PETERBOROUGH SAFEGUARDING ADULTS BOARD Practice Guidance: Pressure Ulcers. This guidance has been written in two parts: Part 1 has been developed to support decision making about when to make a safeguarding adults referral regarding pressure ulcers. Part 2 is about the prevention and treatment of pressure ulcers and is primarily aimed at providers involved in the delivery of care It provides guidance to: Adult Social Care Staff Domiciliary Care Staff in relation to referring a pressure ulcer under adult safeguarding procedures and the management of pressure ulcers. NHS providers including, community nursing and acute hospitals This does not replace locally agreed pressure ulcer guidance but provides advice on when pressure ulcers should be referred under the adult safeguarding procedures. It also provides an outline of expected pressure ulcer care which should be delivered by all social care provides. This guidance also can be used by Adult Social Care contracting and commissioning staff in considering contractual arrangements for providers. Part 1: Pressure Ulcers When to consider making and accepting a safeguarding adults referral and what to include in the Safeguarding Adults Pressure Ulcer Report. 1. Definition A pressure ulcer is a localised injury to the skin and / or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (1) which is caused when the body slips down; the underlying structures move, but the skin stays in the same position. This may result in deeper layers tearing away from the top layer of the skin (The prevention and management of pressure ulcers, NHS Education for Scotland 2009). A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be clarified. (European Pressure Ulcer Advisory Panel (EPAUP, 2009). (Extract 1
taken from the Cambridgeshire Community Services Prevention and Management of Pressure Ulcers Guidelines 2011) Pressure Ulcers can develop very quickly and without appropriate intervention can become very serious. Any pressure ulcer can be painful and cause suffering but severe pressure ulcers can expose bone, and in extreme cases they can cause infection and become life threatening. 1.1 Severity of Pressure Ulcers Healthcare professionals use several grading systems to describe the severity of pressure ulcers. The most common is the European Pressure Ulcer Advisory Panel (EPUAP) grading system. The higher the grade, the more severe the injury to the skin and underlying tissue. Grade one A grade one pressure ulcer is the most superficial type of ulcer. The affected area of skin appears discoloured and is red in white people, and purple or blue in people with darker coloured skin. Grade one pressure ulcers do not turn white when pressure is placed on them. The skin remains intact but it may hurt or itch. It may also feel either warm and spongy, or hard. Grade two In grade two pressure ulcers, some of the outer surface of the skin (the epidermis) or the deeper layer of skin (the dermis) is damaged, leading to skin loss. The ulcer looks like an open wound or a blister. Grade three In grade three pressure ulcers, skin loss occurs throughout the entire thickness of the skin. The underlying tissue is also damaged. However, the underlying muscle and bone are not damaged. The ulcer appears as a deep, cavity-like wound. Grade four A grade four pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged and the surrounding tissue begins to die (tissue necrosis). The underlying muscles or bone may also be damaged. People with grade four pressure ulcers have a high risk of developing a lifethreatening infection. * Please note that care providers should report all grade 3 and 4 pressure sores to the Care Quality Commission (CQC). 2
2. Safeguarding Considerations A grade 3 or 4 ulcer could indicate possible neglect and consideration should be given to making a safeguarding adults referral to Adult Social Care. If it is felt that neglect has contributed to a pressure ulcer then a safeguarding adult s referral should be made to Adult Social Care. Neglect is described in the Peterborough Adult Safeguarding Policy and Multi Agency Procedures (April 2012) as: The failure of any person who has responsibility for the charge, care or custody of an adult at risk to provide the amount and type of care that a reasonable person would be expected to provide. Behaviour that can lead to neglect includes including ignoring medical or physical needs, failing to allow access to appropriate health, social care and educational services, and withholding the necessities of life such as medication, adequate nutrition, hydration or heating. 