Joint care planning with allied health professionals for pressure ulcer prevention in long term care
In Europe by 2020 it is projected that almost 1 in 3 people will be over 65, and more than 1 in 10 will be over the age of 80. (ILC-UK 2014 EU Fact pack)*. We are an increasing aging population staying at home and long term care with complex co-morbidities. *International longevity centre UK 2014.
There is robust evidence that suggests early stage pressure damage (Category 1) identified at an early stage it may be reversed if rapid interventions, as simple as turning the patient off the affected area. Without this basic intervention an unidentified early stage pressure ulcer may deteriorate to a serious deep tissue injury that extends down to the bone. This can happen extremely rapidly (Collier 1999).
The challenge in long-term care settings, such as care homes, nursing homes and hospices, is the increasing complex patients and residents requiring, not only prevention mattresses and cushions, but also increasingly needing specialist chairs and devices allowing protection of the skin with transportation. Sacral pressure ulcers remained the highest reported especially of category 1 and 2.
Although we may think our resident is sitting out of the bed therefore better protected, in fact the highest amount of pressure in the seating position will be around the sacral area, ischial tuberosity, hips and buttocks. If you want to see the degree of pressure this exerts on these areas try sitting on your hands on a hard chair for a few moments and you will feel the amount of discomfort this will cause on your fingers after a very short period of time. (Do not practice this technique for longer than 30 seconds as I do not want to give you a pressure ulcer!)
The fact that we want to keep our residents and patients out of bed is a good thing, however, how do we assess if the chair they are in is adequate, and how able are we to check the areas of skin during the day. Seating assessments historically are undertaken by occupational therapists especially for complex needs, my experience of working in healthcare is this is becoming an increasingly difficult service to access and it certainly isn’t available as a prevention strategy for all residents and patients in long-term care.
Equally for those that have physiotherapy input, will also need to look at the individual’s pressure care needs, especially in the case of friction and shear from their moving and handling care plan. This may be in examples such as transfers from bed to chair, devices which assist with transfers need to be checked that they are not causing undue friction to the skin.
There is a challenge for all long-term care settings to be able to refer to specialist allied health professionals service for advice or guidance. My advice would be to contact your local clinical commissioning group (CCGs) and ask if there is any local training from the specialists in your area that staff may be able to attend.
In most cases it will not be possible for your local occupational therapist or physiotherapist to come and do seating assessments and moving and handling assessments on all your residents, however having a champion or link carer or nurse within your setting aligned to one of the Allied health specialists would mean that expert advice would be filtered back through to your care home setting.
Where there is a complex patient being admitted to your care environment with specialist seating needs and/or moving and handling needs, requesting a MDT meeting prior to admission and asking for specialist care plan advice is key in helping your carers and nurses be prepared for the person’s skin needs. This can then be incorporated into your pressure ulcer prevention care plan or SSKIN prevention bundle.
There is now a wealth of research being done on the importance of incorporating allied health professionals in pressure ulcer prevention planning, it is recognised that prevention planning for complex patients with multidisciplinary involvement is more effective when all professionals discussed the plan. This may be because one professionals recommendations may well clash with another professionals recommendations leaving the person delivering the care i.e. the carer can be caught in the middle of what is best for their resident. An example of this I have experienced as a TVN a few times has been where I have see a new patient with the category 3 pressure ulcer on the sacrum who is sitting for long periods of time, I have recommended that they go on to bed rest to enable turning off the affected area and allow for healing. This has historically sometimes clashed with the physiotherapist recommendation to keep the patient moving and reduce the risk of further immobility and/or muscle wastage from immobility.
Where both professionals have the patient’s best interests at heart it can be confusing for those delivering the care and the patient themselves as to what plan of action to follow. Where you get joint professional planning involving the patient, often a suitable compromise can be made. This will be different to each resident. Where possible if the patient has capacity do involve them in this multidisciplinary discussion, this may prompt better concordance or compliance of the care plan if the patient feels in control of it.
There are many examples of how you can introduce this working practice or care model.
International longevity centre UK 2014
Collier M (1999) Blanching and non-blanching hyperaemia. Journal of Wound Care 8(2): 63–4.
If you would like more information on how to launch this model in your long term care setting or support with this please contact me.