Presentations from the Stop the Pressure Lincoln event held for 500 student nurses and caremakers at The Engine Shed, Lincoln on 15 October 2013 This event supports Stop the Pressure, a campaign to raise awareness of pressure ulcers The hashtag used at this event was #stopthepressurelincoln

1. #stopthepressure
Lincoln
15th October
2013

2. Welcome
Professor Sara Owen
Pro-Vice Chancellor
University of Lincoln

3. Introduction
Lyn McIntyre
Deputy Nurse Director, Midlands and
East
Charlotte Johnston
Student Nurse, University of Lincoln

4. NHS Midlands & East
4

5. 5
• New numbers trend
• Midlands and East
New grade 2, 3 and 4 pressure ulcers

6. Resources
6 NHS | Presentation to [XXXX Company] | [Type Date]

7. 7 NHS | Presentation to [XXXX Company] | [Type Date]

8. The Swan’s Story
http://www.youtube.com/watch?v=IJ
8FEhE561Y&sns=em

9. Pressure ulcer
recognition and
prevention
Mark Collier
Tissue Viability Nurse
Consultant
United Lincoln Hospitals NHS
Trust

10. PRESSURE ULCER RECOGNITION
AND PREVENTION..
United Lincolnshire Hospitals NHS Trust
Mark Collier, Lead Nurse/Consultant - Tissue Viability,
United Lincolnshire Hospitals NHS Trust
mark.collier@ulh.nhs.uk

11. Pressure Ulcers:

12. Current terminology?
• Bedsore
• Pressure Sore
• Decubitus Ulcer
• Pressure Ulcer
What term do you use/prefer?

13. What is a Pressure Ulcer?
‘A pressure ulcer is a localized injury to the
skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or
pressure in combination with shear. A
number of contributing or confounding
factors are also associated with pressure
ulcers; the significance of these factors is
yet to be elucidated. (EPUAP 2009)

14. What is a Pressure Ulcer?
‘Ulceration of the skin due to the effects of
prolonged pressure, in association with a
number of other variables’ (Collier 1995)
‘an area of localised damage to the skin which
can extend to underlying structures such as
muscle and bone. The damage is caused by a
combination of pressure, shearing and friction
forces and moisture’ (NICE, 2005)

18. Pressure
External pressure will be transmitted from the
skin to the underlying bone, compressing the
tissues, including the smaller blood vessels,
between these two structures.
When prolonged this pressure can lead to
inadequate blood supply and cause tissue
death.

19. Shear
A parallel force, shear damage occurs when
deeper skin layers and skeleton move away from
the upper skin layers. This causes stretching of
the small blood vessels which, if unrelieved, will
lead to inadequate blood supply leading to tissue
death.
For example when a patient slides down the bed the skin over the sacral area adheres to the bed
sheets and remains in the sitting position as
gravity forces the deeper underlying tissues and
bone to slip down the bed.

20. Friction
Friction results form is the skin rubbing
against another surface. Friction forces can
contribute to the development of pressure
ulcers by causing the skin layers to separate
forming a blister, or by compromising the
intact nature of the skin.
For example ill-fitting shoes or during poor
moving and handling techniques, such as
moving patients up the bed on a sheet .

21. Can you measure Pressure?..
‘a perpendicular load or force exerted on a
unit of area’
Bennett and Lee (1985)
Force
Pressure = --------------Surface Area

22. Potential Sites for Pressure Ulcers
• Bony prominences
• Consider
–
–
–
–
Oxygen masks
Catheters and tubing
Surgical appliances
Prosthesis

23. Factors that increase the risk of
developing a pressure ulcer

24. Variables - ‘evidence based’
• Age
• Nutrition
• Medical Condition
• Medical Interventions
• Peripheral Vascular
Disease (PVD)
• Patient Support
Surfaces
• Drug Therapy
• Care being Given

25. Age
• Extremes of age
• The skin of elderly patients is thinner, drier
and less elastic increasing the risk of
damage.
• Neonates and young children are also at
increased risk of skin damage because their
skin is still maturing.

26. Nutritional Status
• Dehydration and malnutrition lead to poorly
nourished, inelastic tissues that are more prone to
damage.
• Consider
– Likes and dislikes
– Appetite
– Chewing and swallowing difficulties –
dentures, sore throat/mouth
– Physical ability to feed themselves?

27. BMI
• Very thin patients have less fatty tissue over
the bony prominences to protect from
pressure.
• Obese patients may have difficulty moving
and therefore repositioning to relieve
pressure.

29. Medical History
• Conditions causing reduced mobility & sensation.
• Terminal illness due to multi-organ failure, poor
nutritional status & immobility.
• Conditions affecting the circulation and
oxygenation of the blood.
• Consider
–
–
–
–
–
Heart disease
COPD and lung diseases
Peripheral vascular disease
Diabetes
Anaemia

30. Medication
• Anti-inflammatory drugs (including aspirin)
and steroids may prevent healing.
• Chemotherapy drugs may damage healthy
tissues.
• Sedative drugs may affect mobility and
sensation.