3. The Safeguarding Procedures Upon receipt of a safeguarding adult s referral relating to pressure ulcer care, the Adult Social Care worker dealing with the referral should refer to appendices A and B, on pages 5 and 6 of this guidance. These demonstrate in a table form the safeguarding triggers to consider when deciding whether concerns about pressure ulcer care need investigating under the safeguarding procedures. Appendix A offers guidance around factors to consider when an individual is receiving professional support and experiences pressure ulcers Appendix B offers guidance around factors to consider when an individual is not receiving professional support (i.e. only receiving care from an informal carer). These tables can be extracted from this guidance and used as a desk aid. If having considered these tables it is felt that the safeguarding criteria is appropriate, the Peterborough Multi Agency Safeguarding Adults Procedures must be applied. If a decision is made by Adult Social Care to investigate under the safeguarding policy and procedures, the strategy discussion will agree who will be identified to complete a Safeguarding Adults Pressure Ulcer Report. This person should be sufficiently qualified or experienced to carry out this enquiry. This could be: Adult Social Care Worker with support / specialist advice from the Tissue Viability Nurse. District Nurse 3
Tissue Viability Nurse 3. The Safeguarding Adults Pressure Ulcer Report. Following the referral, if a request is made from the social worker to a health professional to investigate, the report should consider including the following and can be presented in the form of a chronology or a full written narrative. If a Serious Incident investigation is in process then this report would satisfy the requirements of the Safeguarding Adults Pressure Ulcer Report. 3.1 The Individuals relevant past history. Significant health history physical and mental Consideration of whether or not there has there been rapid onset and - deterioration in health The individual s compliance, capacity and behaviour 3.2 The Individuals Care Regime OR Where they were at the time the pressure ulcer was identified? Where were they prior to this? Were they receiving support from a regulated service what is their quality rating? What is Care Contracts view of the quality of care provided by this service? Are there other recent similar incidents? Were they assessed was the assessment robust? Did the individual care plan identify risk and appropriate measure to be taken? Was there specialist equipment in place? Is there evidence the care plan was implemented? Is the service able to give account for staff skills, competences in this area and staff to resident/patient ratio days and nights? Were they living alone? Who was providing support? What is the relationship? Carer s description, age, disability etc. Support networks? Was support and help sought? When? From whom? Was support accepted all, in part, none? 3.3 The Individuals Mental Capacity Has a Mental Capacity Assessment been completed? 3.4 The Individual mobility History just prior to pressure ulcer identification Did the care plan include care needs specific to mobility? 3.5 Hydration and Nutrition Evidence of intake monitoring Fluid monitoring 4
Regular weight records any cause for concern? Care plan should include hydration and nutrition. 3.6 Medication Note use of sedation is the individual immobile for extended periods? Is pain assessed and managed? 3.7 Individual s general appearance At the time of the referral what were the general indicators of care: clean nails, emaciated, oral care, lucid, generally well presented? 3.8 Individuals and relatives/significant others views What is the individual s view of the care and support they have received? What are the views and opinions of the individual s relatives/significant others of the care and support the individual has received? 3.9 Conclusion What does the above suggest/indicate? You need to make an assessment of whether all appropriate risk assessments and actions were in place and an assessment of avoidability / unavoidability and then any recommendations and actions if necessary 3.10 If it is felt that the pressure ulcer was unavoidable to the individual s health and the service they were receiving had taken all appropriate measures available to them in a timely manner then there is no need for further safeguarding action. *An unavoidable pressure ulcer is when the person receiving care developed a pressure ulcer even though the provider of care evaluated the person s clinical condition and pressure ulcer risk factors: planned and implemented interventions that were consistent with the person s needs and goals and recognised standards of practice; monitored and evaluated the impact of the interventions and revised the approaches as appropriate; or the individual person refused to adhere to prevention strategies despite education of the consequences of non- adherence. (Department of Health / National patient safety agency 2010) 3.11 If the pressure ulcer was avoidable and the result of neglect because the service and support they were receiving had NOT taken all appropriate measures available to them in a timely manner then FURTHER SAFEGUARDING ACTION REQUIRED. This can include a Safeguarding Protection Plan and at this stage the police must be involved when neglect may be considered. 3.12 Consideration should also be given to whether or not the Serious Incident process should be instigated, please consult the relevant Serious Incident procedures in your organisation. 5
