Preventing pressure ulcers: Quality Improvement Results in Long Term Care settings.


‘Preventing pressure ulcers are an essential aspect of patient safety. The process of prevention begins with a risk assessment incorporating evaluation of identified risk factors and skin inspection tools must be used alongside clinical judgment, skin assessment and consideration of support surfaces’ (Guy 2012).

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The NICE prevention and management of pressure ulcers guidelines were produced not just for nurses but for the patient’s families, carers and the public, however as a large document it has not been interpreted into a simple tool for carers to access. (NICE 2005.) 

Quality improvement projects for preventing pressure ulcers are varied within active tissue viability network supporting the NHS and wider services. Unfortunately, long-term care settings can be difficult to access, therefore many of the settings are left behind in support for implementing improvement programmes. This can be especially true in small care groups.


Importance of prevention and long term settings

While there is a lot of research evidence looking at management of pressure ulcers (PU) in the acute setting, there is very little evidence available on community and long-term care models (Franks, Winterberg and Moffatt 2002).

In the UK there is an increasing ageing population with complex co-morbidities (Department of Health (DoH) 2013). Patients who are in long term care settings and require personal care, will likely be carried out by formal or informal carers. Whereas early formal risk assessment is performed by nursing staff, it is the long term care provider with the most contact with the patient who is best positioned to observe changes in risk level and any skin damage.

In residential care settings this will likely be carried out by team leads or senior carers with the support of district nursing teams. However this can depend on location and availability of community nursing staff.

Identifying patients who are at risk of developing pressure ulcers is the most important factor in avoidance of their occurrence with assessment being the first stage in prevention (Bethell 2003).

One of the key messages in the Stop the Pressure campaign is to work closer with carers.  Carers UK and the University of Leeds estimate that there are nearly six and a half million carers in the UK, a rise of just over 9%, from 5.8 million in 2001- Carers UK (2015). They advise that this represents 10.5% of the total population, or 12.6% of the adult population (one in eight adults). Carers in the community settings are greatly varied and can be hard to reach. They tend to be divided between two main providers:

• Informal carers may be a family member, neighbour or friend.

• Formal carers from care agencies, nursing and residential homes, hospices or day centres.

Residents and patients in long term care often have multiple services visiting alongside community nurses, including Allied Health Professionals (AHPs). They are a vital service in ensuring the patient may remain as independently as possible. In pressure ulcers prevention care planning, the risk assessment and prevention care plan need to be interdisciplinary.

This is also highlighted in the NHS five year forward view (2014) who describe the need for a radical upgrade in community prevention strategies. It describes that the ‘one size fits all’ care model is ineffective. 

Providers need to be well equipped on how to identify early stage pressure damage and what actions to take to prevent deterioration. A long term individualised prevention plan is then held by the patient and their carer.

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The SSKIN care model may be used as an inter-disciplinary prevention and management plan.

The original SSKIN care bundle focusing on four key aspects of preventative care (Surface, Skin inspection, Keep moving, Incontinence, and Nutrition).

This above model has been in use as gold standard for prevention and management of pressure ulcers, initially brought over to the UK in 2004 it was launched initially in Wales in 2009, Scotland 2011 and adopted by NHS England in 2012. It has been incorporated into acute settings community settings and has been slowly migrating to long-term care settings such as nursing homes and hospices. It has shown great results for not just reducing the amount of pressure ulcer incidences but raising awareness of the main components needed to be risk assessed and monitored for the at risk resident/patient.

It has been brilliantly redesigned for long term care settings by Amesbury Abbey using a Plan, Do, Study, Act model (PDSA). More information on how they did this below.

Visual prompt learning of blanching/non-blanching erythema

There is robust evidence that suggests early stage pressure damage (Category 1) is identified at an early stage it may be reversed if rapid interventions, as simple as turning the patient off the affected area. Much of what we now understand in early detection, is that, where it occurs and the affected area is effectively removed from pressure, then effective tissue reperfusion may take place without a break in the outer skin layers. Russell (2002).