31. Reduced Mobility
• Inability to move self in order to relieve the pressure.
• Consider immobility/reduced mobility due to:
–
–
–
–
–
–
–
–
–
–
#’s
Surgery
Epidurals
Traction
Pain
Paralysis
CVA
MS
Arthritis
Drains & tubing

32. Sensory Impairment/
Reduced Consciousness
• Unaware of the need to relieve pressure.
• Consider
–
–
–
–
–
Unconsciousness
Sedation
Spinal Cord Injury
Diabetic neuropathy
Neurological Conditions egg MS, CVA

33. Moisture Lesions
• A combination of moisture
and friction may cause
moisture lesions in skin
folds.
• A lesion that is limited to
the natal cleft only and has
a linear shape is likely to
be a moisture lesion.
• Peri-anal discolouration /
skin irritation is most
likely to be a moisture
lesion due to faeces.

34. Incontinence
• Urinary and faecal incontinence cause
excoriation of the skin.
• Moisture causes maceration of the skin.
• Consider
– Barrier creams/films

35. Skin Hygiene
• Excessive use of soaps will remove the
skin’s natural protective oils and dehydrate
it.
• Consider
– Skin cleansers

38. Cost of Pressure Ulcers?
Additional treatment / management costs
associated with an Orthopaedic patient with
one Grade 4 Pressure Ulcer equals….
£40,000 Sterling
Collier M (1993) Quality Report, Addenbrookes NHS Trust
from £1,214 (cat 1) to £14,108 (cat IV)
Dealey C, Posnett J et al (2012)

39. © Mark Collier

41. SSKIN - what does it stand for?
•
•
•
•
•
S = Surface
S = Skin Inspection
K = Keep moving
I = Incontinence
N = Nutrition

42. Patient Support Surfaces available?
PRESSURE REDUCING?
PRESSURE RELIEVING?

43. Prevention and Management Support
Surfaces
• Static foam mattresses
• Huntleigh Rentals Contract
– Resource pack on intranet
• Nimbus III – alternating airflow, has heel
guard
• Breeze – low air loss, light weight patients
• Aura cushion
• Consider when to step down!

45. Observation / Skin Assessment
© Mark Collier

46. Prevention and Management
Skin Inspection
• At least daily, frequency will depend on vulnerability
and condition of patient
• Pay particular attention to:
– Areas of healed ulceration
– Bony prominences
• Look for
– Discolouration
– Redness that doesn’t blanche with light pressure
– Blisters
– Localised heat
– Localised oedema

47. Risk Assessment Tools
NICE Guideline No.7 Pressure Ulcer Prevention
‘Whilst there is little evidence to support one tool
over another, there is evidence to suggest that an
assessment process that incorporates a risk
assessment tool improves the patients outcomes’
Which one do we use?
WATERLOW (2005)

48. Prevention and Management
Positioning
• Regular repositioning to
avoid pressure on bony
prominences and existing
pressure ulcers
• Turning/30 degree tilt
• Avoid direct contact
between bony
prominences to avoid
friction and shear –
consider use of pillows
• Consider
– Seating
– Spinal injuries
– Bariatric patients

49. Prevention and Management
• Use of appropriate patient support surfaces
• Skin assessment and good hygiene
• Evidence based moving and handling
practice
• Nutrition
• Hydration
• Incontinence

50. Categories (Grading) of Pressure Ulcers:
GRADE 1
GRADE 2
GRADE 3
GRADE 4
© Mark Collier

51. Pressure Ulcer Categories
Category 1
• Non-blanchable
hyperaemia (of intact skin)
• Discolouration of the skin
• Warmth
• Oedema
• Hardening

52. Pressure Ulcer Categories
Category 2
• Partial thickness skin
loss or damage
involving the
epidermis andor the
dermis.
• The ulcer is superficial
and presents clinically
as an abrasion or a
blister.

54. Pressure Ulcer Categories
Category 3
• Full thickness skin
loss involving damage
to or necrosis of
subcutaneous tissue.
• This may extend down
to but not through the
underlying fascia.

56. Pressure Ulcer Categories
Category 4
• Extensive destruction
and tissue necrosis or
damage to bone,
muscle or supporting
structures with or
without full thickness
skin loss

58. Deep Tissue Injury
• May appear as a purple,
deep bruise, often
mistaken for a Grade 1
pressure ulcer
• Skin is intact
• Occur over bony
prominences
• Tissue damage that occurs
from the inside out
• May quickly progress to
Grade 3 / 4 pressure
ulcers

59. © Mark Collier

61. Guidelines within ULHT for….
• Pressure Ulcer Prevention
• Equipment Provision (Support
Surfaces)
• Pressure Ulcer reporting (PUNT)
• Pressure Ulcer Management

62. Current ULHT Documentation
• Patient assessment/admission documentation
that incorporates all of the principles of SSKIN
• Waterlow Assessment Tool
• Tissue Viability Care Pathway
• PUNT (e-reporting tool on intranet)
• Wound Assessment and Management Chart

