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Challenges and best practice for the prevention of pressure ulcers at the end of life in long term care through COVID-19 and beyond

Reports of increased long-term care home deaths through covid-19

On May 15, 2020, the UK Office for National Statistics (ONS) released provisional figures on deaths involving COVID-19 in the care sector in England and Wales. From March 2 to May 1, 2020, COVID-19 was confirmed or suspected in the deaths of 12,526 individuals living in care homes (Office of National Statistics-ONS 2020).

The ONS noted that 9,039 of the 12,526 deaths involving COVID-19 from March to April occurred within a care home, while 3,444 deaths occurred within a hospital.
In an average year, the care sector in England and Wales sees roughly 20,000 fewer deaths during March and April than have been recorded in 2020. 

It stands to reason that these groups would be most vulnerable being our older population with increased likelihood of co-morbidities. 

Where Covid-19 may break out in a care home it may be incredibly difficult to contain, even with residents isolated. 

Homes have been isolating residents as a precaution but has been difficult as a high percentage of these residents may have a cognitive impairment. These challenges have become evident in similar long term care across Europe. See below table taken from The Health Foundation 2020.

For those affected, the care staff and the families, this may be extremely distressing, especially if they are unable to visit their loved ones.

For carers and nurses seeing an increase in palliative patients, either from a primary or other diagnosis or increased covid-19 associated-pneumonia, the extra trauma of dealing with significant pressure ulcers is not what anyone wants. With that in mind lets revisit how you may continue to protect the skin at end of life and what you should be doing to evidence your practice to be NICE/EPUAP/CQC/MCA compliant.

Firstly let’s revisit the debate on skin change at life end (scale)

As of April 2019 NHS improvement body has advised NHS trusts to cease using the term Skin Change at Life End (SCALE), otherwise known as Kennedy terminal ulcer (KTU). Instead NHS trusts are to report the categorisation of tissue depth as per European Pressure Ulcer Panel (EPUAP) guidelines, such as ‘Category 4’ or ‘Suspected Deep Tissue Injury’.  

This is due to the decision of a SCALE being subjective, with no clear research on what pathophysiological indicators constitutes this event.

There is also concern amongst many nurses, governance teams and regulators that the term may be used too generally without carrying out a Root Cause Analysis to establish if all prevention measures were in place and identify any potential gaps in care. 

However, as clinicians we also see that the skin, as the largest organ of the body, is not immune to dysfunction and breakdown at the end of life. The level of decline can be compromised and include decreased cutaneous perfusion and localised hypoxia, resulting in a reduced availability of oxygen and the body’s ability to utilise vital nutrients and other factors required to maintain skin integrity (Beldon P 2010).

As a result in 2008 an expert panel was established in the USA to formulate a consensus statement on skin changes at life’s end (Sibbald et al, 2009). The panel discussed the nature of SCALE, the concept of the KTU and skin failure towards the end of life. The panel concluded that:

 ‘Our current comprehension of skin changes that can occur at life’s end is limited: that SCALE process is insidious and difficult to prospectively determine; additional research and expert consensus is necessary; and contrary to popular myth, not all pressure ulcers are avoidable.’ 

In a recent collection and review of the current literature (Ayello 2019) surmised that the concept of skin failure is etiologically different than a pressure injury, however pressure injury and skin failure can occur concomitantly.

It may be a challenge for healthcare providers who are caring for patients with end of life to categorise these types of wounds. In my experience there has been many cases where frustration from the professional is felt due to complaints, safeguarding referrals and potential litigation for some patients who have developed pressure ulcers at the end of life, despite evidence of good skin care, repositioning, appropriate pressure relieving equipment, and optimising nutrition and hydration where possible.

We must never be complacent with assuming that a patient who has been given a palliative status that a pressure ulcer is inevitable and thus not investigate each and every category 3, 4, suspected deep tissue injury (STDI) and unstagable acquired pressure ulcer.  

However we also need further guidance on preparing patients and relatives that skin failure may occur as part of the dying process. There is much debate as to what definition  for SCALE but for now organisations that believe the skin is failing due to the dying process may still state this but a full Root Cause Analysis (RCA) must be completed first, to ensure no gaps in care occurred prior to deteriorating and that reasonable steps were taken to minimise risk.

As with all prevention care planning use the aSSKINg acronym to help formulate your care planning.

See below Algorithm taken from the EPUAP in 2009 on SCALE guidance:


This is a question I get asked frequently and it can be a grey area. Particularly around the end of life or cases of rapid skin failure where balancing up regular repositioning to the quality of life of the patient is paramount. Involving Multi-Disciplinary teams into this decision is important to help come up with a individualised and enhanced moving and handling plans and repositioning plan. *See below section on virtual planning.

