While there is much research evidence looking at management of pressure ulcers (PU) in the acute setting, there is very little evidence available on community care models.’FRANKS, WINTERBERG AND MOFFATT 2002
Current and future practice with telehealth and virtual support
Most European countries are making a start on rethinking how we can restart rebuilding everyday life.
The use of telehealth and virtual support during this period may have given us (be it an unwanted) a newly forced way of working for necessity, but many have explored the possibilities of using this platform for improved resident outcomes for the future.
In the UK we have multiple services involved with a residents package of care, and coordinating a MDT care planning approach can be timely. Operationally it has meant that all disciplines involved in the residents care meet to discuss care planning and progress.
Historically I know from attempting to co-ordinate MDT meets myself as a community TVN it has been very challenging and tended to happen mostly if there was a very high risk or safeguarding concern. The main challenge was getting everyone in one place at the same time. In community settings offices are based far and wide and the travel time for some can be a real burden.
This type of care planning (MDT) should be standardised in complex care however can fall short for the above reasons. Under the current climate, services have had to increasingly rely on virtual and telehealth platforms to reach their patients.
While this was being tried in some areas pre COVID-19 it has been standard practice for many areas of the UK especially in some of the isolated islands off the UK.
We can learn a great deal from how these systems can support us in long term care to access specialist advice for residents going forward. This system can also work on discharge from hospital to admission in the care home.
Below I will list the probable services involved with complex care residents and how you may be able to request virtual support for multi-disciplinary team planning through lockdown.
With any wound the GP will need to be informed if requesting a dressing prescription, but also if it’s a suspected deep tissue injury. This is predominately so that any underlying conditions such as infection may be investigated. Most GPs are now communicating through virtual platforms. Ask your local CCG or GP how and if this platform could be used in discussing complex patients as part of a multi-disciplinary meeting place.
Where a wound is palliative such as a fungating tumour, you will need to be clear on likely progression and level of end of life support needed. Wounds such as arterial leg ulcers may be very painful and discussions on pain relief will be needed.
Typically a resident with a pressure ulcer category 3 or 4 would be referred to Tissue Viability Teams. However, through the current climate, TVNs may not be visiting.
As a TVN the first advice will always be prevention is better than management.
Remembering first to rapidly respond to a category 1 pressure ulcer in house may stop the tissue damage in its tracks by simply offloading. Then identify possible causes and root cause of damage, you may then implant actions to prevent further damage.
There is robust evidence that suggests early stage pressure damage (Category 1) identified at an early stage it may be reversed if rapid intervention takes place, such as simply 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).
In terms of managing a complex wound and inherited or acquired pressure ulcers, many TVNs are offering remote support via NHS.Net to help validate pressure damage depth and offer advice. To help with complex care management of a deteriorating wound they will be the key player in your MDT virtual meeting.
Categorising a pressure ulcer can be difficult especially between a category 2 and 3. These are commonly misdiagnosed. This was found in a study by (Defloor & Schoonhoven 2004) on the inter/rater reliability of categorising pressure ulcers. They found the more senior the nurse the less variability between categorising occurred. It is always worth asking the TVN if they would be happy to support validating the category of a pressure ulcer.
For Residential Care homes the key questions to ask may be:
- Are you still seeing a District Nurse? Ask them if they’re using a standardised prevention plan e.g. aSSKINg – Can this information be shared with you and the resident. This should be happening as standard but it does depend on level of engagement you have with the nurses.
- Can you share electronic NHS care plan access? This would be a question to take back to your home manager to ask if in the pipeline. Many homes are now getting access to System 1 or Rio the GP records system, with limited access to relevant care plans and updates.
- Is there Virtual MDT meetings already in the community or CCG regarding residents and can you ask to attend these? Especially if you are closely involved with the resident, asking to follow up their care needs may give you some ideas on any improvements.
- MDT safeguarding meetings. How many times have I heard a care home get frustrated where a new admission with a complex pressure ulcer have received a referral but not an invite to the discharge planning meeting. Ask the District nurse for any information that may have been shared with them following discharge or a resident to your care setting. This is up to the individual home leads to pursue their local relationship with discharge leads, however you may be happy to deputise to this role and sure your manager will be happy for the offer.
Allied, health professionals, including occupational therapists, physiotherapist, dietician, speech and language therapists, wheelchair services
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.
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.
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 for 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.
An example of this I have experienced as a TVN a few times has been where I have seen 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.
With Occupational therapist seating and support surfaces can be a challenge. Long-term care settings and hospices have increasingly complex patients and residents requiring not only prevention mattresses and cushions but also 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 sacred 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 yourself 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 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.
For complex seating residents it would be worth asking the OT if they would participate in virtual MDT.
For example I was involved in a case where an OT had prescribed a fabulous rise recliner chair which was built around the ergonomics of the residents anatomical position. However when the gentleman was admitted then later discharged from hospital, he had lost weight and his anatomical position in the chair had changed. As a result part of his specialist chair was now digging into his hip and he went on to develop a Category 4 pressure ulcer. As a result this prompted some work on joint MDT therapy and nursing projects to make improvements.
At the moment it may not be possible for your local occupational therapist or physiotherapist to come and do seating assessments and moving and handling assessments on your residents, however involving them in residents already referred to them in MDT meetings can then be incorporated into your pressure ulcer prevention care plan or aSSKINg prevention bundle.
Dietician & SALT
Input for those assessed at risk of malnutrition and MUST assessed is paramount.
Also for those with a grade 3 or 4 pressure ulcer. This is a vital component for pressure ulcer prevention AND treatment. The skin is a living functioning complex organ and requires feeding and hydration to function. Vital nutrients help the skin repair and regenerate.
Carers are key preventers as they are the most likely to pick up on a Category 1 pressure ulcer first.
Always invite the carers that have the most contact with the resident. Their input and knowledge will be especially useful. From my experience they will likely have some very practical solutions.
Family or Lasting Power of Attorney
Lastly and most importantly with residents consent or in best interests always involve the family in care planning and decision making. It is incredibly difficult for family to be separated from their loved ones and not able to visit.
There may be the option to include them in MDT virtual planning. From experience the family can help greatly in understanding the habits of their loved one and exploring alternatives in complex situations.
Under duty of candour it is required that any deep tissue injury pressure ulcer being investigated is reported to family. I would invite the NOK to any reflective panel following a root cause analysis as promotes effective openness and transparency and better future patient safety.
Remember if you do have an acquired deep tissue injury as a result of pressure or shear, you will be required to complete an in-house investigation (Root Cause Analysis) of the pressure ulcer – and an alert sent to CQC.
Firstly do not panic! Remember even if gaps are found it is rarely down to one individual, rather it is an organisational gap. Actions set from these incidences should be meaningful and measurable not a tick box exercise. Again being involved in this process although may seem daunting is where real positive change can start, so don’t be worried in asking to be part of this as a MDT process. For example if you felt the communication between the home and the community staff could have been better, say this! If you work together to find solutions this can be effective in protecting further residents and improving relationships with your community colleagues.
For any more advice on the above content please contact Faith Slater RN, OSKA’s Clinical Support Nurse or call 02394 318318.
Collier M (1999) Blanching and non-blanching hyperaemia. Journal of Wound Care 8(2): 63–4.
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.
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.