A review of full-thickness pressure ulcer healing in primary care Sarah Pankhurst This article reports on the monitoring of healing rates of fullthickness 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. KEYWORDS: Pressure ulcer Pressure ulcer healing Wound healing Primary care End of life Avoidable Unavoidable Pressure ulcers occur when an area of skin and the underlying tissues are damaged by being placed under sufficient pressure to impair blood supply to the area (National Institute for Health and Care Excellence [NICE], 2015). The development of pressure ulcers is known to affect quality of life and have a physical, social and psychological impact on patients (Jones, 2013), which can also extend to their families and carers. While all patients are potentially at risk of developing a pressure ulcer, they are more likely to occur in people who are seriously ill, have a neurological condition, impaired mobility or nutrition, poor posture, or a deformity (NICE, 2015). In 2012, an ambition was set in the NHS England area of the Midlands and East to eliminate all avoidable stage 2, 3 and 4 pressure ulcers acquired by patients while under NHS care (Midlands and East, 2012). Strategies were put in place to achieve this ambition, focusing on pressure ulcer prevention and local initiatives, such as Stop the Pressure Ambition (Midlands and East, 2012; NHS Improvement, 2016). Such projects focused on investigating pressure ulcer incidents and developing strategies for prevention and treatment. This, in turn, helped to heighten awareness of pressure damage, resulting in local campaigns and new innovations such as SSKIN bundles. In addition, this also led to discussion by the provider (Nottingham CityCare, a community interest company [CIC], which provides NHS funded services) that anecdotally: Pressure ulcers were not as large or deep in size as the tissue viability team had seen in the past The ulcers which did develop had been healing due to the availability of new pressurerelieving equipment and improved awareness and wound management skills of the staff More rigorous prevention and treatment strategies were improving healing rates for those who did develop pressure damage. However, it was also acknowledged that the time pressure ulcers took to heal had not been investigated locally, resulting Sarah Pankhurst, head of tissue viability, clinical nurse specialist, Nottingham CityCare Tissue Viability Service THE SCIENCE A pressure ulcer is defined as localised injury to the skin and underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers, although the significance of these is yet to be elucidated (NPUAP/EPUAP/PPPIA, 2014). 42 JCN 2018, Vol 32, No 2
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in a Commissioning for Quality and Innovation (CQUIN) target being set to record and review healing in full-thickness pressure ulcers, with the aim of improving healing rates. While prevention of pressure ulcers is the main goal, in the author s clinical experience, there is also a need to achieve optimum wound management for patients at the end of life, improving palliative wound care and symptom control to maintain comfort. MEETING CQUIN TARGETS Methods Data were collected and analysed as part of the CQUIN. The time period was January December 2015 when all stage 3 and 4 pressure ulcers and suspected deep tissue injuries (SDTI) acquired in the organisation were reported nationally on the strategic executive information system (STEIS). The organisation, CityCare, are commissioned by Nottingham City CCG to monitor pressure ulcer rates as a quality measure of performance. This CQUIN was developed for CityCare and involved community patients on community nursing caseloads, people in their own homes referred to the urgent care service, and patients in specialist nursing and residential care homes. The full-thickness pressure ulcers had all been reported as an incident and the stage of pressure ulcer checked by the tissue viability service. They were all investigated using a root cause analysis (RCA) technique, with the exception of SDTI damage which did not progress to a full-thickness pressure ulcer. These were investigated using the organisation s internal procedure for superficial pressure Practice point It is advisable that all wounds have a thorough wound assessment and photographs taken at fourweek intervals (as the maximum time interval), or when there is a significant change in the wound status. ulcers and would not be comparable in healing time with full-thickness pressure ulcers. Each patient s record was reviewed and measurements from wound assessments, descriptions and photographs were obtained to determine wound size at the time of reporting 40 and 80 days. This was updated at each quarter for the CQUIN report. A limitation of this data is that it was written by nurses at the point of care, and the descriptions of healing in the absence of measurements and photographs were subjective. The author tried to mitigate this by having the data checked by a senior clinical nurse specialist in tissue viability and verified by another member of the team when a second opinion was required. However, this analysis may have some bias as staff members might have been keen for their organisation to achieve the CQUIN targets. The data was therefore intermittently checked by the quality monitoring department at the CCG. Any patient whose wound had deteriorated needed to have an