CMDT brings you information from our NHS Partners in the Midlands Partnership Trust about unavoidable Pressure Injury during COVID-19 Pandemic: 

See attached: A Position Paper from the National Pressure Injury Advisory Panel

Additionally the following information has been extracted from the attached:
Assessment Prevention and Control of Pressure Ulcers Policy

Common sites for Pressure Ulcers

Pressure ulcers are caused when an area of skin/and or the underlying tissues is damaged as a result of being placed under sufficient sustained pressure or distortion to impair its blood supply.

It is recognised that many pressure ulcers are preventable and when they do occur they can have a profound impact on the overall well-being of the person affected, being painful, debilitating and in some instances life-threatening.

The NHS has been mandated to adopt a zero tolerance to pressure ulcer development. To help achieve this, the ‘Stop the Pressure Campaign’ and aSSKINg bundle have been updated to help raise awareness about pressure ulcers and the 7 simple steps to prevent them. 

A Summary of the 7 steps is below:

Assess Risk
Each individual receiving care within the Trust must have their risk of developing a pressure ulcer assessed.

Skin Inspection
All patients must be offered a skin inspection regardless of care setting, a visual inspection is best practice, in some clinic setting where the patient/service user is fully independent and mobile, asking the patient/servicer user about the condition of their skin over the pressure area points may be more appropriate to maintain dignity.

Skin assessment within the mental health environment may be difficult due to the patients’ mental health condition, but inability to do so must be documented and further attempts made as soon as feasibly and practically possible

Establishing the condition of the skin via visual inspection or questioning must be recorded at the initial Walsall assessment and continue as part of ongoing risk assessment.

All at risk areas should be checked for signs of skin damage, this can include change in colour or skin tone, a change of temperature or texture, presence of oedema, or if the skin has become broken.

Although bony areas such as heels, hips, elbows, ankles and coccyx are the most vulnerable sites a pressure ulcer can occur, anywhere on the body, especially when related to a medical device, can be affected by pressure.

Guidance on Walsall Community Pressure Ulcer Risk Assessment categories
SEE ATTACHED PRESSURE ULCER POLICY PAPER SECTION 7

Surface - Equipment for Pressure ulcer Prevention
Specialist mattresses, cushions and heel proctors help to reduce pressure by either redistributing the pressure over a larger surface area, alternating the pressure between different areas or offloading the pressure, so that the area is pressure free.

The equipment selecting flowchart can be used as a guide to help ensure patients are on the right level of equipment. The tool kit on the Trust equipment ordering system will also help to ensure the correct equipment is ordered. 

Community Setting: Order equipment via the online Trust equipment ordering system, using the online tool kit to ensure the right equipment has been ordered.

Redistribution

Alternating

Offloading

Choosing equipment – mattresses and cushions

An equipment selection flowchart has been designed to assist community practitioners in selecting the most appropriate equipment for the prevention and management of pressure ulcers.

See Pressure Prevention folder on TV homepage within SharePoint for equipment selection flowchart.

The patient’s need for pressure reducing/relieving equipment must be reviewed as the patient’s condition changes. Alternating mattress that are being used for treatment of a pressure ulcer, may need to be upgraded or downgraded depending on the progress of the pressure ulcer.

All equipment must be evaluated to ensure appropriate allocation of resources.
Although risk reduction is the main objective overall, patient comfort must receive equal priority when selecting equipment.

For patients who sit for prolonged periods of time and/or are at high risk of developing a pressure ulcer, a high specification foam or equivalent redistributing cushion must be offered for use dependent on clinical need.

Manual handling devices should be used correctly in order to minimise shear and friction damage. NB: After maneuvering, slings, slide sheets or other parts of the handling equipment should not be left underneath individuals, unless specifically designed to do so.

If a patient in the community setting declines to use the recommended pressure reducing/relieving equipment, despite having full capacity it is important to question their rationale for this. Document discussions around this and try to ascertain the driving factors for their choice.

This may include pain, lack of space, fear of increased electrical bills etc. A full explanation of why equipment is needed should be reiterated and if this is still declined
then a decision against advice equipment form must be completed.

Choosing equipment for heel protection
Patients with existing pressure ulcers to the heels or patients that are bedbound as a result of surgery, CVA or illness, and have diabetes, neuropathy, gross lower limb oedema and/or peripheral arterial disease, will need equipment and procedures put in to place to off load or reduce pressure to the heels, as they are at greater risk of developing heel pressure ulcers.

Offloading pressure: whilst in bed or when feet are elevated on stool, this can be achieved by placing pillows under the calf and supporting the knee, allowing the heels to float off the mattress or stool. Other products are also available such as leg troughs and inflatable boots that will provide negative pressure to the heels, please refer to the Equipment Directory.

Reducing pressure: this can be achieved by using silicone gel pads and specialist foam heel protectors, these products will not eliminate pressure, but will reduce the amount of pressure to the heels, and are available on ONPOS.

If advice has been given to elevate legs, then care must be taken to ensure an appropriate stool is used that will support the legs, including the backs of the knees, whilst still allowing the heels to float off the stool and maintain negative pressure. See Pressure Prevention folder on TV homepage within SharePoint for management of pressure relief to heels flowchart.

Equipment cleaning and checking – Community 
SEE ATTACHED PRESSURE ULCER POLICY PAPER SECTION 8

Skin inspection
Patients that have been assessed as being low risk, particularly housebound patients, should be given advice on how to self-check skin regularly and how and who to contact if they notice any changes.

Patients that have been assessed as being medium or high risk of developing a pressure ulcer should still be encouraged, if possible, to check their skin regularly and liaise with their nurse to discuss any concerns. If however they are unable to do this then the nurse will need to discuss skin inspection with carers.

Frequency of skin inspections will be dependent on level of risk and clinical judgement and should be included as part of the plan of care.
Document the skin assessment within the care records using the aSSKINg pressure ulcer checklist and communication tool for patients and carers.

If a person regularly declines the inspection, document in the care records and complete a decision against advice form.

If joint care with a care agency is in place, and skin checks are being jointly performed, then the community nursing team need to check that the care agency are completing the aSSKINg pressure ulcer checklist (or their own similar documentation), at each community nurse visit to ensure care staff have not highlighted any issues.

A full visual skin inspection will need to be completed by the health care professional each time a Walsall is completed for at risk patients or sooner if there are any concerns about care agency checking the patients skin, or if the patient or family have any concerns.

If a patient has bandages to their lower legs then special care needs to be taken to check the heels at each dressing change. If the patient has reduced mobility or is unable to elevate their legs to allow full skin inspection, a mirror can be utilised to see the heels more easily.