63. ANY QUESTIONS?

64. Living with a pressure
ulcer – a patient and
carer perspective
Brian and Yvonne Rawson
In conversation with
Delia Muir
Patient and Public Involvement Lead
Institute of Clinical Trials Research
University of Leeds

65. Living With a Pressure Ulcer – a patient and
carer perspective.
Brian and Yvonne Rawson - PURSUN UK
Delia Muir - Patient and Public Involvement Officer, University of Leeds

66. PURSUN UK
• A network of people with some personal experience of pressure ulcers or
pressure ulcer prevention
• We work on pressure ulcer related research projects
• Our members are also involved in education and professional
development projects

67. Patient Stories
• Real life stories are powerful and can create a common focus
• Patients and their families are often the only constant thing in their journey
through services, therefore their perspective very valuable
• We hope that hearing about the impact that a pressure ulcer can have will
help to drive home important prevention messages

68. Brian and Yvonne’s Story

69. For more information contact:
Delia Muir (PPI Officer)
d.p.muir@leeds.ac.uk
www.pursun.org.uk
Twitter @PURSUN_UK
Or talk to us over lunch

70. Comfort Break

71. SSKIN mini quiz
Mark Collier
Tissue Viability Nurse
Consultant
United Lincoln Hospitals
NHS Trust

72. STOP THE PRESSURE...
SSKIN Mini-Quiz
United Lincolnshire Hospitals NHS Trust
Mark Collier, Lead Nurse/Consultant - Tissue Viability,
United Lincolnshire Hospitals NHS Trust
mark.collier@ulh.nhs.uk

73. Question 1
What does the second S of SSKIN
stand for?
• Surface (green)
• Skin Inspection (red)

74. Question 2
What is the prime function of an
alternating pressure mattress (APM),
such as a Nimbus III?
• Pressure reduction (green)
• Pressure relief (red)

75. Question 3
Which of the following skin
discolouration is the most important
to identify and report when
inspecting a patient’s skin?
• Blanching (green)
• Non-blanching (red)

76. Question 4
How would you categorise?
• Pressure ulcer (green)
• Moisture lesion (red)

77. Question 5
All pressure ulcers are preventable?
• True (green)
• False (red)

78. Question 5: Answer
Hibbs, P. (1988) suggested that 95% of all
pressure ulcers are avoidable.
Although everybody would agree that ALL
avoidable pressure ulcers should be prevented,
there is now evidence in the literature to
suggest that around 43% of all pressure ulcers
can be deemed to be avoidable.
Dowie F, Guy H et al (2013) Are 95% of hospital
acquired pressure ulcers avoidable? Wounds 9:3 16-22

79. Question 6
Who is responsible for the
application of the principles that
underpin SSKIN in clinical settings?
• Everybody (green)
• All healthcare professionals (red)

80. ANY QUESTIONS?

81. Impact of good
nutrition and hydration
on pressure ulcer
prevention and care
Dr Ailsa Brotherton
Director for Clinical
Engagement and Leadership
NHS QUEST PMO

82. Ailsa Brotherton
BAPEN Secretary

83. British Association for Parenteral and
Enteral Nutrition
A multi-disciplinary charity committed to raising awareness of
malnutrition and options for nutritional treatment, along with
consequent impacts on health outcomes, resource utilization,
and health & social care budgets.
BAPEN
Malnutrition Matters

84. Malnutrition in the UK
PHYSICAL
Disease related
malnutrition
PSYCHOLOGICAL
Mobility
Depression/bereavement
Feeding
Dementia
Swallowing
Low activity
Decreased
organ reserve
Specific
disease
Multiple drugs
(taste)
Alcohol
SOCIAL
Isolation
Poverty

85. Malnutrition is both a cause and a consequence of disease
Psychology –
depression & apathy
Poor breathing and
cough from loss of
muscle strength
Liver fatty change,
functional decline
necrosis, fibrosis
Impaired wound
healing and
susceptibility to
pressure ulcers
Impaired gut
integrity and
immunity
Poor Immunity
and infections
Decreased Cardiac
output
Hypothermia – decline
in all functions
Renal function –
limited ability to
excrete salt
and water
Loss of muscle and bone
strength – Immobility,
falls, fractures and VTE

86. The Malnutrition Carousel
NURSING
HOME
PRIMARY CARE
 dependency
 GP visits
 prescription costs
 hospital admissions
CARE
HOME
malnutrition
HOSPITAL
SECONDARY CARE
 complications
 length of stay
 readmissions
 mortality
HOME
BAPEN
Malnutrition Matters

87. Nutrition support in
adults 2006
February 2006

88. The effectiveness of
Nutrition Support (Stratton et al)
10 RCT, n = 494;
RR 0.29 (CI 0.18 to 0.47)
30 RCT, n = 3258
RR 0.59 (CI 0.48 to 0.72)
Controls
Controls
Treatment
Treatment
0
10
20
30
Complications %
40
50
0
5
10
15
20
25
Mortality %
>70% reduction in complications and
>40% reduction in mortality
30