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Appendix A - Pressure Ulcers Safeguarding Triggers for an individual receiving professional support receiving professional support (in a care or nursing home, hospital or from a domiciliary care or nursing care agency. This table will help determine if the identification of a pressure ulcer on an individual receiving professional support (in a care or nursing home, hospital or from a domiciliary care or nursing care agency) should result in a safeguarding referral. This table can be used by all staff who work in the delivery of care to inform their decision as to whether they need to make a safeguarding adults referral. It can also be used by Adult Social Care staff to help with their decision making as to whether there is a need to investigate under the safeguarding adult procedures. 1. What is the severity of the pressure ulcer? (Grade) 2. Does the individual have mental capacity and have they been compliant with treatment? Has a capacity assessment been completed? Possibly NOT safeguarding at this stage Grade 1 or 2 pressure ulcer care plan required. Has capacity and has refused / declined treatment. Capacity assessment is recorded. Possibly Safeguarding Several Grade 2 pressure ulcers or Grade 3 or 4 pressure ulcers - consider question 2 below about mental capacity. Does not have capacity or capacity has not been assessed = continue to question 3 below. Definitely Safeguarding Grade 4 and other issues of significant concern make a safeguarding referral. Assessed as NOT having capacity and treatment NOT provided. 3. Provider has completed pressure care assessment completed and care plan developed in a timely manner and care plan implemented? 4. This incident is part of a trend or pattern - there have been other similar incidents with this individual or others. Documentation and equipment available to demonstrate full assessment completed, care plan developed and implemented. Evidence suggests this is an isolated incident. Continue observing patient but no further action required at this stage NOT SAFEGUARDING Documentation and equipment NOT fully available to demonstrate full assessment completed, care plan developed or implemented BUT general care regime (e.g. nutrition, hydration) not of concern - continue to question 4 below There have been other similar incidents. MORE THAN TWO OF THE ABOVE = SAFEGUARDING Little or no documentation available to demonstrate a full assessment has been completed, or care plan developed or implemented AND general care regime (e.g. nutrition, hydration) is of concern. Evidence demonstrates this is part of a pattern or trend. SAFEGUARDING IF IN DOUBT Initiate Safeguarding Adults Procedures Discuss with senior manger Record decisions and reasons for the decisions. 7
Appendix B - Pressure Ulcers Safeguarding Triggers for an individual not receiving professional support i.e. only support available is from an unpaid carer / family member) put the full title This table will help determine if the identification of a pressure ulcer on an individual receiving NO professional support (i.e. only support available is from an unpaid carer / family member) should result in a safeguarding referral. This table can be used by all staff who work in the delivery of care to inform their decision as to whether they need to make a safeguarding adults referral. It can also be used by Adult Social Care staff to help with their decision making as to whether there is a need to investigate under the safeguarding adult procedures. 1. What is the severity? (Grade) 2. Does the individual have mental capacity and have they been compliant with treatment? NOT safeguarding at this stage Grade 2 pressure ulcer or below care plan required. Has capacity and has refused treatment. Possibly Safeguarding Grade 3 & 4 pressure ulcers = consider question 2. Does not have capacity or capacity has not been assessed = continue to question 3. Definitely Safeguarding Grade 4 and other issues of significant concern. Assessed as NOT having capacity and treatment NOT provided. Has a capacity assessment been completed? Capacity assessment is recorded. 3. Unpaid carer raised concerns and sought support at an appropriate time. 4. Full assessment completed and care plan developed in a timely manner and implemented. 