) to measure, compare and monitor pressure ulcers prevalence; (4) to develop network pressure ulcer prevention standards. Methods The approach used to improve quality included strong critical care nursing leadership to develop a cross-organisational pressure ulcer prevention group and a benchmarking exercise of current practices across a well-established critical care Network in the North of England. The National Safety Thermometer tool was used to measure pressure ulcer prevalence in 23 critical care units, and best available evidence, local consensus and another Critical Care Networks' bundle of interventions were used to develop a local pressure ulcer prevention standards document. Results The aims of the quality improvement project were achieved. This project was driven by successful leadership and had an agreed common goal. The National Safety Thermometer tool was an innovative approach to measure and compare pressure ulcer prevalence rates at a regional level. A limitation was the exclusion of moisture lesions. Conclusion The project showed excellent engagement and collaborate working in the quest to prevent pressure ulcers from many critical care nurses with the North of England Critical Care Network. Relevance to clinical practice A concise set of Network standards was developed for use in conjunction with local guidelines to enhance pressure ulcer prevention. [ABSTRACT FROM AUTHOR]

Preventing pressure ulcers in an acute hospital setting is a complex activity. The multiple comorbidities and increased acuity of the at risk patient result in many conflicting care priorities and the current changes in healthcare provision make delivering high quality, evidence-based care challenging. Within the field of pressure ulcer prevention, high level randomised controlled trials are difficult to undertake; an alternative to the prospective RCT is a real world review, in this case a retrospective analysis of the incidence of pressure ulcer occurrence pre and post implementation of a powered hybrid mattress the Dyna-Form® Mercury Advance (Direct Healthcare Services). This is the first review of this scale which examines the implementation of one technology and the impact that this has had on pressure ulcer occurrence, use of clinical resources and operational effectiveness. While it is acknowledged that the provision of specialist equipment forms only one part of pressure ulcer prevention, the size and number of sites included suggest that the equipment implementation -- which is the constant -- has played a significant role in driving down the number and severity of pressure ulcers. [ABSTRACT FROM AUTHOR]

Objective: The use of non-rinse skin cleansers in the care of patients who are at risk of tissue breakdown is not new within the National Health Service (NHS). Back to the Floor Continence Care Rounds (introduced in 2012 to facilitate bedside continence care education) at University Hospitals Birmingham had identified that in the current climate of austerity and efficiency savings, the use of non-rinse cleanser was being randomly rationed. Our objective was to determine whether the introduction of a smaller tube of non-rinse cleanser with targeted education would improve usage and ultimately improve the skin of incontinent patients. Method: There were five clinical areas randomised into two groups. In group I three clinical areas were provided with targeted education and new sizes of tubes of non-rinse skin cleanser. In group 2, the two remaining clinical areas acted as control groups, one receiving targeted education only and the remaining had no education or new sized tubes. The incidence of incontinence associated moisture lesions from each clinical area was monitored for 13 weeks pre and post study period. Results: The in-depth study undertaken at University Hospitals Birmingham, over a 6-month period, confirmed a trend in staff committing to the ethos of prudency, and in turn compromising the use of the most effective treatment and prevention of incontinence associated moisture lesions. The ability of the Trust staff to recognise and respond to a change in practice and the responsiveness of a commercial provider to the proposed new methodology has resulted in a significant reduction in incontinence associated moisture lesions across the trust The clinical areas included in the study demonstrated a 70-76.9% reduction in moisture lesion incidence compared to an 8.3-13.6% reduction in the control groups. Conclusion: The results strongly suggest that a reduction in incontinence associated moisture lesions can be achieved by a simple change in nursing regime. The combination of solid education provision, alongside a more appropriate size of product, has demonstrated significant patient benefit, greater adherence in practice and a reduction in waste. The integrity of the patients' tissue was preserved and staff were satisfied with their input and the patients' progress. The outcomes of this study will have an impact on patient benefit and on the efficiency for trusts resulting in greater patient satisfaction and a more appropriate use of limited resources. Declaration of interest: SCA provided 20ml tubes of TENA Wash Cream free of charge and the TENA Nurse Advisor for support during the education provision element of the study. [ABSTRACT FROM AUTHOR]

In efforts to reduce the number of avoidable pressure ulcers in a large trust, a number of initiatives have taken place to increase staff awareness about the importance of preventing and treating pressure ulcers and moisture lesions. New documentation, the use of the 'Think Pink' folders and a social media campaign have all proved successful in seeing the number of avoidable pressure ulcers reported within the trust reduce. As part of this initiative an evaluation took place of a new hydrocolloid dressing. This proved effective at reducing healing times, reducing dressing spend and facilitating regular inspection of the affected areas. [ABSTRACT FROM AUTHOR]