89. NICE ONS and length of stay
Standardised Mean diff.
(95% CI)
% Weight
Study
{HARTSELL1997}
-0.32 (-0.83,0.20)
12.3
{PEARL1998}
-0.49 (-0.78,-0.21)
12.7
{REISSMAN1995}
-3.00 (-3.45,-2.55)
12.4
Gist 2002
-0.03 (-0.39,0.33)
12.6
Gocmen 2002
-2.54 (-2.93,-2.15)
12.5
Burrows1995
-0.38 (-0.78,0.01)
12.5
Patolia2001
-2.08 (-2.53,-1.63)
12.4
Weinstein1993
0.11 (-0.25,0.47)
12.6
Overall (95% CI)
-1.09 (-1.91,-0.27)
-3.45185
0
3.45185
Standardised Mean diff.

90. 2013 - ??
Costs being recalculated
2007 - >£13 billion p.a.
Public expenditure
associated with disease
related malnutrition
2003 - >£7.3 billion p.a
Over 3 million individuals malnourished
or at risk of malnutrition in the UK
NICE Cost Saving Guidance places malnutrition as
a potential large cost saving to the NHS

91. PRIMARY CARE
 hospital
 dependency
 GP visits
 prescription
costs
HOME
General population
(adults)
BMI <20kg/m2 : 5%
BMI <18.5kg/m2 : 1.8%
Elderly: 14%
SHELTERED HOUSING
10-14% of tenants
Prevalence of
malnutrition
in the UK
HOSPITAL
28% of admissions
SECONDARY CARE
 complications
 length of stay
 readmissions
 mortality
CARE HOMES
30-42% of recently
admitted residents

92. The Challenge:
We know what
excellent
nutritional care
looks like

93. The BAPEN
Toolkit for
Commissioners
& Providers
2010
Malnutrition Matters
Meeting Quality Standards in
Nutritional Care
Ailsa Brotherton, Nicola Simmonds
and Mike Stroud
on behalf of the
BAPEN Quality Group

94. 1) Identify those with malnutrition or risk of malnutrition by screening
e.g. BAPEN‟s MUST Tool and assessment as appropriate
2) Implement „individualised‟ care pathways for the malnourished and
those at risk, appropriate to the care setting
3) Provide training for all care staff on the importance of nutritional
care appropriate to setting, profession and responsibilities
4) Ensure multidisciplinary structures to manage and monitor
nutritional care
...but we struggle to deliver
these reliably

95.  Reliability
is not
about what clinical care
should be given
 Reliability
is about the process
of ensuring patients get best care
consistently
„Every patient, every setting, every day‟

96. Local
Improvement:
Using standards and guidelines to drive quality
improvements in nutritional care
•Use the BAPEN toolkit which simplifies the plethora of
standards and guidelines for improving nutritional care
• Design systems based on the four tenets of nutritional
care
• Embed good nutritional care into everyday work flow
• Use evidence based tools and e-learning to support
front line staff
• Work across organisational boundaries to ensure
seamless nutritional care
• Ensure Trust Board Level engagement
•Identify a BAPEN rep in your organization

97. Royal Devon and Exeter
NHS Foundation Trust
have designed a highly
reliable electronic system
for nutrition screening
using ‘MUST’
MUST
Compliance
Mark Bellas
Divisional Lead Nurse
Critical Care/T&O

98. Trajectory Results Trust-wide
General Compliance with
MUST Screening at Weekly Review
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May10 10 10 10 10 10 10 10 10 10 10 10 11 11 11 11 11
Position
Target

99. Screening alone is not enough
Design
systems to
screen all
patients using
„MUST‟
Develop
individualised
nutritional
care plans
Design
reliable
systems to
deliver care
plans
Monitor
ongoing
nutritional
intake /
status

100. Now is the
time to deliver
good nutritional
care
in the UK to
deliver ‘harm
free’ and
eliminate
avoidable
pressure ulcers.
“You may never know what results come of your
action, but if you do nothing there will be no result”
Mahatma Gandhi

101. Student nurse
design for SSKIN
Charlotte Johnston
and student nurse
colleagues
University of Lincoln

102. #stopthepressurelincoln
#stopthepressure
SSKIN: For Students, BY Students.
University of Lincoln

103. S - Shadow
• Important to spend time shadowing a Tissue Viability Nurse:
- When do you need their expertise?
- Learn from their experiences.
- Your responsibility to arrange to spend an insight day with TVN’s
to supplement your university learning.
36. You must ensure any advice you give is evidence-based if
you are suggesting healthcare products or services.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013

104. S – Signs/Symptoms
• Understand and recognise the early signs of pressure ulcers or
potential/further damage:
- Start to form a care plan and ensure appropriate action is taken.
- To educate the patient and their families in ways to prevent
potential/further damage.
- Also improves patient-centred care – by improving nurse-patient
communication.
54. You must act immediately to put matters right if someone in
your care has suffered harm for any reason.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013