5. This incident is part of a trend or pattern - there have been other similar incidents with this individual or others. Evidence available to show concerns raised and support sought e.g. from GP, DN, SW. Evidence available to show unpaid carer cooperated with assessment and has implemented care plan. Evidence suggests this is an isolated incident NOT SAFEGUARDING Evidence NOT CLEAR that concerns were raised or support sought in a timely manner. Evidence of partial cooperation or implementation of care plan some aspects may have been refused - e.g. certain equipment There have been other similar incidents or other areas of concern. MORE THAN TWO OF THE ABOVE = SAFEGUARDING No support sought. NO cooperation and refusal to implement care plan and or purposeful neglect. Evidence demonstrates this is a pattern or trend. SAFEGUARDING IF IN DOUBT Initiate Safeguarding Adults Procedures Discuss with senior manger Record decisions and reasons for the decisions. To make a safeguarding adults referral please contact Adult Social care. PETERBOROUGH SAFEGUARDING ADULTS BOARD Practice Guidance: Pressure Ulcers 8
Part 2: Prevention and Treatment of Pressure Ulcers 1. Causes Anyone can get a pressure ulcer but some people are more at risk than others. Identifying those at higher risk will help identify appropriate prevention measures. 1.1 Risk Factors Include Pressure Friction (the rubbing of the skin causing superficial abrasions) Shearing (the tearing and stretching of the skin caused by a person sliding down or being dragged up the bed, combined with the individual s weight)reduced mobility or immobility Lack of feeling/sensation in the skin Long term chronic illness Acute illness e.g. chest infection Levels of consciousness Extremes of age (over 65, under 5) Extremes of weight Previous history of pressure damage Poor nutritional input Medication e.g. night sedation or strong pain killers, steroids Moisture (incontinence, leaking wounds, perspiration) 2. Skin Inspection Skin inspection provides essential information for pressure ulcer prevention. Frequency of inspection will be dependent on a patient s condition and is likely to be daily. The first change in a service user s skin condition would require an intervention. Inspection of vulnerable parts of the body will enable early detection of tissue damage. Skin should be inspected for any redness or change of colour. 2.1 If it is not possible to see redness on the skin of people with darkly pigmented skin, then it should be assessed for the following signs: Darkening of the skin Localised heat Localised swelling Localised hardening of the skin 9
A later stage of tissue damage would be blistering or a break in the skin. Any skin changes noted should be documented immediately and discussed with the individual and the multidisciplinary team. Form B & C in this document can be used to record skin inspections and areas of concern. 2.2 The areas of the body that are most vulnerable are typically: Heels Sacrum/base of the spine Buttocks Hips Elbows Back or side of head Ears Shoulders Toes Parts of the body that are affected by the wearing of anti-embolic stockings Parts of the body where there are external forces exerted by equipment and clothing e.g. Wheelchairs, catheters, intravenous lines, shoes. 3. Prevention The following will help to prevent significant pressure ulcers from occurring and thus reducing the harm to individuals. 3.1. Assessment Early identification of people at high risk of pressure ulcers will ensure preventative measures can be implemented quickly. The use of clinical judgement and a formal risk assessment tool, such as the Waterlow Risk Assessment Tool, will ensure all risk factors are assessed in a consistent way. Paper based risk assessments should not be completed in isolation but in conjunction with a thorough skin inspection of the most at risk areas (as listed above). Visual skin assessments must be carried out each time personal care is given, the findings must be documented and the care plan updated depending on the findings. 3.2 It is recommended that the forms at the end of this document are used as examples of good practice. Form A. Skin Inspection Form - This tool can be used by health and social care staff and informal carers. Form B. Body Map - This can be used in two ways in conjunction with the Skin Inspection Form or on its own. Form C. Skin Assessment Tool (Ref: Waterlow) 10
