2. Procedure for managing pressure sores through the safeguarding process 2.1 The Initial Response Team will receive a concern reporting the presence of a pressure sore. The source of the referral could be a member of the public, GP, district nurse, tissue viability nurse, care home, domiciliary care agency, hospital, family member or the person who has the pressure sore. 2.2 An officer in the Initial Response Team will make enquiries and gather the necessary information in order that it can be ascertained whether or not the incident meets the safeguarding threshold. This includes establishing the source of the pressure sore; whether for example it be a hospital, residential care environment, within the community, or as a result of possible self-neglect. The officer will also confirm whether a treatment plan is in place, whether or not this is working and whether an interim protection plan is required. 2.3 A Duty Senior will establish whether or not the incident meets the threshold for a safeguarding enquiry. This will be, in part, dependent upon establishing whether the pressure sore is avoidable or unavoidable. In some cases; for example, where a person is at the end of life stage, it may not be possible to prevent pressure sores from occurring. Therefore, this matter would not fall under safeguarding. It may be useful to refer to the risk assessment published by the National Institute for Health and Care Excellent (NICE) as part of its guidance on the prevention and management of pressure sores: http://www.nice.org.uk/guidance/cg179/chapter/1-recommendations 2.4 In many instances the pressure sore is avoidable and therefore in cases where the safeguarding threshold is met, the matter is delegated to the relevant health or social care provider for further enquiry. Although the London Borough of Bromley will retain its position as the safeguarding lead, the clinical enquiry would be undertaken by a practitioner with appropriate clinical training and knowledge. Those professionals would conduct a root cause analysis in order to determine the reason why the pressure sore developed. If a nursing home is the source of the pressure sore, the nursing home can also be asked to undertake a root cause analysis. 2.5 The outcome of the root cause analysis is incorporated into the enquiry report (SA3), which is then presented at the safeguarding case conference. The Chair will establish, using the evidence provided, whether harm was avoidable, unavoidable or if there was not enough evidence on which to base a decision. Based on this information, the case conference discussion will then conclude whether a protection plan is required, whether the case will need to be reviewed within a certain period of time or whether the case can be closed. 3. Pressure Sore Passport 3.1 The Pressure Sore Project was launched with the aim of standardising reporting and practice protocols across four boroughs; Bromley, Lewisham, Greenwich and Bexley. 3.2 A review of existing procedures found there was a non-consensus approach across these boroughs, the main issues being: Enquiries were taking a great deal of time Lack of ownership at ward/care home/community level Lack of up-to-date knowledge on pressure sore prevention Lack of clarity on pressure sore grading The use of varying protocols across boroughs and Clinical Commissioning Groups Blame culture relating to pressure ulcer management
3.3 In order to resolve the above issues, a joint pressure sore group has been established with representation from the four boroughs, clinical commissioning groups; and local acute, mental health and community providers. 3.4 The Pressure Ulcer Passport was designed with the assistance of Kings College NHS Foundation Trust. The passport, which stays with the patient, provides a contemporaneous record of any pressure issues they have. A pilot passport scheme began in February 2015, and several care homes and all health partners have signed up to the scheme. 3.5 It is estimated approximately six in every 10 pressure sores should not be dealt with under the safeguarding process. A standardised tool, that will be piloted by Bromley Healthcare, is being developed to enable a consistent approach to be taken toward pressure sore management and to support staff to distinguish between pressure sores that are avoidable and those that are not. 3.6 Due to the fact some care homes still do not report all their pressure sores to the Care Quality Commission, it is recognised changes must be made so residential and domiciliary care providers are contractually obliged to report their pressure sores every month. 3.7 A need has also been identified for the implementation of appropriate and targeted training to ensure care providers understand what is going wrong in the treatment and prevention of pressure sores. 4. The Willows Integrated Care Team Pilot 4.1 Whilst work with the adult may frequently require the input of a care manager, other aspects of enquiries may be best undertaken by others with more appropriate skills and knowledge. For example, health professionals should undertake enquiries, treatment plans and root cause analysis relating to pressure sores. 4.2 The London Borough of Bromley, in partnership with the Bromley Clinical Commissioning Group, has seconded a Senior Care Manager to the Willows Integrated Care Team as part of a pilot project, which it is hoped will culminate in the proposed safeguarding adults process for pressure care management. 4.3 The Integrated Care Team is made up of the following professionals: Occupational Therapists (OTs), Community Matrons, District Nurses (DNs), Community Psychiatric Nurses (CPNs), Physiotherapists (PTs) and Care Managers (CMs). 4.4 The aim of the Willows Integrated Care Team is to: Support existing structures to safeguard adults with care and support needs in the community and in care homes; provide an holistic approach to safeguarding investigations involving pressure sore management; increase the monitoring of services; promote good enough pressure care within care homes and the community via open communication and information sharing; identify appropriate referrals relating to pressure sores in order to reduce the amount of adult safeguarding referrals to LBB s Initial Response Team within the Willows area; continuity and consistent support for clients, patients, GPs, DNs, Community Matrons, OTs, PTs and providers; provide clear and consistent feedback to regulators and commissioning.