105. K - Knowledge
• As new guidelines are coming out, we know and understand how to apply
these in practice:
- Read, Read, READ!
- Challenge yourself and develop your own best methods of nursing
based on your own evidence-based research.
- Training doesn’t stop at the end of a module, end of the year or the
end of training.
40. You must keep your knowledge and skills up to date
throughout your working life.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013

106. I – Innovate/Implement
• If you have any ideas to improve practice, share it!
- If you observe something that could be improved on, go
and speak to your mentor/ward manager.
- Be the change you want to see.
22. You must work with colleagues to monitor the quality of
your work and maintain the safety of those in your care.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013

107. N - NMC
• Nurses are accountable for all action:
- NMC Code of Conduct: YOU, as students, are accountable
for all action/knowledge you have
- This is equally important for all healthcare professionals
regardless of level, branch or speciality.
Page 1: We exist to safeguard the health and
wellbeing of the public.
NMC UK, The Code of Conduct: Professional Standards for Nurses and Midwives, http://www.nmc-uk.org/Documents/Standards/The-code-A420100406.pdf Date Accessed: 07/10/2013

108. Change agents and
boat rockers
Video: Dr Helen Bevan
Introduced by
Lyn McIntyre
Deputy Nurse
Director, Midlands and

109. Ready, set -PLEDGE
Joe McCrea
Film maker and Strategic
Adviser
NHS Change Day

110. Lunch
……..and
pledge, pledge, pledg
e!

111. Tweets
Can we trend?
Lynnette Leman
Digital Communications
Officer
NHS Improving Quality

113. Unique individuals that received a
#stopthepressurelincoln tweet … 214,130
Total number of timeline deliveries… 1,610,570
Total number of tweets… 1,420

114. Stop the pressure
and nutrition:
interactive session
Lyn McIntyre
Deputy Nurse Director
Midlands and East
Andy Yeoman
Focus Active Learning

115. Pressure ulcer conference
Lincoln University
15th October 2013

116. Introduction
• Each table will play either;
- The Nutrition Game
or
- Stop The Pressure Game
• Games last for 30 minutes
• Each table splits into 2
teams

117. The Nutrition Game
• 1 board
• 1 set of question
cards (face down)
• 2 counters
• 2 dice
• 1 sand timer
• 1 “Pee chart”

118. Starting to play
• Place counters on
board
• Roll dice; highest
score starts
• First team roll dice
and move counter
• Land on square;
opposite team picks
up a question card

119. Answer questions
• Team answers
question (use timer)
• Correct answer
MOVE forward 2
squares
• Opposite team roll
dice and move
• Repeat as before

120. Up Straws & Down Carrots
• Land on the bottom
of a STRAW – move
UP
• Land on TOP of
carrot - move DOWN
• Do this before
answering a question

121. Winning
• Get to FINISH first
OR
• Closest to FINISH

122. Stop the Pressure Game
• 1 board
• 1 question pack
• 1 SSKIN question
pack
• 2 counters
• 1 dice
• 1 sand timer
• 10 SSKIN tokens

123. Stop the Pressure Game
• Place counter on
Start (green
square)
• Roll dice; highest
score starts
• First team roll dice
and move counter
• Land on square;
opposing team
reads out a
question

124. Stop the Pressure Game
• Team answers
question (use timer)
• Correct answer
MOVE 2 squares
• Opposing team roll
dice and move
• Repeat as before

125. Stop the Pressure Game
• Team LAND on an
SSKIN square
• Opposite TEAM picks
up a SSKIN question
card and reads out
the question

126. Stop the Pressure Game
• Correctly answer
WIN an SSKIN token
• TEAM places SSKIN
token on board

127. Stop the Pressure Game
• Correctly answer
WIN an SSKIN token
• TEAM places SSKIN
token on board
• Place SSKIN token on
board

128. Stop the Pressure Game
• Correctly answer
WIN an SSKIN token
• Place SSKIN token on
board
• Collect 5 tokens to
WIN
• Facilitators will help
and break up any
fights

129. Enjoy

130. www.stopthepressure.com

131. Making a difference
through practice led
pressure ulcer
research
Professor Jane Nixon
Deputy Director
Institute of Clinical Trials
Research
University of Leeds

132. Making a difference through practice led
pressure ulcer research
Jane Nixon PhD, MA, BSc(Hons) RGN
Professor of Tissue Viability and Clinical Trials Research
Clinical Trials Research Unit
School of Medicine
University of Leeds
© CTRU 2013

133. Impact of Pressure Ulcers on QOL
QOL Conceptual Framework
Symptoms
Physical
Functioning
Psychological
Well-being
Pain &
Discomfort
Mobility
Mood
Exudate
Daily
activities
Anxiety &
Worry
Odour
General
malaise
Self-efficacy &
Dependence
Sleep
© CTRU 2013
Social
Functioning
Appearance & selfconsciousness
Source: Gorecki, C et al
Isolation
Participation

