Pressure points - eliminate hospital-acquired pressure ulcers

Pressure ulcers - also known as bedsores, pressure sores or decubitis ulcers and commonly associated with bed-bound patients - occur when the skin's soft tissue is compressed against a bony prominence as a result of pressure, friction or shear from an external surface. Rising in severity from category 1 to 4, the most serious ulcers present the added menace of not being immediately detectable on the skin's surface, meaning unseen damage can mount over time.

While viewed as a familiar occurrence in the long-term care of patients, and the elderly in particular, the fact that many incidents are avoidable has led to pressure ulcers being included as one of four key areas for reduction in the government's Quality, Innovation, Productivity and Prevention (QIPP) agenda. Incentives for their elimination are also included under the NHS's Commissioning for Quality and Innovation (CQUIN) payment framework, and its 'patient safety thermometer'.

The forgotten minority

But while NHS trusts must be seen to be reducing incidents in order to maintain their funding, government targets cannot themselves identify the gaps in patient care where pressure ulcers are able to creep in, nor can they provide the answers to questions regarding prevention strategy.

South Tees Hospitals NHS Foundation Trust's Sharon Bateman explains that awareness of the primary origins of such wounds - and, therefore, the likelihood of increased prevention on the part of nurses, carers and patients - is key to striking avoidable pressure ulcers from the record.

"I always promote the ideal that if we don't feed, water and move our patients, they will get a pressure ulcer - and it doesn't matter whether they're fit or in ill health, they are likely to develop one," she explains. "It's part of the biology of our tissue, so the fundamental issue of the patient receiving inadequate care is usually one of the above three or an accumulation of the three.

"Patients are either not getting the right nutrients, getting dehydrated or are not actually being positioned or repositioned appropriately for whatever reason," says Bateman.

Negligence of these key provisions can occur in any healthcare setting, but there are a few major patient groups that present the greatest challenge. Bateman describes one as "the forgotten minority, becoming the majority" - patients alone at home with no family or friend support, or those cared for at home by family members who have no healthcare training, often with no input from healthcare professionals to date. There are also those patients who do not wish to have any input to the detriment of their own health and skin integrity.

"In effect, from an NHS healthcare perspective, it's a question of how do we access people we don't know exist, because these patients often don't go and see their GP for ten or 20 years," says Bateman.

"It's often elderly patients who are cared for by their elderly spouses or children, and they don't know any different. They just think that the skin deteriorating is part of the illness, so the patient doesn't get the full impact of the care they need - from ignorance and naivety really, rather than purposeful neglect."

Eventually, these patients turn up in hospitals, normally as a result of their primary disease or disorder.

It is only at this point that the ulcers come to the attention of clinicians, but these often lead to patients being kept in hospital long after their initial illnesses have been dealt with. It is well accepted within the literature that pressure ulcers increase hospital stays and delay planned discharge.

Clearly, education and guidance are key, but for an already stretched health service, disseminating information to patients who are mostly beyond the reach of the internet is a challenge. However, another of the key patient groups suffering with pressure ulcers is certainly part of the online age: the young, overweight or obese patients who are increasingly presenting with conditions and disorders commonly associated with aging patients.

"The bigger you are, the less active you are, and these patients usually have psychological dysfunctions - so they may suffer from depression or stress, which results in them eating more and not acknowledging their weight and size, which then stops them moving."

It is a well-known vicious circle, perhaps, but its consequences with regard to pressure ulcers are less widely publicised, as Bateman illustrates: "For a heavy young person sat down, your body weight will cause internal ischaemia over your bony prominences; the patient quickly develops a nasty deep cavity, and everyone's wondering where it's come from - but the damage has started internally a lot sooner and worked its way out visibly."

Cachectic patients, severely underweight from diseases such as cancer or eating disorders, are also more susceptible, as they lack the subcutaneous fatty layer that protects skin from the shear and friction that cause lower-category ulcers, and blocks the outward pressure from bony prominences that leads to category 3 and 4 ulceration.

Missed connections

The difficulty of preventing pressure ulcers doesn't stop once patients have entered NHS hands, and Bateman has been instrumental in highlighting areas in patient care where risks have been overlooked.