It is strongly recommended this assessment tool is only completed by a staff member who has had appropriate training. 4 4. Interventions Preventative measures should be tailored to the individuals needs. The following preventative interventions should be considered for all people identified at risk. 4.1. Mobility One of the best ways of preventing pressure ulcers is to reduce or relieve pressure on the areas of skin that are vulnerable. This can be done by encouraging or assisting the person to move or change position as often as needed to prevent persistent redness of the skin. If an individual already has a pressure ulcer, lying or sitting on this area should be avoided as much as possible. The following is recommended: At risk people should have an individual care plan, identifying a repositioning regime. A chart may be needed to document this. Individuals should be given advice about how to change their position in bed/chair and how often they should do this to prevent pressure ulcers developing. People that need support to move or transfer should be assisted in a way that reduces the risk of friction or shearing. If a person s skin condition is deteriorating despite a regular and frequent turning regime then a specialist mattress and/or cushion should be used. 4.2. Aids and Equipment There are many different types of mattresses and cushions that can help to reduce the pressure on bony parts of the body and help prevent pressure ulcers. It is important to document what is being used and that it has been checked to ensure it is being used correctly and not broken. All Health and Social care providers must ensure that people are using equipment and aids that meet their needs and promote their comfort, safety and dignity. It is important to note that specialised equipment will not eliminate the need for regular turning or changing positions. 4.3. Nutrition Eating well and drinking enough fluids is very important to help reduce people s risk of developing pressure ulcers and effective wound healing. If there are concerns regarding whether a service user has sufficient nutrition and fluid intake, a food and fluid intake chart should be implemented. Care home residents should in addition have a The Malnutrition Universal Screening Tool (MUST) assessment, it is the most commonly used screening tool in the UK to assess malnutrition. Resources and information can be found at: http://www.bapen.org.uk/screening-for-malnutrition/must/introducing-must In all cases service users should be referred to a GP when a concern has been identified. 11
4.4. Moisture Control If skin is exposed to moisture for long periods of time it can cause skin damage. The most common causes of moisture are: Urinary and/or faecal incontinence Sweating Wounds Ensure that skin is clean and dry, consider assessment for continence aids and a possible referral to a GP or the continence adviser 4.5. Skin Care Skin that is dry or sensitive will be more susceptible to becoming damaged by friction and shearing. Things to consider: Do not rub skin but pat it dry If the individual insists on using talcum powder, they should be advised to use it sparingly. Keep beds and chairs free from crumbs and wrinkles Check clothing and footwear for prominent seams or zips that may cause skin damage. Foot care is an important area to consider, at least daily checks of the feet and heels should be undertaken. 5. Record Keeping and Information Sharing Good record keeping is essential to demonstrate full assessments have been completed and to identify the care or treatment required and delivered. 5.1 The following records must be kept in relation to pressure ulcers, as it should be for all care which is given, and should include date, time and signature: Assessments (including risk and skin assessments) Individual care plan Consent to treatment Daily records of care given 6. Mental Capacity An individual s mental capacity to understand their care plan and to be compliant with the treatment, or not, will need to be considered and may need to be formally assessed. If you are not sure, discuss the concern with your manager. An IMCA (Independent Mental Capacity Advisor) through VoiceAbility services can do this. Appendix 1 6.1 The Mental Capacity Act 2005 (MCA) is underpinned by 5 guiding principles, which everyone must follow these are: 1. An assumption of capacity 12
2. Supporting people to make their own decisions 3. People have the right to make eccentric or unwise decisions 4. Where someone lacks capacity staff must act in the person's best interests 5. Where someone lacks capacity any action we take on their behalf must generally be the least restrictive option. 7. Training & Education All staff involved with the health and care of service users must have access to training, information and guidance on prevention of pressure ulcers and skin damage. Such training, information and guidance must be appropriate to their role and responsibilities. The requirements of regulators such as the Care Quality Commission (CQC) and Local Authorities must be met. All staff must be up to date with their training and learning in line with their organisational policy and organisations must have a system to record details of training and training requirements for each member of staff 8. Quality Monitoring The following will ensure Quality Monitoring is successful: All staff receive support and clinical supervision in the form of a discussion with a peer or manager / professional on a regular basis regarding complex cases or scenarios which the member of staff would like to review. Organisations and agencies have systems in place for checking that prevention of pressure ulcer practices are in place, assessments are being undertaken and care plans implemented. Organisations and agencies should check trends and patterns of pressure ulcers including grades of pressure ulcers, equipment used and any contributing factors so improvements can be identified and implemented. Compliance with performance indicators should be included in contracts with care homes and care providers and compliance should be monitored. 