With more confirmed cases of COVID- 19 deaths in care homes each day, it is a testing time not just keeping our residents safe but ourselves and families too. The normal status quo has ceased in most areas of health and social care.
Reported increases in numbers of complex patients being fast tracked into care settings from hospitals has meant homes are having to rapidly adapt to this increased admission rate.
Keeping ourselves safe and well means we can care for residents both affected and non affected.
Even without confirmed diagnosis many homes are having to create isolation areas and many residents are needing to be distanced within their own room. It can be confusing and upsetting for residents and difficult to manage for those with reduced capacity.
I have heard of some great practices in homes that have been flooded with offers from volunteers and senior managers redeploying to the floors again just to sit with residents and offer company and care. This will be a great opportunity to prompt 1-1 repositioning with your resident. Please see below further information on how you may want to adapt this into your repositioning chart while residents are isolated in their room.
Undoubtedly with the current issues there may be a risk of increased pressure ulcer numbers.
As we do not have a national database for reporting all care home pressure ulcers it will be difficult to ascertain if this period of lockdown has contributed to a rise in numbers. Therefore it is vital that organisations continue to complete incidence forms for all categories of pressure injuries acquired in-house.
Remember reporting and investigating at a category level is key, as identifying potential causes and amending the resident’s care plan may stop the damage occurring into deeper structures of the skin, affectively becoming a deep tissue injury and reportable to the CQC.
The main concerns and issues listed below are from qualitative/verbal feedback from Nursing & Residential homes I have been virtually supporting, here I offer some clinical tips and advice for you to reduce the risk in your home:
Social isolation and reduced mobility:
With reports of the need to keep some residents in isolation from each-other has meant they may be spending extra time in their rooms. This may in turn reduce the activities of mobilising they are used to. With increased risk of developing pressure ulcers.
Possible solutions and tips:
Keep Moving! We have all seen the keep moving tips online from personal trainers, advising even in the smallest place we can exercise. It is all too easy to fall into a sloth position, especially when feeling anxious, sad and depressed. This becomes a vicious circle as we feel depressed we are less likely to want to move, but the act of movement may help our depression. For our residents the same may apply, so when in their room regular movement and physical therapy may greatly help their emotional state and help protect their pressure areas by offloading.
Sustained periods in bed or chair:
The pelvis is a heavy boney structure and as you can see from the below diagram, there are many areas where protruding boney areas can be affected from sustained pressure.
The ischial tuberosity (see pic) takes a lot of forces of gravity pushing down on it.
Those residents that rely on wheelchairs for mobility develop serious tissue breakdown at pressure points such as the ischium and greater trochanter because of prolonged sitting without proper pressure relief. (Makhsous et al 2007).
After any longer period in bed, when rehabilitating and increasing mobility once more, don’t forget to repeat your falls assessment, as balance and gait may be impaired following sustained period in bed (NICE 2013).
Any resident that becomes unwell and requiring increased time in the bed will need a full reposting reassessment.
Possible solutions and tips:
Ensuring adequate pressure relieving cushions are on the chair and bed is paramount to redistribute the tissue load across the surface. This may be a high specification foam up to pumped AIR cushion depending on the level of self or prompted mobility available.
For advice on choosing the support surface we cannot go from the risk score from Waterlow/Braden/Purpose T but has to be from an individual assessment of their mobility and moving and handling plan.
See the update 2019 EPUAP guidelines page 22 for guidance on support surfaces here:
For any of the above you will need to embed updates into the residents pressure ulcer care plan, ensuring it is clear for all staff.
Using the aSSKINg care plan as a guide of what needs to be included.
There are many aSSKINg care templates available for you to use either through paper notes or electronic systems such as person centred software (PCS).
I am happy to share mine if you would like to utilise this so let me know.
You also may want to consider using the updated Purpose T risk assessment tool in replacement of the more out of date Waterlow or Braden tool. I have covered this extensively in past articles and blogs so please access the OSKA journal or contact me for further info.
Many other long term care and hospice organisations have been trialing and using this tool so ask them on the facebook page how they’re getting on for peer feedback.
It is essential that skin inspection is part of the pressure ulcer prevention care plan. Also essential that it is documented that skin has been checked each day by a care giver in the daily log.
If our resident is independent with personal care, teaching them the importance of skin inspection and reporting any of the below symptoms or skin changes is paramount.
I have heard too many times where skin changes and risks have not been explained to the resident and an ulcer has occurred. The resident has advised if they had known they may have been more vigilant and potentially prevented the pressure ulcer. This comes up frequently where there is poor use of recommended support surfaces without explanation to the resident as to its purpose.
It is important therefore to have awareness of the other reported early signs of pressure damage such as:
- An area of skin over bony prominence that feels cooler or warmer to touch.
- reports of pins and needles.
- Report of pain. Those residents that have capacity, the classic ‘nurse my heel/bottom is sore’ can be an early warning indicator and it would be worth checking for the above symptoms as soon as possible. However, people with sensory neuropathy may not experience the pain caused by pressure damage.
- The area may feel warm.
- The area may be oedematous with areas of hardness.
(Clark, M 2010)
Remember it is important those with darkly pigmented skin discolouration (non blanching erythema) may be harder to detect.
Click here for an excellent video of how to test the skin using the blanching method.
Monitoring your pressure ulcer numbers
Long term care organisations all have their own system of reporting incidences of pressure ulcers, some using spreadsheets to monitor and others electronic incident platform such as DATIX.
Reporting needs to be more than a task exercise, this data can help us identify themes such as a rise of pressure ulcers in one home may prompt an internal focused inspection to review practices.
It is also where under duty of candour we can keep a record of information gathered (RCA) and actions taken and measured where gaps are identified. The resident or LPA needs to be informed and ideally involved in this process.
A Safety Cross is a simple and good visual prompt for all to monitor incidences and trends.
Free downloadable safety cross available on the NHS care home resource page can be found here.
Other free resources
These are challenging times and with reduced face to face support from external specialists, access to resources is paramount.
I have listed below some key resources for you that may help:
- For current government advice on safety in care homes through Covid-19 including PPE, click here.
- Don’t forget the long term care champion network group page. There are over 220 members on this group now, sharing resources and asking advice. This is a closed professional network page. Click here to join.
- For a fantastic downloadable guide for care homes on prevention pressure ulcers see here.
- I am offering virtual training to groups on Monday to Wednesdays via the Zoom platform. Subjects may include:Pressure Ulcer Prevention, categorising & management.Wound care Management and dressings.Root Cause Analysis (RCA) Investigating our harms.CQC journey to outstanding in pressure care and improvement plans.Bespoke Tissue Viability Training as requested.1-1 virtual Tissue Viability support
This can be for current staff or new starters. Full CPD certification will be sent after attended.
For more information contact OSKA on 02394 318318 or email Faith Slater RN, OSKA’s Clinical Support Nurse.
Clark, M (2010) ‘Skin assessment in dark pigmented skin: a challenge in pressure ulcer prevention’. Nursing Times; 106: 30 accessed online13th May 2020. Available at: https://www.nursingtimes.net/clinical-archive/dermatology/skin-assessment-in-dark-pigmented-skin-a-challenge-in-pressure-ulcer-prevention/5017918.article
Makhsous, M. Rowles, DM, Rymer WZ, et al (2007) Periodically relieving ischial sitting load to decrease the risk of pressure ulcers. Archive of Physical Medical Rehabilitaion.;88(7):862‐870 accessed online 12th May 2020. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861140/