Tissue Viability

Guidance for Reporting and Safeguarding

Version 6.1 FINAL16thJune 2011

June 2011

Acknowledgements

West Midlands Strategic Health Authority wishes to thank the following organisations/groups for their assistance in compiling this guidance:

  • NHS Staffordshire
  • NHS Stoke on Trent
  • West Midlands Regional Tissue Viability Advisory Group (TAGS)
  • Heart of Birmingham NHS FT Tissue Viability Team
  • Bradford PCT
  • Solihull Care Trust
  • Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership
  • University Hospital Coventry and Warwick Tissue Viability Team
  • West Midlands Regional ‘Your Skin Matters’ High Impact Action Working Group

Further information

For further information please contact:

Contact: Manjeet Garcha. Interim Head of Patient Safety, NHS West Midlands

Michelle Mello. Modernising Nursing Careers Lead,NHS West Midlands

Telephone: 0121 695 2561/0121 695 2300

Email:

Contents / Page
Number
1.0 / Introduction
-Purpose / 4
2.0 / Background / 4
3.0 / Definitions of a Pressure Ulcer / 5-7
Definitions of Avoidable and Unavoidable Pressure Ulcers / 7
4.0 / Reporting Guidance
- Pressure Ulcer Reporting Chart
- Definition of timescales for Hospital and Primary Care Acquired Pressure Ulcers
- Assurance / 8-9
5.0 / Pressure Ulcer Reporting Flowchart / 10
6.0 / Safeguarding
-Pressure Ulcer Safeguarding Triggers Pathway 1
-Pressure Ulcer Safeguarding Triggers Pathway 2
-Safeguarding Referral Pathway for Pressure Ulcers / 11-14
15
16
17
7.0 / References / 18
Appendices / Page
Number
Appendix 1 / NHS West Midlands High Impact Action
Your Skin Matters Recommended Route Cause Analysis (RCA)
Investigation Report (Template) / 19-34

Serious Incident Reporting

Introduction

Experience of reporting and managing pressure ulcer related serious incidents (SI’s) has indicated the need for additional guidance, support and clarification of the criteria to be used when evaluating pressure ulcer related serious incidents. This guidance has been designed to offer further guidance for safeguarding, reporting and investigating tissue viability related pressure ulcers and should be used in conjunction with the previously published National Framework for Reporting Serious Incidents (2010) and NHS West Midlands Serious Incident Reporting Policy (2010).

1.0Purpose

The purpose of this guidance is to:

a)Ensure management of SI’s related to pressure ulcers conform to the processes and procedures set out for managing all SI’s

b)There is a consistent approach to evaluating Pressure Ulcers related SI’s

c)Early reports of pressure ulcer reporting SI’s are sufficient to decide on appropriate escalation, notification and communication to interested parties including Safeguarding

d)Appropriate action is taken to prevent damage to patients, staff and the reputation of the NHS

e)All aspects of the SI are fully explored and ‘lessons learned’ are identified and communicated; and

f)Appropriate corrective action is taken to prevent/reduce the number of incidents occurring.

2.0Background

In November 2009 Dame Christine Beasley, Chief Nursing Officer for England, launched the High Impact Action for Nursing and Midwifery’.This document identified 8 key examples of high quality and cost effective care that potentially would make a transformational difference in the NHS.

The reduction target for reducing pressure ulcers is now a major work stream in Safety Express, CQUINs including CNO’s High Impact Actions. The target reduction was set at 80% for hospital acquired pressure ulcers and 30% for community acquired by 2014 as identified in the Nurse Sensitive Outcome Indicators (2010).

Pressure ulcers of grade 3 and 4 are to be reported as a serious incident on the Strategic Executive Information System (STEIS) and to clarify the process; the following reporting guidance has been developed.

3.0

3.1 Definition of a Pressure Ulcer

A localized area of damaged tissue as a result of pressure in combination with other variables of which there are 4 grades; these are described in detail on pages 5 and 6.

Grade 1: Non-blanchable erythema

Description:Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Grade 1 may be difficult to detect in individuals with dark skin tones.

