Articles Clinical Blog Downloads

NHS Improvement guidelines update to the SSKIN model called aSSKINg. Why the update and what does it mean to your organisation?

The SSKIN bundle has been identified as a key process/intervention in pressure ulcer prevention which has been tested widely since its development in the Ascension Hospital system in 2004 in the USA and more recently across the UK in programmes such as the 1000 lives campaign and Transforming Care in Wales and Stop the Pressure Collaborative across the Midlands and East of England. The bundle methodology was designed to facilitate consistency in practice.

This developed a blueprint for change in pressure ulcer prevention. Part of this blueprint involved defining and prioritising best known evidence and practices, into a ‘bundle of care’. 

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.

This model is often benchmarked while investigating pressure ulcers as routine such as root cause analysis, if any of the above SSKIN care components were not included in the individual’s care plan or their are clear gaps in this model it may indicate improvement needed in the care setting.

As a CQC specialist advisor it is this model that I use first as a benchmark when checking care records and practices.

I have been completing these root cause analysis for pressure ulcers in community and long-term care setting for many years, as a tissue viability nurse and investigator clear emerging themes and gaps come up time and time again. When meeting with colleagues here in the UK and looking at international research, these challenges are similar. 

One of these challenges is that the risk assessment completed may not have been holistic and did not incorporate all of the above model of prevention. Whilst the Waterlow, Braden are tools for risk assessing, the research shows that they do not allow for individualised care planning and are out-dated as assessment tools. The updated Purpose T assessment tool developed in Leeds University by Dr Suzanne Coleman uses up to date research methods to develop its tool.

However none of these tools will tell you that your resident will refuse to be repositioned due to pain or not wanting to lie on side etc, or that they tend to lean on their left elbow for most of the day. This must come from your observations and interventions explored. 

The other is where the residents has full capacity or reduced capacity and there is a informal or formal carer in place that information must be given to them so that they understand their own risks to their skin, thus being able to make informed decisions with their care plan. Or that the carers fully understand how to prevent a pressure ulcer and what are the early stages so that they can report such as non blanching erythema (Category 1 Pressure ulcer) 

It is great therefore that the NHS improvement updated recommendations have included two more letters to the acronym SSKIN , namely A – Assessment and G – Giving information.

The new recommended aSSKINg guidelines therefore are as below:

A- assessment

S – surface

S – skin inspection

K – keep moving

I – incontinence

N – nutrition and hydration

G – Giving information


For those of you that are already using the SSKIN care model, you can look here at an example of how people are updating their model.

We have designed our own aSSKINg poster here at OSKA, which you can see below or come on to the Facebook Page where it has been shared under the file section.

Here at OSKA we have partnered with organisations to support their SSKIN model development and implementation process, if you would like advice or to gain some ideas of how you can implement this model in your care setting contact me or have a look at the closed Facebook champion page for long-term care settings and ask the active members what they are doing and share information.

Whatever stage you are at for pressure ulcer prevention care planning, don’t forget to share your journey and successes at #stopthepressure on Twitter which is the national # for improvement, support and sharing of information. This is very NHS dominated so it would be great to see long term care settings on here sharing their work and feeding into the national strategy network. More often than not long term care settings are not seen as key preventers, however you have a very high risk group and in my experience some of the lowest rates of acquired deep tissue injuries. For advice on how you can collect data on your pressure ulcer numbers contact me of ask the Facebook page. 

Start celebrating your numbers!