In recent years, the danger of ulcers forming in patients undergoing surgery for long periods of time - and positioned to make the required areas operable - has been highlighted. National Institute for Clinical Care and Excellence (NICE) guidelines now recommend that surgical patients must, at the very least, be assessed for vulnerability and placed on a pressure-redistributing surface such as a single-patient-use foam theatre mattress. But while surgery, along with most areas of patient care, has its action plans for ulcer prevention, it is the gaps between those points of call that most concern Bateman.

"We can have little blips in journeys where the care is not continuous," she says. "It's the patient who leaves a department or ward to go to another department, who is on the right equipment, has the right repositioning plans in place and is put on a porter's trolley to go for, say, a chest X-ray - and then, the minute they hit that trolley, the care seems to stop, and it only starts again when they come back.

"An X-ray might take an hour or two depending on where in the hospital it is. But it's all kinds of transportation of patients we need to be thinking of," says Bateman.

As well as between hospital departments, such journeys could be a patient being discharged to a care home or to their own home, or arriving by car or ambulance.

"They can be in an ambulance for two or three hours; is anybody protecting their bony prominences during that journey?" Bateman asks.

"It's not about snippets of 'where are they now?' and it's not about doing that patient assessment on day one - it's about continual assessment and the change in risk levels that the patient will experience, because they will go through different ups and downs in their care journey."

It's essential that the patient, clinician and carer acknowledge this, which is key to prevention. In her own organisations, Bateman has ensured that every single surface a patient encounters passing through a hospital is fit for purpose - a good start towards making patients' journeys safe, although she acknowledges that it's a limited one, because "patients don't live here".

In the pink

On one level, however, the stop-start nature of patient pressure-wound care provided Bateman with the question and answer she needed. Observing single-patient-use pressure-redistributing foam used in theatres, which are disposed of post-intervention, something occurred to her.

"I just thought, if that patient needs it while they're on the operating table, then they're going to need it on that trolley back to the ward. And then, when I was watching a patient with their heels on a bedside table bar, I came up with the idea: 'that pink foam that they were using in theatre - if we put it on the floor, I wonder if the patient would put their feet on it?' And they did, straightaway.

"Then the physiotherapists commented upon it and said all the patients love it because they can stand and do their exercises on it rather than on a hard surface, and they're baby pink in colour, so everyone can see them," she continues.

"Some elderly people will wear the same slippers they've had for ten years, which can be soiled, worn and ill-fitting, causing friction and skin damage, but because we don't let them use footwear on the pink foam, they are able to put their feet straight onto them. And if they want to sit with their heels on the floor, it's fine, because their heels are going on a pressure-relieving device."

Remarkable feat

Already spreading like wildfire throughout the UK, Bateman's simple pink-foam approach, which costs no more than a couple of pounds a sheet, has been particularly successful in protecting what, for her, are a top-priority but often ignored area in pressure-wound management - the feet.

A sitting patient's heels and ankles, resting against a chair and the floor, are very prone to damage, and healthcare workers may forget to reposition patients who, in the simple act of sitting, appear to be more agile.

"We traditionally think of patients lying supine on a bed, but actually, the research that's been carried out over the past 30 years suggests that those people have fewer pressure ulcer incidents than patients who are sitting out in a chair," says Bateman. "If a patient is supine in a bed, they more clearly need repositioning than a patient sat out."

Damage sustained in this way not only increases the patient's pain and anxiety, but can also inhibit their recovery by reducing their mobility.

"If you've got damage to your feet, it usually stops you doing anything you can normally do; you can't stand properly and you can't walk properly, so your mobility is reduced, you're then bed-bound - and if you've got a lung condition, it exacerbates that. It's a catalogue of circumstances that makes a patient really poorly," Bateman says.

More-informed postural practice has been an NHS-wide concern in recent years, with a much greater focus on the manner in which patients are positioned and, crucially, repositioned in chairs, and for Bateman the pink foam has been pivotal. At one department she introduced it to, she has seen pressure ulcers on feet reduced by 80% during a six-month period, and patient falls have also decreased, perhaps as a result of its non-slip properties.

"It is madness about the pink foam, it even sounds silly," says Bateman. "But I think the simplest ideas are the ones that work. The NHS, and private as well, always looks into high-tech, complex processes, thinking 'how can we do it, how can we do it?', and they're missing the basic trick, which is what are people putting on their feet, what are they putting on their elbows?"