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What and how to measure pressure ulcers in long-term care and hospices

After involving a range of stakeholders, in 2018 NHS Improvement published new guidance on definition and measurement of pressure ulcers, to reduce disparities in reporting. The implementation process launch for these updates are April 2019 and NHS organisation Tissue Viability Teams have been busy updating their reporting structures and training on the updates.

One of the key targets for these revised guidelines is to create a more uniformed reporting of pressure ulcers and skin damage.

There has been and still is a variance on what is reported, measured and investigated across NHS organisations and a lack of guidance for long-term care and hospices. In the long-term care settings data may be collected in-house and not shared to a data porcine spine system such as the national reporting learning system or NLRS. Monitoring incident data patterns may also vary in each organisation, with some settings starting to use electronic incident reporting systems such as data text while other small organisations are reporting using other means. The revised definition guidance can be found below:

Where it comes to investigating our in-house pressure ulcers guidance long-term care on when and how to do this is also lacking.

Below are my recommendations for long-term care on to investigate, report and refer a pressure ulcer.

At present long-term care settings are asked by CQC to report all category 3 and 4 pressure ulcers, this may include a prompt to the local safeguarding team who may ask for an internal investigation to identify any gaps in care and/or learning needs. 

In the NHS services, the EPUAP 2015 updated pressure ulcer categories including unsustainable and suspected deep tissue injury in most cases will be reported as an incident such as a category 3 or 4 and investigated as such. It is important to remember that monitoring pressure ulcer data in clusters of incidences is not about associating blame on the clinical area organisation but about identifying potential gaps and areas of improvement. This in my experience becomes most effective as a learning tool when multidisciplinary teams are involved in full transparency and the process is shared with your commissioners or CTC inspectors. Preventing pressure ulcers is multifaceted and ensuring compliance of key prevention standards can seem complicated. For those that haven’t heard of the aSSKINg bundle I would highly recommend to see if you would like to implement within your environment, this can be a key compliance audit and/or implemented care plan to ensure the key standards of preventing a pressure ulcer are covered for your residents

Although CQC is not at present asking organisations to report their unstageable or suspected deep tissue injuries, I would still ask the advice of your local inspector and monitor and investigate these in-house through root cause analysis.

Moisture Associated Skin Damage or Incontinence Associated Dermatitis (moisture lesions) can be extremely painful and uncomfortable for the resident, sometimes described as a burn like pain. In most cases these are preventable with good risk assessment as part of your skin care plan, good personal care and barrier cream or spray. As a result, monitoring these instances is also highly recommended and where there are re-occurring cases, discuss with your local incontinence nurse specialist for a product review and/or monitor skin care plan.

Current nursing care home and hospice reporting as requested by CQC:

Multiple Category 2s
Category 3
Category 4

Note: Residential sections of care homes will likely have their pressure ulcers reported by district nurse or tissue viability nurse teams, therefore fall under the remit of local NHS reporting systems.

Care home leads should use their initiative in reporting anything outside this remit they feel may need investigation if they’re not sure.

NHS Reporting

Varies on organisation. NHS improvement recommendations.

All categories of pressure ulcers to be reported including modulations and stage goals, suspected deep tissue injuries, medical device injuries, modulations.

Multiple category 2, category 3, category 4, unstagable, suspected deep tissue and medical device injuries will in general prompt an internal root cause analysis to identify key themes and any potential gaps in care.

To find out more about how organisations are monitoring and reporting their pressure ulcers and share any quality improvement work you may be involved in, don’t forget to join the OSKA Quality improvement Champion Facebook group.