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Without this basic intervention an unidentified early stage pressure ulcer may deteriorate rapidly to a serious deep tissue injury that extends down to the bone. This can happen extremely rapidly (Collier 1999). In long term care settings, the majority of daily skin care is undertaken by formal carers.  

The research highlights the poor inter/intra rater reliability in grading pressure ulcers. Defloor & Schoonhoven (2004). Carers need to be well equipped on how to identify early stage pressure damage and what actions to take to prevent deterioration, so they in turn may educate the resident. A visual prompt of the blanching technique can be easily shared and promoted within the home with the ‘React to Red’ campaign there are many free resources available to download.


At OSKAs tissue viability training academy, we have been able to support clients with bespoke training packages for staff. Along with their quality improvement plans for pressure ulcer prevention.

Groups are at variant stages of development so working with quality leads has been key in identifying areas of best practice and areas of improvement with recongnised methodology for change intervention.

We wanted to demonstrate improvement in understanding from the OSKA tissue viability training, so we carried out a perception audit post training sessions for quarter 4 of 2017/18 = 51 feedback surveys over 3 different care groups received. The training perception survey was completed by a mix of carers, nurses and quality leads in long term care. See below tables where we asked:

  • Was the training appropriate to your level of experience?

  • Will the training benefit your practice?

  • Has the training increased your understanding of pressure ulcer prevention?

Was the training appropriate to your level of experience?

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Will the training benefit your practice?

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Has the training increased your understanding of pressure ulcer prevention?

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The results show an increase in the value carers felt that the training was relevant to their role. With a marked increase in understanding and confidence on being able to identify category 1 Pressure Ulcers. Making this mandatory in induction for all carers, and encouraging a tissue viability champion in house means that you can work towards sustainability of improvements through audits and outcome measurements. This is also a very CQC friendly approach!

In the case of Amesbury Abbey they have been pressure ulcer free since the training and SSKIN bundle launch. A small video was made with kind permission from the Amesbury group to demonstrate how they made changes.

For information on how they adapted the SSKIN bundle and implemented the QI plan, contact me on and I will forward your details.

Also check out the OSKA facebook support pages for PU prevention:

*Terms of Reference available on request.


Bethell, E. ( 2003) ‘Controversies in classifying and assessing grade 1 pressure ulcers’, Journal of Wound Care, 12(1), pp. 33-36

Carers UK (2015) Facts about carers. Carers UK. Available at:

Collier, M. (1999) ‘Blanching and non-blanching hyperemia’, Journal of wound care, 8(2), pp. 63-64

Defloor, T. Schoonhoven, L. (2004) ‘Inter-rater reliability of the EPUAP pressure ulcer classification system using photographs’, Journal of clinical Nursing, 13, pp. 952-959.

Department of Health, 2013. Comorbidities: A framework of principles for system-wide action.: Department of Health. Available at: [Accessed 20th November 2018].

Downie F, Perrin AM, Kiernan M (2013) Implementing a pressure ulcer prevention bundle into practice. British Journal of Nursing 22(15): S4-S10

Franks, P.J. Winterberg, H. Moffatt, C.J. (2002) ‘Health related quality of life and pressure ulceration assessment in patients treated in the community’, Wound repair and Regeneration, 10(3), pp. 133-140.

Gibbons, W. Shanks, H. Kleinhelter, P. Jones, P. (2006) ‘Eliminating Facility-Acquired Pressure Ulcers at Ascension Health’ Journal on Quality and Patient Saftey’ 32(9). pp. 488-496. [online] Available at:

Great Britain. National institute for Health and Clinical Excellence (2015) Pressure ulcers, NICE quality standard 89. [Online]. Available at: (Accessed on 20th November 2018).

Russell, L. (2002) ‘Pressure ulcer classification: defining early skin damage’, British Journal of Nursing: Supplement. 11(16), pp. S33-S41

Sutton Manor | Amesbury Abbey group - Pressure ulcer free with the SSKIN bundle

For more information on this content contact me at OSKA