5. Raising an alert/multi-disciplinary Team (MDT) decisions 5.1 As the lead agency, the London Borough of Bromley will be responsible for receiving safeguarding alerts relating to pressure sores. Using the referral form, AC1 (see section 4.4), district nurses, nurses, physiotherapists and occupational therapists should raise the alert to the allocated senior care manager based in LBB s Initial Response Team. 5.2 The pressure ulcer guidance will be consulted and the case will be discussed to determine if a Serious Incident (See Section 6) is raised and a safeguarding enquiry started. 5.3 The Multi-Disciplinary Team (MDT) is responsible for the following actions: Act to protect the adult by evaluating the risk; minimise immediate risks; decide if a referral is needed to other agencies; report to line management; provide an interim protection plan, to minimise further skin breakdown; decide if the NHS considers reporting as a significant incident; consider police involvement. 6. Making a referral 6.1 The referrer should work in partnership with the adult with care and support needs and complete the pressure ulcer passport (see section 5 below). This will enable the referrer to have an holistic understanding of the factors that could contribute to the skin breakdown. 6.2 The referrer should follow Bromley Health Care (BHC) guidance regarding serious incidents and pressure sore guidance; and inform the risk manager within BHC of their concerns. The referrer will then complete the referral form (AC1), clearly highlighting their cause for concern. 6.3 The following decisions and actions will need to be taken: MDT to agree who will undertake the enquiry; Safeguarding Adults Manager from LBB to take the lead in coordinating enquiries; refer to advocate if agreed by the client/patient; MDT to decide if further investigation is needed, and by whom; inform regulators, LBB commissioning and the Care Quality Commissioning of concerns raised in the serious incident. 6.4 The MDT strategy discussion should do the following: Evaluate the risk with the Safeguarding Adult Manager (SAM); support the immediate needs; MDT to decide the relevant points of enquiry; collate evidence and share with involved organisations. 7. Safeguarding Enquiry 7.1 The enquiry is conducted in partnership with the client, their advocate and other involved organisations. The evidence is received and a report is produced and distributed with clear recommendations. 7.2 During the Case Conference, the report is discussed and the outcomes and recommendations are confirmed. The risks to the client/patient and others are evaluated
and a protection plan is formulated. It is then agreed whether the protection plan is either kept under regular MDT review or if the case is closed. 7.3 When the process is closed, the following should be done: The safeguarding case work signed off; Contracts and the Care Quality Commission are informed of the outcome; and if the relevant professionals were involved and there were concerns about negligence by them, the General Medical Council and Nursing and Midwifery Council would also be informed; lessons learnt discussed; the process may also be closed pending the outcome of a prosecution. 7.4 Please see below for an example copy of the AC1 referral form and guidance notes. 8. Serious Incidents 8.1 Step 1: Event or incident: 1. An incident of concern is reported. (This could include an oral or written complaint or concern raised by anyone with regard to a person, place or act, or any type of incident). This report should be completed immediately after the event has occurred. It can also be made directly to the commissioner and regulator. 2. Confirm any immediate safety issues have been addressed. Consider whether a crime has been committed (See Section 44 of the Mental Capacity Act 2005: Illtreatment or neglect). 