Pressure ulcers are a frequent, but often preventable, occurrence among patients in acute care facilities, and the heel is one of the anatomical locations most commonly affected. Multiple clinical guidelines recommend the use of robust assessments to identify at-risk patients and the application of heel protection devices to reduce the likelihood of developing heel pressure ulcers. A quality improvement initiative involving robust skin-assessment practices, staff education, and the use of heel protection devices was analysed retrospectively to evaluate the effiˆcacy of current practice interventions. These analyses revealed that the incidence of heel pressure ulcers was inversely correlated with the number of heel protectors used at two large acute NHS teaching hospitals in inner London, and that the consistent and early use of heel protectors improved patient outcomes and reduced costs of care. [ABSTRACT FROM AUTHOR]

The article evaluates the use of negative pressure wound therapy (NPWT) in management of closed surgical incisions. Proposed functions of NPWT are mentioned including increased tissue perfusion, reduction in oedema and interstitial tissue fluid and reduced bacterial colonisation. Information on incisional negative pressure wound therapy (INPWT) is offered.

The article presents the discussion on transition for the National Wound Care Strategy Programme (NWCSP) for England. Topics include expertise invaluable in helping acute, primary and community health care provider organisations improving the delivery of lower limb care across the locality; and tackling the known interoperability gaps in relation to the digitisation of wound care data.

This article outlines an innovative joint working strategy, as well as a partnership project, between two NHS Foundation Trusts—a community trust and industry partner—to develop a mobile training app to deliver pressure ulcer prevention and management for clinical staff. The aim of the innovation was to enable a new way of delivering education to large numbers of staff by moving away from traditional classroom-based training. The process included development of the app, along with testing and implementation, followed by a review of the qualitative data after the app's implementation. The review takes into account the key outcomes that have had an impact on this method of delivering education, its challenges and how it has been received by clinical staff and patients. [ABSTRACT FROM AUTHOR]

In 2013, the Royal Cornwall Hospitals NHS Trust undertook a 6-week evaluation of the AtmosAir 4000 non-powered reactive pressure redistribution mattress replacement system to determine its suitability in supporting the prevention of pressure ulcers in high-risk patients (phase one). The results demonstrated that the AtmosAir 4000 mattress system, together with skin assessment and repositioning regimes, met the pressure ulcer preventative needs of patients at high and very high risk of developing pressure ulcers. It also resulted in a notable reduction in the use of dynamic air mattresses. Consequently, 50 AtmosAir 4000 mattresses were purchased for two acute medical wards in the evaluation site, where the majority of patients are elderly with an acute medical condition. This article discusses the second phase where an audit compares the number of hospital-acquired pressure ulcers reported over a 6-month period with the equivalent time period in 2014. Results show that the number of pressure ulcers reduced by 65% and 50% in the two wards. The number of dynamic mattresses used on the two wards reduced significantly from 28 to 7, which represents a 75% reduction in usage. [ABSTRACT FROM AUTHOR]

Pressure ulcer prevention is a primary requirement for the NHS. Robust nursing procedures and the provision of pressure-relieving equipment is vital in meeting this requirement. However, the Department of Health also regards making considerable financial savings as a fundamental requirement. There is a firm clinical consensus among national and international bodies that patients at a high risk of developing pressure ulcers, or with existing tissue damage, should be cared for on an alternating (pressure-relieving) mattress system. This evaluation process looks at the performance of the lower cost Air-Flo® 8 Acute alternating (pressure-relieving) mattress system to see if it is effective in meeting the needs of patients. The outcomes suggest that when combined with a pressure ulcer management plan and turning schedule the Air-Flo® 8 Acute performed well, giving an option to continue to care for high-risk patients with an empirically proven effective therapy, while making considerable financial savings. [ABSTRACT FROM AUTHOR]

This article describes a study to ascertain what it is like to follow the processes in practice for prevention and management of pressure ulcers as one aspect of care among others. The participants in this study were bands 5 and 6 staff nurses and healthcare assistants (HCAs) (n=72) recruited from two acute and two primary NHS trusts. Data were gathered from open-ended questions via an online survey (n=61) and interviews (n=11). The interviews were transcribed and all the data were analysed by thematic analysis. The findings show that participants believe there has been a high-profile imposition of guidelines and policies by management during at least the past 18 months, resulting in perceived good outcomes in the form of fewer pressure ulcers generally and less fragmentation of care, particularly within primary care. However, a number of perceived obstacles to the implementation of recommended interventions remain, notably lack of time and lack of knowledge. [ABSTRACT FROM AUTHOR]

