Under Pressure…… by @fionacgreen

In November 2013 “Dave” was admitted to hospital following a hip fracture. Dave didn’t always like the food choices and at times found it difficult to drink enough. Several days into his admission his wife noticed a blister on his heel- she mentioned it to the ward team but felt she was dismissed.

By the time of his discharge from hospital Dave had an established ulcer that required regular input from the community nursing team and podiatry.

In June 2014 Dave was admitted to hospital again. The fact that he had already one pressure sore, combined with diabetes meant that he was at high risk of developing further pressure sores and this time he left with a further two pressure sores.

Further prolonged admissions followed to treat deep-seated infection of bone resulting from the presence of pressure sores and ultimately surgical debridement and vascular intervention was required to aid the healing process. With each further admission Dave and his wife became increasingly terrified of what might happen and worried that he may leave with further pressure sores. Last year Dave spent his wife’s birthday, Christmas and New Year in hospital and throughout was visited daily by his wife -it is clear from his story the human impact of developing pressure ulcers

Dave and his wife have given their permission to share their story in the hope that we can begin to learn how important it is that we work together to prevent

pressure ulcers

Lesson one -Prevention is better than cure.

Each year 700,000 people in the UK develop pressure ulcers. Each pressure ulcer adds approximately £ 4000 to the cost of care. It has been suggested that 80-95% of pressure ulcers may be avoidable. Sometimes in healthcare as we concentrate our efforts on the complicated and exciting new developments that come our way we can lose sight of the simple things that can make a huge difference to the outcomes for our patients. By paying attention to early detection of risk, encouraging patients to keep as mobile as possible, addressing incontinence appropriately and by improving hydration and nutrition we can make steps to reduce the risk of pressure ulcers developing.

FG 1

Preventing Pressure Ulcers- the CPR approach

1 Check and identify problems early– this means that socks, TED stockings, and dressings must be removed to allow the pressure areas to be properly visualised

2 Protect – if pressure areas are at risk encourage regular changes in position, consider a pressure relieving mattress and apply REPOSE heel splints or Sundance Z-flex boots to relieve pressure. These are available locally by ordering through the PECOS system.

3 Refer – it is never too early to refer to the podiatry team if you have concerns

Repose Heel protectors and Sundance Z-Flex protectors

FG 2

FG 3FG 4If you want make sure you are skilled in the CPR approach to pressure ulcer prevention you can like me complete a short and practical e-learning module available on the NHS Learnpro site ( you’ll be pleased to see that I passed!)

 

Lesson 2- Improving Patient Experience/reducing harm/ improving financial efficiency

Sadly Dave’s story is one of many but so clearly illustrates that developing a pressure ulcer is an important physical harm that also impacts significantly on the healthcare experience of the patient and their family. Pressure ulcers are not just a huge burden to the patient and their family but also to the NHS and its staff as a consequence of prolonged hospital admissions and ongoing intense community treatment that may be required to heal the pressure ulcer. In Dave’s case listening to his wife’s concerns and making sure that he was eating and drinking well may have helped to prevent the prolonged and costly treatment that followed

Lesson 3 Changing Practice

Over the last few years we have all found ourselves under increasing pressure in the NHS. Some of these pressures relate to our desire to reduce harm, improve our patient’s experience of care, and finally to make financial efficiency savings.

People who come into hospital are also under pressure- they are in a frightening and alien environment and their illness may make it difficult to eat, difficult to maintain hydration and difficult to keep mobile. These factors are all important in the development of pressure ulcers. In Dumfries and Galloway we have begun work to accurately record the numbers of pressure ulcers acquired and we implemented a risk assessment pathway incorporating the elements of the ACTIVE PATIENT CARE bundle, Waterlow score and NATVNS pressure ulcer recording tool on pilot wards. Work is currently ongoing to spread these practices throughout the acute sites and the community

FG 5

21st November 2015 marks worldwide STOP PRESSURE ULCER day- Following on from Dr Bell’s blog last week this is one aspiration that we cannot afford to give up on

Dr Fiona Green is a Consultant Physician and Diabetologist and Clinical Lead for Pressure Ulcer workstream

 

 

7 thoughts on “Under Pressure…… by @fionacgreen

  1. Thank you, Fiona. The NHS is a pretty hierarchecal organisation and the patient and their relatives may be seen to be at the very “bottom” of the hierarchy. But we know that steep hierarchies are anathema to patient safety. So the idea of a real partnership with the patient and their relatives is so important. Within the staff group itself, we have to get away from the HIPPO phenomenon- the Highest Paid Person’s Opinion counts the most. People at all levels of the staff hierarchy have very crucial contributions to make in terms of ideas about improvements to our service.

  2. Whatever happened to basic nursing care? I trained in the days when there were 2 hourly pressure sore rounds where we turned patients, rubbed their backs and heels with various creams or powders and checked their skin condition. Not rocket science! Developing pressure sores were considered a real nursing care failure.Too few nursing staff and too much paperwork causes a negative impact.

    • You echo my thoughts exactly! As an about to retire nurse I too trained in the days of the “back round ” as we called it. ” a 2 hourly check made on all patients concentrating on those who were bed bound and immobile, all presssure points checked, positions changed fluids administered to those who needed help.

    • This is a great reminder of the fundamentals of care. But we didn’t have it right all those years ago either. 24 years ago this was recognised as a problem in D&G and started the pressure sore group, now the tissue viability group. I remember as I wrote the draft report when on Mat leave!) I am in infection control now because of my experiences with infected pressure ulcers. It is right they should be seen as a ‘never’ event and simple things like movement and hydration do help, the rubbing on of creams and powders or even egg white and oxygen didn’t.

      Most importantly we need to listen to concerns and treat the person with those concerns with respect.

  3. Excellent reading Fiona,i agre so much on focussing on the ‘simple’ things in improving outcomes.We need to concentrate on nursing care,…

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