Grade 2: Partial thickness

Description:Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (indicating deep tissue injury). This grade should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

Grade 3: Full thickness skin loss

Description:Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. Mayinclude undermining and tunneling. The depth of a grade 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and grade 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep grade 3 pressure ulcers. Bone or tendon is not visible or directly palpable.

Grade 4: Full thickness tissue loss

Description:Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a grade 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Grade 4 ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making Osteomyelitis or osteoitis likely to occur. Exposed bone/muscle is visible or directly palpable EPUAP (2009).

3.2 Defining avoidable and unavoidable pressure ulcers

In the absence of definitions in the UK, theDepartment ofHealthhasused two definitions from The Wound, Ostomy and Continence Nurses Society of the US and created one modified definition for use in the UK:

Avoidable Pressure Ulcer: “Avoidable means that the person receiving care developed a pressure ulcer and the provider of care did not do one of the following; evaluate the person’s clinical condition and pressure ulcer risk factors; plan and implement interventions that are consistent with the persons need and goals, and recognised standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.”

Unavoidable Pressure Ulcer: “Unavoidable” means that the person receiving care developed a pressure ulcer even though the provider of the care had evaluated the person’s clinical condition and pressure ulcer risk factors; planned and implemented interventions that are consistent with the persons needs and goals; and recognised standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate; or the individual person refused to adhere to prevention strategies in spite of education of the consequences of non-adherence”.

Guidance:In determining whether the pressure ulcer is avoidable; commissioners, regulators or others could request to see evidence demonstrating the actions outlined in the “avoidable” definition are demonstrated.

4.0 Reporting Guidance

The guidance chart for reporting pressure ulcers can be found in figure 1 and a flowchart capturing the timescales for reporting and investigating can be found in figure 2

Figure 1Pressure Ulcer Serious Incident Reporting Chart

STAGE / ACTION
Reporting organisation /
  • Hospital acquired grade 3 and 4 pressure ulcers should be reported on STEIS by the acute Trust.
  • Primary care acquired pressure ulcers should be reported on STEIS by the community provider organisationand performance managed by commissioners via the Care Quality Review process.
  • Primary care acquired pressure ulcers in commissioned independent providers should be reported on STEIS by the commissioning organisation, this includes care commissioned in nursing or residential care homes.
  • Incident found in patients own homes where there is no input from any health services, these should be reported to the commissioner and internal analysis undertaken of any significant trends. These do not need to be reported on STEIS.

Safeguarding /
  • All Grade 3&4 Pressure Ulcer Incidents should first be assessed for evidence of neglect or abuse and if this is substantiated then reported to the trust safeguarding lead for further investigation. (The person (s) undertaking the initial assessment must have undertake appropriate Safeguarding training).
  • Should signs of neglect be identified using locally agreed or regional tissue viability criteria, the Trust must report this to the Local Safeguarding Board and the Care Quality Commission (CQC).

Reporting
Timeframe /
  • All incidents should be reported on STEIS within 2 working days in line with the SHA’s policy for the ‘Reporting & Management of Serious Incidents’ 2010.

Root Cause Analysis /
  • The Root Cause Analysis (RCA) should be completed within 21 working days following notification of the incident. This is in line with current local agreed CQUINs and the SHA High Impact Action Group for ‘Your Skin Matters’.

STEIS Closure /
  • On completion of the RCA, the lessons learnt and actions planned and completed must all be summarised on STEIS; the Trust can then request closure from the SHA, including any actions arising from referral to the Local Safeguarding Adults Board.
  • The commissioning PCT should also assure compliance with action plans via the normal Quality Review Group Meetings.

4.1Definition of timescales for Hospital and Primary Care Acquired Pressure Ulcers

For patients admitted or transferred to a healthcare setting without any obvious signs or symptoms of skin damage, the development of a stage 3 or 4 pressure ulcer within 72 hours of admission to that institution is likely to be related to pre-existing damage incurred prior to admission or transfer of care.