3. Consider the person at the centre of the event (e.g. a member of staff or a patient, or both) and the information and support they may require during and after the incident. 8.2 Step 2: Report: 1. The person who has identified the concern reports this in line with local organisational procedures and regulatory requirements e.g. completion of an incident/serious incident form. 2. Details about any immediate or on-going care for the person are recorded within the patient's notes/hr files as appropriate. 8.3 Step 3: Review: 1. The incident form/complaint is reviewed within 24 hours to identify if harm has occurred that requires a safeguarding adults response. (This will be in addition to any action subsequently to be taken under the multi-agency procedures and NHS Complaints (England) Regulations 2009) Consider: Is this a safeguarding concern that falls within the safeguarding adults procedures? 2. Services should have robust local processes in place to ensure that this review is comprehensive, timely and effective. This should be linked into existing processes for incident reporting/complaints, so that reviews forms part of this process. The process should be in line with local multi-agency safeguarding adults procedures and protocols. 3. Ensure that appropriate notifications are made to CQC (via patient safety reporting systems for NHS services). Communicate with commissioners, regulators and governing bodies according to national and local guidelines.
8.4 Step 4: YES or NO: 1. A 'yes' or 'no' route is then selected. 2. In the event that there is a safeguarding concern, complete a referral in line with local procedures and send to the safeguarding team. (In addition, an incident form should still have been completed). 3. Normal trust policies and procedures for follow-on actions still apply and should be carried out in partnership with the safeguarding process. 4. If there are no apparent safeguarding concerns, normal procedures for investigation etc. should apply. However if, through the investigation process, a safeguarding concern should emerge, an alert should be raised immediately and progressed as above. 8.5 Direct Referral 8.5.1 In the unlikely event a safeguarding concern is not progressing satisfactorily within the organisation s systems, staff involved in raising the incident or alert may send/discuss the concern directly with the local safeguarding adults service (see local Adult Safeguarding policies and procedures) and directly with their commissioners. 8.5.2 Many of the factors are likely to be on a continuum of concern and no singular decision will determine that a referral should not be made. 8.5.3 The assessment must be a 'broad brush' assessment that should not try to replace the more detailed assessment that would happen within the local safeguarding adult service. Where there is any doubt, the decision maker should consult with the local safeguarding adults service. 8.5.4 Remember: A safeguarding adults referral is about fuller consideration with multi-agency partners on the best way forward; referral does not necessarily lead to an investigation under formal safeguarding adults procedures. A safeguarding adults referral is about finding the best way to support the patient; it accesses wider multi agency information, perspectives, skills and resources A safeguarding adults referral is about accountability, openness and transparency; it is about learning and improving patient care. A safeguarding adults referral is not about pre-determining that neglect or abuse has occurred. It is the start of seeking more information, finding out if something went wrong and then putting it right. A safeguarding adults referral is not about setting up long and complicated investigations by other agencies. The response must be proportionate and, in many cases, the service may lead the response. 8.5.5 See the flowchart below for the provided framework for decision making.