exception report, with details of their clinical condition and situation. The tissue viability team completed root cause analysis for all full-thickness pressure ulcers, so the investigation was not carried out by the team that had cared for the patients. This ensured a level of objectivity for the investigation when deciding whether pressure ulceration was avoidable or unavoidable. The patients were treated under the local pressure ulcer treatment and policy guidance for CityCare (Nottingham CityCare, 2016) and were referred to tissue viability and dietetic services. All patients had their wound care and equipment discussed with a specialist on referral, and were treated according to the local wound care formulary with topical wound care products and pressure-relieving equipment for the treatment of full-thickness pressure ulcers, e.g. replacement electric air mattresses available from the Nottinghamshire Integrated Practice point Pressure ulcers are not inevitable, even if patients are seen as being at high risk, and thus prevention should always be a priority for healthcare professionals (National Patient Safety Agency [NPSA], 2010). Community Equipment Loan Stores. Results One hundred and thirty-eight patients with full-thickness pressure ulcers during the evaluation period were subject to root cause analysis, with their healing times being monitored. The status of the wounds at 40 and 80 days is shown in Figures 1 and 2. Where data were missing, this was due to wound assessment not being undertaken, photographs or measurements not being recorded by clinicians, patients being admitted to hospital or moving out of the area. At 40 days, there was information recorded for 135 patients, as three of the 138 had two wounds; one smaller and one larger at 40 days, so they were not included in this graph. At 80 days, there were 84 patients, as 13 had completely healed and 40 had died before 40 days, and one patient had two wounds, one that was smaller and one larger at 80 days, so they were not included. Of the 135 patients, 34% of the pressure ulcers had healed or were healing and 13 (9.6%) had fully healed at 40 days. Thirty percent of patients with a full-thickness pressure ulcer had died within 40 days of the pressure ulcer being reported, and 15% of the wounds were static or deteriorating (Figure 1). Of the patients with no measurements at 40 days, 16 had been admitted to hospital, three moved out of the area, and 10 had no wound documentation about this time. There were 84 patients with unhealed pressure ulcers after 40 44 JCN 2018, Vol 32, No 2
n=29; 21% n=40; 30% Healed or healing Deteriorated or static Deceased No measurements Figure 1. Outcomes at 40 days (n=135). n=14; 17% n=16; 19% n=8; 9% Healed or healing Deteriorated or static Deceased No measurements Figure 2. Outcomes at 80 days (n=84). n=46; 34% n=20; 15% n=46; 55% days and 16 patients (19%) had died. A further 46 (55%) were healed or healing, with 24 (28.6%) being fully healed at 80 days and eight (9%) remaining static or deteriorating (Figure 2). Of the patients remaining in the cohort at 80 days, 14 patients (17%) had no measurement; 10 had been admitted to hospital; two had moved out of the area and one had been admitted to a care home. One patient had no wound documentation. The number of full-thickness pressure ulcers reported and investigated fell during 2015 (Figure 3). Clinically avoidable but unavoidable to the provider is an outcome used if all appropriate plans of care were put in place by the organisation and the pressure ulcer developed under the care of another provider, such as care homes or care agencies who did not implement the planned care appropriately. These were included as unavoidable to the provider in the figures reported to the CCG (Figure 4). The root cause analysis showed that 75% of full-thickness pressure ulcers were unavoidable during 2015. Discussion The outcomes of patients at 40 and 80 days cannot be added together as patients can feature in both datasets unless they died. Of the 138 patients who had a fullthickness pressure ulcer, a total of 56 died (41%). A higher proportion of patients died within 40 days of developing a pressure ulcer than at 80 days. It is known that patients at the end of life are at increased risk of developing pressure ulcers and that skin perfusion is reduced at life s end (Sibbald et al, 2009). Patients may be slowly deteriorating but not predicted to die; however, the presence of a pressure ulcer may show that their physiological systems are severely impaired and they are unable to heal. The number of patients developing a full-thickness pressure ulcer in primary care who subsequently die from causes other than the pressure ulcer is the largest outcome in this dataset. None of the patients with missing measurements died. Of the group, 13 (9.6%) had fully healed at 40 days. Patients with SDTI were included in incidents for investigation, however, if they were found to be superficial they were removed from the STEIS and not investigated, so that those left would have been full-thickness ulcers. This demonstrates that some full-thickness pressure ulcers are small in size and able to heal by 40 days. This mirrors the findings of the tissue viability team in practice that some ulcers reported are relatively small in size but meet the criteria of a stage 3 pressure ulcer. At 40 days, a further 33 patients had wounds that were improving and progressing to