District nurses at East Coast Community CIC, a social enterprise providing community care across Norfolk and Waveney, flagged high numbers of referrals for suspected skin tears in local care homes. The Tissue Viability team, including a specialist tissue viability nurse and three Assistant Practitioners (APs), then led a structured change to address the unwarranted variation identified in referral practice and capabilities of care home staff to treat skin tears – including providing training for care home staff.
Where to look
The Tissue Viability team identified unwarranted variation in the referrals process. Some care homes in their area referred much more frequently than others, which indicated a possible issue with their understanding of good skin care, what is a skin tear, risk factors, how they occur, and how to manage a resident with a skin tear. Carers would often seek a visit for a ‘skin tear’ which turned out not to need specialist intervention. This highlighted a need to address how skin tears were managed within the care home environment.
What to change
The literature and evidence suggest that active care of an older person’s skin, including applying emollients and the ability to identify those at high risk, can reduce the likelihood of skin tears. The registered nurses identified that carers were unclear or hadn’t had exposure to which dressing needed to be used for different skin tears. There was also a need to streamline the referral process according to the severity of the skin trauma, at the same time as enhancing care home staff’s understanding of how to identify good skin care and to address poor skin care.
How to change
The Tissue Viability team started by considering if care homes were well equipped to apply an initial dressing for a resident with a skin tear and provide safe practice. They reviewed the local wound dressing formulary – identifying which dressings were easy to apply, could be left in place for seven days, and could be assessed by district nurses without removal.
The Tissue Viability team created an evidence-based education package to promote skin integrity, prevent tears and explain the care pathway. The pathway for the care homes had to ensure the patients would have safe care and include when to refer or escalate to other services. This included guidance on when to refer to emergency care or the district nursing service.
The educational session included explanation on how to care for the older person’s skin, how to realign a skin tear, apply the dressing and complete paperwork for scanning onto patients’ electronic records as well as more practical aspects of how to manage a tear. The skin tear pathway was also fully explained and provided to all care home staff.
Three care homes were identified to pilot the skin tear pathway for three months and improvements in skin tear management and understanding of the referral process were identified. All three sites in the pilot welcomed a wider roll-out and continued adherence to the pathway.
The training and pathway is now being rolled out to all other local care homes and district nursing teams, and will begin to include Health Care Assistants and Assistant Practitioners (APs) providing care to patients at home. There has been a request from a neighbouring Clinical Commissioning Group (CCG) for a similar programme.
To continue to evaluate this pathway whilst it is being embedded in practice, the APs and nursing team are using an audit tool to review skin tear outcomes and how well the pathway is being followed, paired with a qualitative questionnaire to review carers’ experience of the training and pathway.
- Better outcomes – The number of skin tears requiring escalation for specialist care have reduced in the pilot care home(s) and healing rates for such injuries have improved. As a result of following the pathway, 2 of the 26 residents in the pilot were found not have a skin tear, following review by the District Nursing team. Twenty four residents had the correct wound care dressing applied, leading to improved healing rates.
- Better experience – Care staff are identifying possible skin tears earlier because they have more comprehensive education in how to identify a skin tear and subsequently manage it appropriately. All of the carers responding to the evaluation survey agreed or strongly agreed that the training objectives had been met. They expressed satisfaction with the improved healing of residents’ skin tears. Use of the right dressing has reduced pain and trauma for residents.
- Better use of resources – The district nursing team are receiving fewer requests for a same-day visit and skin tear ‘false alarms’. In the evaluation period, of the visit requests from the pilot care homes, the District Nursing team received only one same-day visit request, for a skin tear that remained beyond the capabilities of the care home. This reduced the same-day visits by 25. As a result of the skin tears pathway, a noticeable reduction in variation in the use of the first dressing is apparent.
Challenges and lessons learnt for implementation
- Education was the key to success, including responding to requests for advice and being available to discuss skin tears throughout the transition and implementation of the skin tears pathway.
- It was difficult to establish a pre-pilot baseline due to a lack of a UK Read Code for a skin tear in the patient electronic dataset.
- During the development of the pathway and training, a lot of consideration was given to ensuring carers’ understanding and residents’ safety.
- It was important to involve all stakeholders, and to complete a small-scale pilot that could be reviewed, audited and then changed as necessary. The Tissue Viability team are building additional quantifiable measures to ensure they can further evidence the outcomes of the changes made.
- The East Ambulance Trust are also now using the skin tear audit tool to review adherence to the pathway and skin tear outcomes continuing the roll out of the pathway.
Watch the prevention and management of skin tears in residential homes video
This video features Tissue Viability team of East Coast Community Healthcare and how they identified unwarranted variation with a high level of requests for same day visits for residents in care homes with reported skin tears:
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Tissue Viability Specialist Nurse