9 The Waterlow Score 9.1 Unrelieved pressure on a specific area of the body (eg the heels, the hips) will affect the blood supply to the skin and underlying tissues, causing the area to become damaged. Mild tissue damage results in skin discolouration, giving a brown or purple appearance. This may look darker if the skin is very fair. More severe pressure ulcers can expose muscle and even bone. The area around the dead tissue will look red and inflamed and may become infected. 9.2 There are four recognised grades of pressure sores in the European Pressure Ulcer Advisory Panel (EPUAP) Wound Classification system. GRADE 1: Discolouration of intact skin not affected by light finger pressure (no blanching erythema). This may be difficult to identify in darkly pigmented skin. GRADE 2: Partial-thickness skin loss or damage involving epidermis and/or dermis. The pressure ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. GRADE 3: Full thickness skin loss involving damage of subcutaneous tissue but not extending to the underlying fascia. The pressure ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. GRADE 4: Full thickness skin loss with extensive destruction and necrosis extending to underlying tissue. 9.3 Pressure ulcers tend to develop on bony prominences and on areas of the body that have little body fat to cover them. This includes the hips, buttocks, heels, shoulder blades and the small of the back. Sitting in a chair or wheelchair for long periods of time, without pressure being relieved, is even more likely to cause pressure ulcer development. 9.4 Pressure ulceration occurs when the skin and underlying tissues are compressed for a period of time, between the bone and the surface, on which the patient is sitting or lying. Blood cannot circulate causing a lack of oxygen and nutrients to the tissue cells. Furthermore, the lymphatic system cannot function properly to remove waste products. 9.5 If the pressure continues, the cells die and the area of dead tissue that results is called pressure damage. The amount of time this takes will vary, but may develop in as little as one hour in patients at greatest risk. 10. The broad principals of good practice in relation to maintaining skin integrity 10.1 Preventing pressure sores should be a key priority for all agencies and may or may not be an indicator of abuse. They do however have a significantly adverse effect upon a person s quality of life and should be prevented. 10.2 If they do occur, irrespective of which investigation is being used, organisational learning has to occur. All care, support and explanation for patients who are at risk of developing pressure ulcers or who have pressure ulcers has to be done within: The principals of the MCA and the principals of duty of care and autonomy for those who have capacity. The engagement of, carers, paid and unpaid and legal representatives such as those holding LPOA for Health and welfare and relatives should be evident for those who lack capacity. Patients should receive an initial and on-going risk assessment within 6 hours of the first episode of care. Those assessed as at risk should be cared for as guidance suggests dependent upon the degree of risk.
This should include a care plan that records the frequency of pressure area care required/skin care regime and the type of pressure relieving equipment required. An optimum environment should be created to maintain skin integrity or where compromised the ideal wound healing interventions. This will include satisfactory maintenance/referral/management of nutrition and Hydration; hygiene; continence care and maintaining mobility. Good communication is essential, which would include accurately recorded assessments; care/treatment plan; transfer/discharge forms and includes open/transparent and appropriate information sharing between agencies. All NHS organisations and those that provide social care have a duty of candour and transparency in their outcomes. Any pressure ulcer may be an indicator of neglect/abuse ;therefore all should be appropriately assessed to identify any possible safeguarding concerns. Not all grade 3 /4 pressure ulcers are indicative of abuse/neglect. Patients must be involved and empowered to engage with all stages of the safeguarding process and, their preferred outcome must be recorded. Once a safeguarding concern is identified, a safeguarding alert must be raised within the guidelines of the Local Policy and procedure timescales to safeguard adults from abuse. Keep up to date with best practice/evidence through learning the lessons from the investigation process. A duty of candour and openness is applicable and important for all concerned. 11. The role of the tissue viability nurse² 11.1 Tissue viability is a relatively new discipline, which started in the 1980s and has been defined as a growing speciality that primarily considers all aspects of skin and soft tissue wounds, including acute surgical wounds, pressure sores and all forms of leg ulceration (Tissue Viability Society, 2014). However, tissue viability nurses (TVNs) have a multifaceted role, which has developed differently in each region to reflect local requirements. 