1. Pressure Ulcer Prevention PUTZ, SSKIN
ICHN
29/08/2018

2. Focus on pressure ulcers
A pressure ulcer is a complication of care in terms of safety and the service users experience of healthcare.
Pressure ulcer incidence in Ireland ranges from 8% to 14.4% depending on the patient group.

3. Focus on pressure ulcers
There are no published incidence figures from paediatrics, hospice or obstetric services available for Ireland(2014).
It costs €119,000 to successfully treat one patient with a grade 4 pressure ulcer (Gethin 2005).
From this figure it is extrapolated that it would cost €250 million per annum to manage pressure ulcers across all care settings in Ireland (Gethin 2005).

4. Focus on Pressure Ulcers
The Quality and Patient Safety Division(HSE)and the Royal College of Physicians of Ireland, as part of the National Quality Improvement Programme, undertook the first large-scale quality improvement Collaborative in Ireland in partnership with Dublin North East (DNE).

5. Focus on Pressure Ulcers
The aim was to reduce the incidence of avoidable pressure ulcers across DNE by 50% during the six months of the Collaborative.
The ultimate goal of reaching an avoidable pressure ulcer rate of 0%.

6. Pressure Ulcers to Zero
The ‘Pressure Ulcers to Zero’ collaborative facilitated healthcare services in the DNE region (acute and primary and community services) to adopt a structured approach to improvement.

7. Pressure Ulcers to Zero
Achievements
The participating teams achieved a 73% reduction in avoidable pressure ulcers.

8. Pressure Ulcers to Zero
Increased awareness of pressure ulcers – not just the nurse’s job but the team’s job
Increased capability in using quality improvement tools and methodologies
Forging of stronger team working
Supporting integration – greater networking across the region
Creativity and innovation within the teams in supporting their colleagues to implement the changes for improvement.

9. Definition Definition
“a lesion on any skin surface that occurs as a result of pressure and includes reactive hyperaemia as well as blistered, broken or necrotic skin”(Parish et al 1983)
A pressure ulcer is a “localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear”(NPUAP/EPUAP/PPPIA, 2014).

10. Pressure Ulcers Pressure Shear Friction – to a lesser degree
BUT not the only factors that influence pressure ulcer development.

12. Factors Age Medication Spinal or other Injury Nutrition General Health
Diseases
Mobility

13. Pressure Ulcers
Classification Stage one Stage two Stage Three Stage Four

14. Pressure Ulcers

16. Pressure Ulcers

17. Pressure Ulcers

18. Pressure Ulcers

19. Pressure ulcers

20. Pressure Ulcers

22. Pressure ulcers

23. Pressure ulcers

25. Pressure Ulcer Prevention
Pressure ulcer prevention is based on the principle that prevention strategies are planned and based on the individual risk factors that the service user presents with (Moore 2004).
Pressure ulcer prevention strategies are informed by risk assessment and clinical judgement.
Risk assessment is therefore the first step in the prevention process (Moore and Cowman, 2014).

26. SSKIN
Pressure Ulcers to Zero (PUTZ) is a quality improvement collaborative which aims to eliminate pressure ulcers within all health care settings in Ireland.
Evidence and best practice documented for pressure ulcer prevention have been structured into a care bundle known as the SSKIN. (The SSKIN Safety Bundle)

27. SSKIN
A Care bundle is a structured way of improving client care and outcomes.
It is a set of evidence-based practices, that when preformed collectively and reliably, has been proven to improve patient outcomes (Institute of Healthcare Improvement, 2017).

28. SSKIN Initially an American healthcare initiative
Tool to define & tie best practice together
Makes the process of preventing pressure ulcers visible to all
The aim is to minimise variation in care & improve the pressure area care delivered.
Impact on improving care outcomes
Use of Audit to monitor

29. SSKIN
Surface
Skin Inspection
Keep Moving
Incontinence
Nutrition

30. SSKIN- Surface

31. SSKIN- Surface Check what mattress and cushions they are using.
Is it the correct surface level of risk?(See risk assessment tool)
Is it working?
Does it need replacing?
What else is the client lying on? E.g. sheets, pads, crumbs, equipment

32. Skin Assessment

33. SSKIN- Skin Assessment
Check skin when giving personal care
Check if client is complaining of discomfort
React to RED – check for blanching
Document if skin is at risk (e.g. very dry or over moist)

34. SSKIN- Skin Assessment
What skin regime are they currently present?
Can client check and maintain their own skin health?
Have they got carers to help them with personal care?
Use Risk assessment tool

36. SSKIN- Keep Moving

37. SSKIN- Keep Moving Can they move? Are they motivated to move?
Do they need prompting?
Do they need assistance to move?
All part of risk assessment

38. SSKIN- Keep Moving
Do they need referral to OT/Physiotherapy (passive exercises-adaptations /equipment)
Do they need a turning regime or a positioning plan?
Has the patient been educated to move , stand, change position?

39. SSKIN- Incontinence

40. SSKIN- Incontinence What is their toilet regime?
Function-can they get to the toilet?
Have they been incontinent-Urine or faeces or both?
Are they wearing pads-are they fitted correctly, how often are they changed?
Do they need a continence assessment?

41. SSKIN- Incontinence What is their skin regime?
What are they washing with?
Do they need emollients, skin barriers, soap substitutes?
Any problems with moisture or moisture lesions?

42. SSKIN- Incontinence

44. SSKIN- Nutrition

45. SSKIN- Nutrition MUST (Malnutrition Universal Assessment Tool)
Is the client at risk ?
What is the action plan/care plan?
Has the plan been followed?
What are they eating & drinking?
Does the client know what a good diet is?
Recording intake (food and fluid)
Supplementation
Referral

46. National Guidelines
The HSE National Wound Management Guidelines (2018)
Pressure Ulcers to Zero and SSKIN(HSE)
Pressure Ulcers- A practical Guide for Review (HSE 2018)

48. Reference www.hse.ie/pressureulcerstozero
The HSE National Wound Management Guidelines (2018)