10. Further Reference Materials The stop the pressure website contains further useful information: http://www.stopthepressure.com/path/ 11. Concerns Which Require Escalation Refer to the Peterborough Safeguarding Adults Multi-Agency policies and procedures available on the Peterborough City Council website. 12. If you require any further information, please contact the Peterborough Safeguarding Adults team: Strategic Safeguarding Adults Lead Peterborough City Council Telephone: 01733 452434 Or 13
Julie Hall - Adult Safeguarding Lead Nurse Cambridgeshire and Peterborough CCG Telephone: 01733 775184 Email: julie.hall@cambridgeshireandpeterboroughccg.nhs.uk 13. Contributors Julie Hall: Adult Safeguarding Lead Nurse Cambridgeshire and Peterborough CCG Lynn Rodrigues: Infection, Prevention and Control Matron Cambridgeshire and Peterborough CCG Doreen Simpson: Risk Manager (Serious Incidents), Quality Directorate, Cambridgeshire and Peterborough CCG Janet Small: Tissue Viability Nurse, Cambridgeshire Community Services and Peterborough and Stamford Hospitals Foundation Trust Lesley Crosby: Assistant Director, Nursing and Care Quality, Peterborough and Stamford Hospitals Foundation Trust 14
FORM A. Skin Inspection Form NAME: Date & Time Head Left Ear Right Ear Left Elbow Right Elbow Sacrum Left Buttock Right Buttock Left Hip Right Hip Left Knee Right Knee Left Heel Right Heel Left Ankle Right Ankle Other Please state Sign/initial Normal Appearance 0 Change in Appearance 1 If 1 is written there must be an entry in the care records stating what the change is, the intervention required and when the intervention has been completed. 15
FORM B. Body Map Guidance The following Body Maps should be used to document and illustrate visible signs of harm and physical injuries. Clearly mark on the body map: Pressure ulcers Red areas Bruises Cuts, lacerations and wounds Scalds and burns Swellings. Insect Bites Provide details such as: Size Colour Grade of pressure ulcer if known. Always record: The date of the record The time the record was made and The name and designation of the person making the record. Use the notes section to add any further comments. As the wound or mark changes a new record should be made. A copy of all body charts must be kept in the individuals records. Always use a black pen 16
BODY MAP Name: Date: Notes: 17
FORM C. Skin Assessment Tool Undertake and document risk assessment within 6 hours of admission or on first home visit. Reassess if there is a change in individual s condition and repeat regularly according to local protocol. More than one score/category can be used: 10+= At Risk : 15+ = High Risk : 20+ = Very High Risk Sex Male 1 Female 2 Age 14 49 1 50 64 2 65 74 3 75 80 4 81+ 5 Build/Weight for Height (BMI=weight in Kg/height in m 2 ) Average BMI 20-24.9 0 Above average BMI 25-29.9 1 Obese BMI > 30 2 Below average BMI < 20 3 Continence Complete/catheterised 0 Incontinent urine 1 Incontinent faeces 2 Doubly incontinent (urine & faeces) 3 Skin Type Visual Risks Area Healthy 0 Tissue paper (thin/fragile) 1 Dry (appears flaky) 1 Oedematous (puffy) 1 Clammy (moist to touch)/pyrexia 1 Discoloured (bruising/mottled) 2 Broken (established ulcer) 3 Mobility Fully mobile 0 Restless/fidgety 1 Apathetic (sedated/depressed/reluctant to move) 2 Restricted (restricted by severe pain or disease) 3 Bedbound (unconscious/unable to change position/traction) 4 Chair bound (unable to leave chair without assistance) 5 Nutritional Element Unplanned weight loss in past 3-6 months < 5% Score 0, 5-10% Score 1, >10% Score 2 0-2 BMI >20 Score 0, BMI 18.5-20 Score 1, BMI < 18.5 Score 2 0-2 Patient/ client acutely ill or no nutritional intake > 5 days 2 Special Risks Tissue Malnutrition Multiple organ failure/terminal cachexia 8 18
Single organ failure e.g. cardiac, renal, respiratory 5 Peripheral vascular disease 5 Anaemia = Hb < 8 2 Smoking 1 Special Risks Neurological Deficit Diabetes/ MS/ CVA/ motor/ sensory/ paraplegia Max 6 4-6 Special Risks Surgery/Trauma On table > 6 hours 8 Orthopaedic/ below waist/spinal (up to 48 hours post op) 5 On table > 2 hours (up to 48 hours post op) 5 Special Risks Medication Cytotoxic, anti-inflammatory, long term/high dose steroid 4 Max 4 Total Score Date Initials Time Ensure plan of care is implemented / reviewed for all identified areas of concern. (Adapted form from Scotland NHS Quality Improvement Waterlow Pressure Area Risk Assessment Chart) 19