11.2 Wound care is not the only aspect of the job; TVNs also deliver education, develop practice, and undertake audit and research. Some TVNs may manage a budget and some work within a well-defined speciality, however, most work across all specialities autonomously, without direct medical or nursing supervision, in collaboration with medical, nursing and all professions allied to medicine. 11.3 Currently, most tissue viability teams (TVTs) across the UK are working hard to reduce the incidence of pressure sores across all settings. TVTs have the responsibility to ensure that all damage is accurately categorised and reported as most Trusts have been set Commissioning for Quality and Innovation (CQUIN) targets, which typically involve an ongoing reduction of Trust-acquired pressure damage. (²Ref: Wound Essentials 2014, Vol 9 No 2, http://www.wounds-uk.com) 12. Treating Pressure Sores & Pain Management³ 12.1 Treatment for pressure ulcers can vary, depending on the grade of the ulcer. Treatment options may include regularly changing your position, or using special mattresses and dressings to relieve pressure or protect the skin. In some cases, surgery may be needed. 12.2 Pressure ulcers are a complex health problem arising from many interrelated factors. Therefore, your care may be provided by a team comprising different types of healthcare professionals. This type of team is sometimes known as a multidisciplinary team (MDT). 12.3 The MDT may include:
a tissue viability nurse (a nurse who specialises in wound care and prevention) a social worker a physiotherapist an occupational therapist a dietitian medical and surgical experts with experience in pressure ulcer management 12.4 It's important to avoid putting pressure on areas that are vulnerable to pressure ulcers or where pressure ulcers have already formed. Moving and regularly changing your position helps to prevent pressure ulcers developing and relieves the pressure on the ulcers that have developed. 12.5 After your risk assessment is completed, your care team will draw up a "repositioning timetable", which states how often you need to be moved. For some people, this may be as often as once every 15 minutes. Others may need to be moved only once every two hours. 12.6 The risk assessment will also consider the most effective way of avoiding putting any vulnerable areas of skin under pressure whenever possible. 12.7 You may also be given training and advice about: correct sitting and lying positions how you can adjust your sitting and lying position how often you need to move or be moved how best to support your feet how to maintain good posture the special equipment you should use and how to use it 12.8 There are a range of special mattresses and cushions that can relieve pressure on vulnerable parts of the body. Your care team will discuss the types of mattresses and cushions most suitable for you. 12.9 Those thought to be at risk of developing pressure ulcers, or who have pre-existing grade one or two pressure ulcers, usually benefit from a specially designed foam mattress, which relieves the pressure on their body. 12.10 People with a grade three or four pressure ulcer will require a more sophisticated mattress or bed system. For example, there are mattresses that can be connected to a constant flow of air, which is automatically regulated to reduce pressure as and when required. 12.11 Specially designed dressings and bandages can be used to protect pressure ulcers and speed up the healing process. Examples of these types of dressings include: hydrocolloid dressings these contain a special gel that encourages the growth of new skin cells in the ulcer, while keeping the surrounding healthy area of skin dry alginate dressings these are made from seaweed and contain sodium and calcium, which are known to speed up the healing process 12.12 Topical preparations, such as creams and ointments, can be used to help speed up the healing process and prevent further tissue damage. 12.13 If you have a pressure ulcer, you will not routinely be prescribed antibiotics. These are usually only prescribed to treat an infected pressure ulcer and prevent the infection from spreading.
12.14 Antiseptic cream may also be applied directly to pressure ulcers to clear out any bacteria that may be present. 12.15 Certain dietary supplements, such as protein, zinc and vitamin C, have been shown to accelerate wound healing. 12.16 If your diet lacks these vitamins and minerals, your skin may be more vulnerable to developing pressure ulcers. As a result of this, you may be referred to a dietitian so that a suitable dietary plan can be drawn up for you. 12.17 In some cases, it may be necessary to remove dead tissue from the ulcer to help stimulate the healing process. This procedure is known as debridement. 12.18 If there is a small amount of dead tissue, it may be possible to remove it using specially designed dressings and paste. Larger amounts of dead tissue may be removed using mechanical means. Some mechanical debridement techniques include: cleansing and pressure irrigation where dead tissue is removed using highpressure water jets ultrasound dead tissue is removed using low-frequency energy waves laser dead tissue is removed using focused beams of light surgical debridement dead tissue is removed using surgical instruments, such as scalpels and forceps 12.19 A local anaesthetic will be used to numb the area of skin and tissue around the ulcer so that debridement does not cause any pain or discomfort. 