134. UK world leading pressure ulcer prevention
clinical research
Critical mass Australia, Japan, Germany, the
Netherlands, Belgium and USA
UK has 4 fundamental ingredients
1. Nursing research agenda
2. Research funding through National Institute for Health Research
Large trials, Programme Grants, Research for Patient
Benefit , Fellowships
3. Clinical Research Networks – Research Nurse infrastructure
4. Clinical Trials Units/Methodologists
© CTRU 2013

135. Research areas/pathways- Leeds
Risk Factors
QOL
Living with a
PU
Pain
Living with PU
Severe Pu
Erythema
Imaging
Mattress
effectiveness
OR mattress
Case studies
Conceptual
Framework
Outcome
Measure
Development
QOL/Pain
systematic
reviews
Epidemiology
Risk Factor
Studies
Epidemiology
Prevalence
PUQOL Field
Testing
Epidemiology
Risk Factor
PUQOL
Instrument
Pain
assessment
and
management
© CTRU 2013
Systematic
review
Clinical
Practice – NHS
investigation
Clinical
Practice
Service
Development
HTA
Pressure
HTA
PRESSURE
2
Early phase
trial design
Risk
Assessment

136. Pain and pressure ulcers
Living with a pressure ulcer
Qualitative study
Patients reported pain preceding PU development and
said nurses ignored their concerns
Living with a pressure ulcer
QOL and Pain systematic reviews
Pain worst symptom of having a pressure ulcer. Pain
impacts upon quality of life and is not addressed by hcps
© CTRU 2013

137. Pain and pressure ulcers
Extent of pressure area related pain
Prevalence hospital and community populations
3397 hospital
patients, 15.9%
pressure area
pain
© CTRU 2013
287 community
patients with
PUs, 75.6%
reported pain
Severity not
related to PU
Category
Pain reported
on skin sites
with no PUs
Mix of
inflammatory
and
neuropathic
pain

138. Pain and pressure ulcers
Is pain important in predicting Category 2 PU development?
Cohort study hospital and community populations
30+
centres, 634
patients
analysis
population 602
.
© CTRU 2013
Variable
Presence of category 1 PU(yes vs no)
Odds Ratio
3.25
p-value
<0.0001
Presence of skin alterations(yes vs no)
1.98
0.0014
Presence of pain on a normal, altered or Category 1.56
1 skin site(yes vs no)
0.0931

139. Severe PU
•
•
Inquiry style study (Laming Inquiry, 2003)
Innovative retrospective case study design to examine
whole system failures
Results:
 Clinicians fail to listen to patients/carers
 Clinicians fail to assess risk/respond to superficial PUs
 Co-ordination failures
 Current practice of investigation
does not include patient account
and as a result there are gaps
© CTRU 2013

140. Risk Assessment
Which of your patients are at risk?
Multiple risk factors – which risk factors are most important?
Only 0.34% of hospital patient admissions will develop a pressure ulcer.
© CTRU 2013

141. PU Risk Factor Systematic Review
Research Question:
Which risk factors are
independently predictive
of PU development in
surgical, medical and
community-based
populations?
Result
15 Risk factor Domains
46 Sub-Domains
How useful is this for
clinical practice?
© CTRU 2013
Flow of studies:
5,462
5,097
Abstracts/papers
retrieved
Excluded – not
satisfying
eligibility criteria
365
311
Potentially
relevant, obtained
in full for further
scrutiny
Excluded – not
satisfying inclusion
criteria
Included
54 Studies
34 Prospective cohort
9 Record Review
11 RCTs

142. PU Risk Factor Systematic Review
Key Risk Factor Themes included:
 Immobility
 Skin condition
 Perfusion (including diabetes)
Less consistently emerging themes included:
Moisture
Body temperature
Nutrition
Age
Gender
Mental Status
Race
Sensory Perception
Medication
General Health Status
Haematological measures
© CTRU 2013

143. Risk Assessment Framework
Aim: to agree a pressure ulcer risk factor
minimum data set (MDS) to underpin the
development & validation of a risk assessment
framework (RAF) for use in clinical practice.
Phase 1
Development of
evidence base
Phase 2
Consensus study
Phase 3
Design & Pre-Test
PU Risk Factor
Systematic Review
to identify risk
factors
independently
predictive of PU
development
Agree:
- risk factors &
assessment items for
inclusion in draft risk
factor MDS & RAF
- Conceptual
framework
development
- RAF Design
- Assess & improve
acceptability, usabilit
y, format, design, cla
rity, comprehension
language & data
completeness of
draft RAF with
clinical nurses
Clinical
Pre-Clinical
© CTRU 2013
Pre-Clinical
Phase 4
Clinical Evaluation
- Evaluate
reliability, data
completeness, clinica
l usability, & validity
(convergent &
known groups) of
preliminary RAF
Clinical
Phase 5
Long-term
Implementation &
Clinical Evaluation
- Dissemination of
RAF into routine NHS
care
- Predictive Validity
testing
- Multivariable
modelling & revision
of RAF
Clinical