Aims and objectives To evaluate the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers. The objective was to identify the extent to which these frameworks take account of the setting where the ulcer originated as being the person's home rather than a hospital setting. Background Pressure ulcers involving full-thickness skin loss are increasingly being regarded as indicators of nursing patient safety failure, requiring investigation using root cause analysis frameworks. Evidence suggests that root cause analysis frameworks developed in hospital settings ignore the unique dimensions of risk in home healthcare settings. Design and methods A systematic literature review and documentary analysis of frameworks used to investigate community-acquired grade three and four pressure ulcers by home nursing services in England. Results No published papers were identified for inclusion in the review. Fifteen patient safety investigative frameworks were collected and analysed. Twelve of the retrieved frameworks were intended for the investigation of community-acquired pressure ulcers; seven of which took account of the setting where the ulcer originated as being the patient's home. Conclusion This study provides evidence to suggest that many of the root cause analysis frameworks used to investigate community-acquired pressure ulcers in England are unsuitable for this purpose. Relevance to clinical practice This study provides researchers and practitioners with evidence of the need to develop appropriate home nursing root cause analysis frameworks to investigate community-acquired pressure ulcers. [ABSTRACT FROM AUTHOR]

Objective: Pressure ulcers (PUs) cost the National Health Service (NHS) up to 4% of its health care expenditure. Arising from this are also clinical negligence claims, where inadequate risk assessment has been cited as one of the principal drawbacks in the prevention of PUs. This two-cycle audit aims to examine the consistency and accuracy of risk assessment of patients, and demonstrates how simple focused interventions can improve the quality of care provided. Method: The Waterlow pressure ulcer risk assessment tool was employed to assess inpatients during a 6-month period at a London teaching hospital. Patients were risk assessed, and examined to detect PUs and to determine the type of mattress. We compared our findings with clinical (nursing and medical) documentation. Interventions were made through questionnaires given to staff, educational sessions, presentations and posters addressing where improvements could be made in risk stratifying patients. A repeat audit was carried out 24 months later and the results from both cycles were compared. Statistical analysis was carried out using Fisher’s exact and the Student’s T-test. Results: In total 100 in-patients were assessed in each cycle with a mean age of 71.4 years in cycle 1 and 70.1 years in cycle 2. A nursing Waterlow score was recorded for 81% of patients in cycle 1 and 100% in cycle 2 (p<0.05). In cycle 1, the average nursing score was significantly lower than that from the study (mean 13.7 versus 17.1, median 14.0 versus 18.0; p<0.05), but after intervention this had reduced to a minimal difference (mean 8.5 versus 9.0, median 8.0 versus 9.0, p=0.08). Conclusion: Nursing scores recorded in the notes were lower than the study scores in cycle 1, primarily from a failure to appropriately assess certain categories of the Waterlow scale. These differences reduced after focused education of staff. Our results suggest that targeted interventions tailored towards nursing and medical staff can result in improvements in the risk assessment for prevention and subsequent management of PUs. However, it also highlights the need for increased input from the entire multidisciplinary team in order to reduce the morbidity caused by PUs. Declaration of interest: The authors have no conflict of interest. No funding was received for this study. [ABSTRACT FROM AUTHOR]

To address measurement of patient safety, the NHS in England has introduced the NHS Safety Thermometer using the Commissioning for Quality and Innovation (CQUIN) scheme. The scheme offers a financial reward to all providers of NHS care measuring four common harms using the NHS Safety Thermometer on one day each month, with further incentives to achieve improvement goals in subsequent years of the scheme. This article discusses the background to the scheme and a rationale for the focus on pressure ulcers, falls in care, catheter use and urinary tract infection, and venous thromboembolism. The implementation process for this scheme in a large NHS foundation trust is detailed together with its effect within the authors' organisation on harm-free care for their patients. [ABSTRACT FROM AUTHOR]

Background Pressure ulcers are costly to the healthcare provider and can have a major impact on patient’s quality of life. One of the most distressing symptoms reported is pain. There is very little published data on the prevalence and details of pain experienced by patients with pressure ulcers, particularly in community populations. The study was conducted in two community NHS sites in the North of England. Methods The aim was to estimate the prevalence of pressure area related pain within a community population. We also explored the type and severity of the pain and its association with pressure ulcer classification. A cross-sectional survey was performed of community nurses caseloads to identify adult patients with pressure ulcers and associated pain. Consenting patients then had a full pain assessment and verification of pressure ulcer grade. Results A total of 287 patients were identified with pressure ulcers (0.51 per 1000 adult population). Of the 176 patients who were asked, 133 (75.6%) reported pain. 37 patients consented to a detailed pain assessment. Painful pressure ulcers of all grades and on nearly all body sites were identified. Pain intensity was not related to number or severity of pressure ulcer. Both inflammatory and neuropathic pain were reported at all body sites however the proportion of neuropathic pain was greater in pressure ulcers on lower limbs. Conclusions This study has identified the extent and type of pain suffered by community patients with pressure ulcers and indicates the need for systematic and regular pain assessment and treatment. [ABSTRACT FROM AUTHOR]