12.20 Maggot therapy, also known as larvae therapy, is an alternative method of debridement. Maggots are ideal for debridement because they feed on dead and infected tissue without touching healthy tissue. They also help to fight infection by releasing substances that kill bacteria and stimulate the healing process. 12.21 During maggot therapy, the maggots are mixed into a wound dressing and the area is covered with gauze. After a few days, the dressing is taken off and the maggots are removed. 12.22 Many people may find the idea of maggot therapy off-putting, but research has found that it is often more effective than more traditional methods of debridement. 12.23 It's not always possible for a grade three or four pressure ulcer to heal. In such cases, surgery will be required to seal the wound and prevent any further tissue damage occurring. 12.24 Surgical treatment involves cleaning the wound and closing it by bringing together the edges of the wound (direct closure), or by using tissue moved from a nearby part of the body (flap reconstruction). 12.25 Pressure ulcer surgery can be challenging, especially because most people who have the procedure are already in a poor state of health. There is a risk of a large number of possible complications occurring after surgery, including: infection tissue death of the implanted flap muscle weakness blisters (small pockets of fluid that develop inside the skin)
recurrence of the pressure ulcers blood poisoning infection of the bone (osteomyelitis) internal bleeding abscesses (painful collections of pus that develop inside the body) deep vein thrombosis (a blood clot that develops inside the veins of the leg) 12.26 Despite the risks, surgery is often a necessity to prevent life-threatening complications, such as blood poisoning and gangrene (the decay or death of living tissue). (³Ref: http://www.nhs.uk/conditions/pressure-ulcers/pages/treatment.aspx) 12.27 *Pain is an ever-present problem in patients with pressure ulcers. Irrespective of a patient s age or health status, pressure ulcer pain needs to be assessed and treated because it has widespread physical and psychological implications for the patient, family, and clinician. 12.28 *Pressure ulcer pain may be caused by tissue trauma from sustained loads, inflammation, damaged nerve endings, infection, dressing changes, debridement, operative procedures, and other treatments. The skin has more sensory nerves than any other body organ. As the pressure ulcer cellular damage expands, chemicals are released that irritate nerve terminals. The ulcer erodes through tissue planes and destroys nerve terminals. A heightened sensitivity to pain in the wound is primary hyperalgesia (an increased response to a painful stimulus); a heightened sensitivity to pain in the surrounding skin is secondary hyperalgesia. Infection further irritates free nerve endings and may cause pain. Pain, particularly acute pain, is also a stimulus to the stress response; thus causing deprivation of adequate oxygen supply that may develop because of limited painful breathing and impede wound healing. Pain also may diminish appetite and decrease nutritional status. Simple painkillers like paracetamol may be helpful. Sometimes stronger painkillers are needed. *(Ref: http://www.npuap.org/wp-content/uploads/2012/01/pieper_2009_feb1.pdf) 13. **Complications from Pressure Sores 13.1 Cellulitis. This acute infection of the skin's connective tissue causes pain, redness and swelling, all of which can be severe. Cellulitis can also lead to life-threatening complications, including sepsis and meningitis - an infection of the membrane and fluid surrounding the brain and spinal cord. 13.2 Bone and joint infections. These develop when the infection from a pressure sore burrows deep into the joints and bones. Joint infections damage cartilage and tissue within days, whereas bone infections may fester for years if not treated. Eventually, bone infections can lead to bone death and reduced function of joints and limbs. 13.3 Necrotizing fasciitis. This rapidly spreading infection destroys the layers of tissue that surround the muscles. Initial signs and symptoms include fever, pain and massive swelling. Without treatment, death can occur in as little as 12 to 24 hours. 13.4 Gas gangrene (myonecrosis). A rare and severe form of gangrene, develops suddenly and dramatically and spreads so rapidly that changes in tissue are noticeable within minutes. The clostridium bacteria responsible for gas gangrene produce toxins that completely destroy affected muscle tissue and cause potentially fatal systemic problems.
13.5 Amputation. When left untreated pressure sores will continue to fester and destroy live tissue. If left unchecked long enough it will manifest in the bone. This then leads to the need to amputate a limb (usually a leg) to stop the spread of the deeply burrowed wound. 13.6 Sepsis. Sepsis occurs when bacteria from a massive infection enters the bloodstream and spreads throughout the body - a rapidly progressing, life-threatening condition that can cause shock and organ failure. 13.7 Cancer. This is usually an aggressive carcinoma affecting the skin's squamous cells. It often can spread to the lymph nodes by the time it is diagnosed **(Ref: http://www.pressuresores.org/pressure-sore-complications.html)