healing. A total of 34% of patients were healed or healing at 40 days, and 24 (28.6%) had fully healed at 80 days. Eight patients were deteriorating or static at 40 days. This was attributed to uncontrolled diabetes, palliative diagnoses, infection and patient concordance. Patients who develop pressure ulcers in primary care commonly have an underlying condition that has led to the pressure damage, such as reduced mobility and nutritional intake. These conditions have been found to delay healing (Karahan et al, 2018). Therefore, in the author s clinical opinion, 28.6% fully healed at 80 days does not indicate that healing has been protracted for a full-thickness wound. At 80 days, a further 22 patients had wounds that were improving and progressing to healing. A total of 46 (55%) of the remaining patients were healed or healing at 80 days. About 20% of the data is missing in both sets, which, if present, could have affected the results. However, the findings could pave the way for future research in this area. In the author s clinical opinion, this has particular relevance to expectations of wound healing outcomes if further outcomes or wound healing metrics are to be developed. Practice point Identification and prevention of pressure ulcers is seen as an indication of the quality of care given (Vowden and Vowden, 2015). JCN 2018, Vol 32, No 2 45
CONCLUSION Patients develop full-thickness pressure ulcers in primary care settings, which community service providers may not be able to prevent. This was found in 75% of cases here. There are a variety of reasons for this, which are not discussed in this article. The patients in this analysis were being cared for in their own or residential care homes, where their nursing care plans were developed by community nurses. Those ulcers which were considered clinically avoidable, but were unavoidable to the provider, should be prevented with the implementation of correct care plans. The development of a pressure ulcer may be an indication that the patient s condition is deteriorating, making them more susceptible to pressure ulcer development as they near the end of life. Such deterioration may be subtle changes in condition which may not be detected by risk assessment. This area warrants further research and may indicate that when a pressure ulcer develops, further physical investigations and changes in care and communication with patients and carers need to be developed, alongside treatment for the pressure ulcer. The thematic review of the root causes of full-thickness pressure ulcers in 2016 showed that the failure to identify and adapt care in deteriorating patients is a major theme. This limited review has also demonstrated that of those patients who had not died after 80 days, the majority had the capacity to heal and the healing was not protracted. Those patients whose ulcer deteriorated had complex and chronic conditions. Since the launch of the Midlands and East Stop the Pressure Ambition, Nottingham CityCare has reduced avoidable full-thickness pressure ulcers from 96 in 2013 to 21 in 2016. However, although numbers have reduced, pressure ulcers that are avoidable and unavoidable continue to occur and need to be helped to heal by working with patients, staff and carers to implement preventive care and to encourage the physiological conditions to optimise healing. JCN 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Figure 3. Total number of full-thickness pressure ulcers reported. REFERENCES 44 Jan-March 2015 April-June 2015 July-Sept 2015 Oct-Dec 2015 Jones D (2013) Pressure ulcer prevention in the community setting. Nursing Standard. 28(3): 47 55 Karahan A, Abbasoglu A, Avci Isik S, et al (2018) Factors affecting wound healing in individuals with pressure ulcers: a retrospective study. Ostomy Wound Management 64(2): 32 9 Midlands and East (2012) Stop the Pressure Ambition. Available online: www.eoecph. nhs.uk/files/commissionning%20 Support%20Services/Market%20 place%2013%202%2012.pdf National Institute for Clinical Excellence (NICE) (2015) Pressure Ulcers Quality Standard QS89. NICE, London. NHS Improvement (2016) Stop The Pressure. NHSI, London. Available online: http:// nhs.stopthepressure.co.uk National Patient Safety Agency (2010) NHS to adopt zero tolerance to pressure ulcers. Available online: www.npsa.nhs. uk/corporate/news/nhs-to-adopt-zerotolerance-approach-to-pressure-ulcers 36... when a pressure ulcer develops, further physical investigations and changes in care and communication with patients and carers need to be developed, alongside treatment for the pressure ulcer. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and 28 Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed). Cambridge Media: Osborne Park, Australia Nottingham CityCare (2016) Pressure Ulcer Prevention and Treatment Policy. Nottingham CityCare Tissue Viability Team, Nottingham Sibbald RG, Krasner DL, Lutz JB et al (2009) SCALE: Skin Changes at End of Life. Final Consensus Document. Available online: www.epuap.org/wp-content/ uploads/2012/07/scale-final- Version-2009.pdf Vowden K, Vowden P (2015) Documentation in pressure ulcer prevention and management. Wounds UK 11(3 suppl 2): 6 9 n=23; 17% Avoidable Unavoidable n=80; 58% 30 n=35; 25% Clinically avoidable but unavoidable to the provider Figure 4. Outcome of pressure ulcer root cause analysis investigations. 46 JCN 2018, Vol 32, No 2
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