144. Consensus methods
Questionnaires
Face to face meetings
© CTRU 2013

145. Risk Factor Progression
15 Risk factor
domains & 46
sub-domains of the
systematic review
reduced to 26 risk factors
following initial expert
group meeting
1. Immobility
2. Existing PU
3. Previous PU
4. General skin status
5. Chronic wound
6. Friction & shear
7. Sensory Perception
8. Diabetes
9. Pitting oedema
10. Lowering BP
11. Smoking
12. Cardiovascular disease
13. Albumin
14. Haemoglobin
15. Skin moisture
16. Dual incontinence
17. Medication
18. Acute illness
19. Infection
20. Body Temp
21. General health status
22. Nutrition
23. Mental status
24. Race
25. Gender
26. Age
Cycle 1:
Risk factor premeeting
questionnaire
1. Immobility
2. Existing PU
3. Previous PU
4. General skin status
5. Diabetes
6. Nutrition
7. Sensory Perception
8. Dual incontinence
9. Skin Moisture
10. Acute Illness
11. Body Temp
12. Albumin
Cycle 1:
Risk factor postmeeting
questionnaire
1. Immobility
2. Existing PU
3. Previous PU
4. General skin status
5. Perfusion
6. Diabetes
7. Nutrition
8. Sensory Perception
9. Skin Moisture
10. Dual incontinence
11. Albumin
Cycle 2:
Minor Refinement
of Risk Factors
(incorporated in
pre-meeting
questionnaire)
1. Immobility
2. Existing PU
3. Previous PU
4. General skin
status
5. Perfusion
6. Diabetes
7. Nutrition
8. Sensory
Perception
9. Moisture
Risk Factors for
Screening & Full
Assessment
Stage of MDS
and RAF
Screening Stage
Immobility
PU Status (existing
& previous)
Full Assessment
Stage
Immobility
PU Status (existing
& previous)
General skin status
Perfusion
Diabetes
Sensory perception
Moisture
Nutrition

146. Initial draft of the RAF and underpinning MDS
© CTRU 2013

147. Pre-test - Focus Groups
© CTRU 2013

148. Take home messages
at your patients skin
Ask and listen to patients
Problem solve for complex patients

149. References
Pain
Briggs M, Collinson M, Wilson L, Rivers C, McGinnis E, Dealey C, Brown JM, Coleman SB, Stubbs N, Stevenson R, Nelson EA,
Nixon J (2013) The prevalence of pain at pressure areas and pressure ulcers in hospitalised patients BMC Nursing Vol 12 (1),
p19 http://www.biomedcentral.com/1472-6955/12/19
Stevenson R, Collinson M, Henderson V, Wilson L, Dealey C, McGinnis E, et al. The prevalence of pressure ulcers in
community settings: An observational study. International Journal of Nursing Studies 2013;DOI:
http://dx.doi.org/10.1016/j.ijnurstu.2013.04.001.
Gorecki C, Closs J, Nixon J, Briggs M. (2011) Pressure ulcer pain: a mixed method systematic review. Journal of Pain and
Symptom Management. Journal of Pain and Symptom Management Vol 42(3):443-59
Risk factors
Coleman S, Gorecki C, Nelson EA, Closs J, Defloor T, Halfens R, Farrin A, Brown JM, Schoonhoven L and Nixon J. Patient
Risk Factors for Pressure Ulcer Development: Systematic Review International Journal of Nursing Studies Vol 50 (7) p9741003 http://www.sciencedirect.com/science/article/pii/S002074891200421X
Nixon, J., Cranny, G. and Bond, S. (2007) Skin alterations of intact skin and risk factors associated with pressure ulcer
development in surgical patients. International Journal Nursing Studies Vol 44: 655-663
Nixon, J., Nelson, E. A., Cranny, G., Iglesias, C., Hawkins, K., Cullum, N., et al on behalf of the Pressure Trial Group. (2006)
Pressure Trial: Pressure RElieving Support SUrfaces: a Randomised Evaluation. Health Technol Assess Vol 10 (22).

150. References
QOL
Gorecki C, Brown JM, Cano S, Lamping DL, Briggs M, Coleman S, Dealey C, McGinnis E, Nelson EA, Stubbs N, Wilson L,
Nixon J (2013) Development and validation of a new patient-reported outcome measure for patients with pressure ulcers: The
PU-QOL instrument. Health & Quality of Life Outcomes, DOI: 10.1186/1477-7525-11-95
Gorecki C, Lamping D, Alvari Y, Brown J, Nixon J (2013) Patient-reported outcome measures for chronic wounds with
particular reference to pressure ulcer research: A systematic review. International Journal of Nursing Studies, DOI:
10.1616/j.ijnurstu.2013.03.004
Gorecki C, Nixon J, Madill A, Firth J, Brown JM (2012) What influences the impact of pressure ulcers on health-related quality
of life? A patient-focused exploration of contributory factors. Journal Tissue Viability Vol 21: 3-12
Gorecki C, Closs J, Nixon J, Briggs M. (2011) Pressure ulcer pain: a mixed method systematic review. Journal of Pain and
Symptom Management. Journal of Pain and Symptom Management Vol 42(3):443-59
Gorecki C, Lamping DL, Brown J, Madill A, Firth J, Nixon J. (2010) Development of a conceptual framework of health-related
quality of life in pressure ulcers: a patient-focused approach. International Journal of Nursing Studies, 47: 1525-1534.
Gorecki CA, Brown JM, Briggs M, Nixon J. (2010) Evaluation of five search strategies in retrieving qualitative patient-reported
electronic data on the impact of pressure ulcers on quality of life. Journal of Advanced Nursing, 66 (3): 645-652.
Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, Defloor T, and Nixon J on behalf of the European
Quality of Life Pressure Ulcer Project Group (2009). Impact of pressure ulcers on quality of life in older patients: a systematic
review JAGS 57: 1175-1183
Spilsbury K, Petherick E, Cullum N, Nelson EA, Nixon J and Mason S. (2008) The role and potential contribution of clinical
research nurses to clinical trials. Journal of Clinical Nursing 17 (4), 549–557.