As providers we must adhere to our Nice pressure ulcer prevention and management guidelines which currently say 2, 4, 6 hourly repositions need to be prompted and documented. Clinically, this is done mostly on the repositioning chart either at the bedside or through electronic care plan systems. 

For a resident with rapid skin failure in bed is this enough? Quite often we will recommend more regular repositions through the day and sometimes night. The reason being that, from what we know from the research, that external pressure interrupts the flow of blood to tissue (ischemia), causing tissue cells to breakdown or die (necrosis). The formation of a pressure ulcer may begin in under an hour (Gefen 2008).

Waiting for 2-4 hours and especially 6hrs at night may be too long and increase the risk of tissue decline. However will your patient want to be repositioned every hour?

Although the single most effective prevention method from tissue hypoxia leading to a category 1 pressure ulcer is to remove the pressure forces on the affected area, this may not always be possible. Not just with compliance but due to physical factors such as contractures, MND, MS and palliative care.

What can you do?

Working with your multi disciplinary team, either Physiotherapists, Occupational Therapist, Tissue viability nurse, District nurse, you may come up with some alternative plans. This can be documented as the home have explored all alternatives and worked for active solution. This is important, as just saying the resident cannot be moved is not enough, we must be clear as to why and that alternatives have been explored.

*The above may be done virtually. Virtual planning incorporating palliative care, nursing and AHP services for complex care:
Where you may need further advice for complex care planning such as unable to reposition at all due to contracture’s or pain, multi-disciplinary virtual planning may be available to you. See last weeks blog
here for further information on how you may approach community services to see if there is something already set up that you can access.

Lateral tilt mattresses.

Although an air mattress may be in place, there will still be a point of contact whereas the same with most pumped devices the cells will offer temporary offload alternately. The use of lateral tilts have been around for a while and vary in comfort. With OSKA offering inbuilt lateral technology. No lateral device can replace a manual turn, so these still need to be prompted as per NICE guidelines. If you’re not sure seek advice from your local TVN.



Where the recommendations are to gain a 30 degree angle tilt on turns, its may not always be possible. Any movement is better than none, so if you are able to encourage micro-movements this may offer a degree of offloading. This may be achieved with the use of wedges, beanbags (decubitus cushions).

Governance & duty of candour

As with any deep tissue injury, either with an open and exposed ulcer or suspected deep tissue injury we need to be investigating.

This is standard internationally and is done routinely in the NHS. It is vital that all long term care settings have a standard operating procedure or policy on what steps need to be taken and in what time frame.

There are many available online to use as a benchmark, or again you could ask your local CCG, Local Authority or TVN if they are happy to share their template for you to use.

If you would like to see mine then please contact me and I will be happy to share. Otherwise click here to see previous guidance on how to conduct a Root Cause Analysis.

Under duty of candour we must involve the patient, and/or with reduced capacity the family member or next of kin that has lasting power of attorney.

Where gaps are identified we must be open and transparent, apologise and advise what actions will be taken to minimise future risk.

Training on this is available at the OSKA Tissue Viability Training Academy, please contact me for further information.

The key through this phase is to not take your eye off the ball in terms of quality and governance of systems. With increased isolation in care homes and potential increase in respiratory virus, it is highly likely the risk of developing pressure ulcers will increase. Being prepared and confident in your prevention, management and governance structures may reduce the possibility of further investigations down the road.

Using the aSSKINg model can be a very useful and quick internal audit and check tool. Ask your team to use this to ensure all the documentation and care plans are in line with this tool.

For more information on the aSSKINg model click here.


Ayello, E. Levine, J. Langemo, D. Kennedy-Evans, K. Brennan, M. Sibbaid, G. (2019) Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries.Journal of Advanced Skin Wound Care. Mar;32(3):pp.109-121. available online: accessed 27th May 2020

Beldon, P (2010) Skin changes at life’s end (SCALE): a consensus document,  wounds UK (6) 1 pp. 169-170.

Elizabeth A. Ayello,Jeffrey M. Levine, Diane Langemo, Karen Lou Kennedy-Evans, RN, FNP, Arizona Mary R. Brennan, R. Gary Sibbald. (2019) ‘Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure injuries’. Advances in skin & wound care.   Volume 32 – Issue 3 – p 109–121. available online: accessed 26th May 2020

Gefen, A (2008) How Much Time Does it Take to Get a Pressure Ulcer? Integrated Evidence from Human, Animal, and In Vitro Studies. Ostomy Wound Management. 2008;54(10):pp.26-35. accessed 26th May 2020.available online:

Office for National statistics (2020) ‘Deaths involving COVID-19 in the care sector’. England and Wales: deaths occurring up to 1 May 2020 and registered up to 9 May 2020 (provisional) accessed 26th May 2020. Available at:

Sibbald RG, Krasner DL, Lutz JB, et al (2009) The SCALE expert Panel: Skin Changes At Life’s End. European Pressure Ulcer Panel. Final Consensus Document.