For any pressure area damage arising after 72 hours thereafter, the most likely cause will be related to care within the healthcare setting the patient is in, this must be regarded as a new event.

All professionals must ensure that pressure ulcer details are stated in any clinical correspondence e.g. discharge or admission letter, should clearly identify relevant information in respect to the initial source of occurrence

4.2Assurance

It is the responsibility of the Commissioner to ensure that all grade 3 and 4 pressure ulcers are reported on STEIS and investigated. In addition, the trust must ensure that the incidence and progress is analysed and reported internally through the organisation’s governance reporting framework and ultimately to the Trust Board.

5.0 Pressure Ulcer Reporting Flowchart

Figure 2: Flow Chart showing timescales for reporting and investigating

Incident

Pre 72 hrs Post 72 hrs

Community Hospital

Report on STEIS and refer to trust Safe Guarding Lead within 2 working days

(Assess for suspected neglect)

Yes No

Report to Local Safe Guarding

Board

And CQC

Investigate and complete RCA with 21 working days

6.0 Safeguarding

6.1Introduction

This guidance has been written to provide a framework for decision making in relation to establishing the need for raising a safeguarding referral in the event of tissue damage occurring.

6.2What is safeguarding?

Safeguarding is defined within the Staffordshire and Stoke on Trent Inter-agency adult protection procedures (2010) as “All work which enables an adult who is or may be eligible for community care services to retain independence, wellbeing and choice and to access their human right to live a life that is free from abuse and neglect” This includes people in need of health care services.

6.3 Who is a vulnerable adult?

Vulnerable adult is a term used to describe a person who is aged 18 or over, who is, or may be in need of community care services, by reason of mental or other disability, age or illness and who is, or may be unable to take care of him or herself or take steps to protect him or herself from significant harm or exploitation. (DOH, 2000)

6.4 What is Neglect or Acts of Omission?

The withholding, either deliberately or unintentionally, of help or support necessary to carry out daily living tasks. This includes ignoring medical and physical care needs or failing to provide access to health, social or educational support, the withholding of medication, nutrition and heating.

Pressure ulcers are cited twice in Staffordshire and Stoke-on-Trent Policy Inter Agency Adult Protection Procedures(2010);

  1. Physical abuse: section 6

Under possible indicators of physical Abuse:

“Ulcers, pressure sores and left in wet clothing”

  1. Neglect and acts of omission: section 6

Under possible indicators of neglect

“Inadequate physical care both of the person and the environment”

6.5 What is a pressure ulcer?

A localized area of damaged tissue as a result of pressure in combination with other variables of which there are 4 grades as described in section 2.1.

Notification Required

6.6 Primary/Secondary Care

A clinical incident form should be completed for all grade 2, 3 and 4 pressure ulcers in line with the National Institute for Health and Clinical Excellence (NICE, 2005) and all grade 3 & 4 pressure ulcers must be reported as an SI as per the SHA SI Reporting Policy 2010.

6.7 The Health & Social Care Act

Outcome 20 (Notification of other incidents) in the CQC Guidance about Compliance - Essential Standards of Quality and Safety states:

The registered person(this now includes NHS, Adult Social Care & Independent Health) must notify CQC of:

"The development after admission of a pressure sore of grade 3 or above that develops after the person has started to use the service (European Pressure Ulcer Advisory Panel Grading)."

Outcome 20 relates to Regulation 18 of the Care Quality Commission (registration) Regulations2009

6.8Safeguarding adult referral in relation to Tissue viability

Potential indicators for a safeguarding referral:

  • Development of a Grade 3/4 EPUAP pressure ulcer
  • Rapid onset/deterioration of tissue damage
  • Unexplained weight loss/dehydration
  • Unexplained bruising or injuries of any sort
  • Poor physical condition i.e. failure to attend to physical needs such as toileting, dressing and washing
  • Poor continence management
  • Burns
  • Leaving a resident unattended for an extended length of time

This is not an exhaustive list and there may be other areas of tissue viability that would trigger a safeguarding referral. (See local Safeguarding Adults Policy).