151. Acknowledgement
PURSUN (Pressure UlceR Service User Network)
NIHR: This presentation presents independent research
funded by the National Institute for Health Research
(NIHR) under its Programme Grants for Applied
Research Programme (RP-PG-0407-10056). The views
expressed in this presentation are those of the author(s)
and not necessarily those of the NHS, the NIHR or the
Department of Health.
© CTRU 2013

152. Student Competition to be launched
Student Rate £35.00 per day

153. On the couch:
an interview
Video: Dr Helen Bevan
Introduced by
Charlotte Johnston
Student nurse
University of Lincoln

154. 6 c’s – aims, website
and Care Makers
Dr Ruth May
Chief Nurse NHS England
Midlands and East
and
Care Makers

155. Compassion in Practice
Progress and Developments
Presented by Ruth May
Regional Chief Nurse
NHS England (Midlands & East)
October 2013

156. The Nursing Narrative
156 NHS England | Ruth May | Twitter:
RMayNurseDir

157. The Keogh Review
•
A limited understanding of and failure to genuinely listen to patients and staff
•
The lack of value and support being given to frontline clinicians, particularly
junior nurses and doctors
•
More work needed at some trusts on issues such as reducing incidents of
pressure ulcers
•
Essential standards for staffing
157 NHS England | Ruth May | Twitter:
RMayNurseDir

158. Developing the culture of
compassionate care
158 NHS England | Ruth May |
RMayNurseDir

159. Our values and behaviours are at
the heart of the vision and all we do
Care
Compassion
Competence
Communication
Courage
Commitment
159 NHS England | Ruth May | Tw
itter:RMayNurseDir

160. Six Areas for Action
Helping people to stay
independent, maximising well-being
and improving health outcomes
Working with people to provide a
positive experience of care
Delivering high quality care and
measuring impact
Building and strengthening
leadership
Ensuring we have the right
staff, with the right skills in the right
place
Supporting positive staff
experience
160 NHS England | Ruth May |
RMayNurseDir

161. The children’s community nursing team at Cambridgeshire Community
Services NHS Trust has been announced as the winner of NHS
England’s 6C’s Live! September Story of the Month
161 NHS England | Ruth May |
RMayNurseDir
Catherine Ray, a senior sister at
Solihull Hospital, has been picked
as the first ever winner of NHS
England’s 6C’s Live! And Nursing
Times’ story of the month
competition

162. 162 NHS England | Ruth May | Twitter:
RMayNurseDir

163. What are Care Makers?
• We are looking for individuals who can be ambassadors for compassion in practice
and who can demonstrate and advocate the 6C’s in their practice
• Care makers are ambassadors for the 6C’s
• The first cohort of 55 Care Makers were recruited prior to the CNO Conference in
2012 of newly qualified nurses, student nurses, midwives, and healthcare assistants
• Principles for creating this network include
To inspire young people
A shared purpose to transform the NHS Culture in Nursing,
midwifery and care staff
To be advocates for compassion in practice
163 NHS England | Ruth May |
RMayNurseDir

164. How to become a Care Maker
• From mid-October applications can be downloaded from
http://www.nhsemployers.org/caremakers/Pages/How-do-I-become-a-caremaker.aspx
• Applications should be submitted, including a reference from an appropriate senior
representative, to caremakers@nhsemployers.org
• NHS Employers sift through applications into yes – queries to go to Region
• On a set day every month NHS Employers will send applications to regional nurses for
review with partner organisations if agreed
• Applications will be assessed against the definitions of the 6C’s
• We need to recruit 350 in the next round; the national target is 1000 by the end of
March 2014
164 NHS England | Ruth May | Twit
ter:RMayNurseDir

165. Tweets and Pledges:
how have we done?
Lynnette Leman
Digital Communications Officer
NHS Improving Quality
Joe McCrea
Film maker and Strategic Adviser
NHS Change Day

166. Wrap
up, thanks, reflections
on the day and looking
to the future
Professor Sara Owen and
Charlotte Johnston
University of Lincoln
Dr Ruth May and Lyn McIntyre
NHS England Midlands and East