6.9Reasonable measures that should be taken to prevent tissue damage:

  • Implementation of, or increase in repositioning regime with clear documentation
  • Evidence of a 24 hour approach to repositioning at regular intervals appropriate to each individual
  • Regular skin inspection and clear documentation to include continence management and protection of skin with barrier creams and/or emollients
  • Appropriate plan of care which is updated accordingly and addresses the cause of the pressure damage.
  • Care Homes: Monthly risk assessment acknowledging changes in need
  • Primary care: Three monthly risk assessment or as clinical condition changes acknowledging changes in need
  • Secondary care: Risk assessment within 6 hours of admission and daily risk assessment thereafter
  • Appropriate equipment with supporting documentation
  • Nutritional assessment and involvement of necessary professionals
  • Wound assessment and evaluation to include photographs and regular wound measurements
  • Appropriate dressing selection with a treatment chart
  • Pain assessment and liaison with the GP
  • Documented evidence of offering care to non concordant residents

Absence of any of the above may indicate a safeguarding referral but would be considered on an individual basis.

6.10Factors that may influence the safeguarding referral decision

In some cases pressure ulcer development may be inevitable for example;

  • Palliative diagnosis
  • End of life care
  • Non concordance of patient with recommended treatment and interventions
  • Multiple co-morbidities
  • Change in condition
  • History of development
  • Capacity and mental health issues( these are patients that may not co-operate with treatment or prevention interventions due to capacity or mental health problems i.e. taking off wound care dressings or declining to be repositioned)

This is not an exhaustive list, medical conditions along with other professionals opinions needs to be taken into account. Reasonable measures still need to be carried out regardless of diagnosis. Failure to do so may still result in a safeguarding referral

6.11Consideration of Capacity

If a person lacks capacity to make a decision in relation to the care or treatment of the pressure ulcer a decision must be taken to act in the best interests of the patient utilizing the Mental Capacity Act 2005.

The two diagrams (pages 13 and page 14) indicate the pathway for individuals who are receiving professional support i.e. in a care home, hospital, from a domiciliary care provider, a nursing agency and those individuals who are not receiving any professional care and are looked after by an unpaid carer, family or friend.

Pressure Ulcers – Safeguarding Triggers- Pathway 1

To determine if the identification of a pressure ulcer on an individual receiving professional support(in a care home, hospital or from domiciliary care of nursing agency care) should result in a safeguarding referral the following triggers should be considered.

IF IN DOUBT Initiate Safeguarding Adults Procedures Discuss with senior manager Record decision and reasons for decision.

Possibly NOT Safeguarding at this stage / Possibly Safeguarding / Definitely Safeguarding
1. What is the severity (grade) of the pressure ulcer? / Grade 2 pressure ulcer or below – care plan required / Several grade 2 pressure ulcers/ grade 3 to 4 pressure ulcers- consider question 2 / Grade 4 and other issues of significant concern
  1. Does the individual have mental capacity and have they been compliant with treatment?
Has a capacity assessment been completed? / Has capacity and declined treatment
Capacity assessment is recorded. / Does not have capacity or capacity has not been assessed- continue to question 3 / Assessed as NOT having capacity and treatment NOT provided
3. Full assessment completed and care plan developed in a timely manner and care plan implemented? / Documentation and equipment available to demonstrate full assessment completed, care plan developed and implemented. / Documentation and equipment NOT fully available to demonstrate full assessment completed, care plan developed or care plan implemented BUT general care regime (e.g. nutrition, hydration) not of concern- continue to question 4 / Little or no documentation available to demonstrate a full assessment has been completed, or care plan implemented AND general care regime (e.g. nutrition, hydration) is of concern.
4. This incident is part of a trend or pattern- there have been other similar incidents with this individual or others. / Evidence suggests this is an isolated incident. / There have been other similar incidents / Evidence demonstrates this is a pattern or trend.
NOT SAFEGUARDING / If 2 or more of the above apply - SAFEGUARDING / SAFEGUARDING

Always clearly record decision and reasons for decision.