Leading change

A Tissue Viability Team at Bassetlaw Clinical Commissioning Group (CCG) led the development of the ‘React to Red’ resource to support the prevention of pressure ulcers in care homes and the community. This resource and programme of work has significantly improved outcomes, experience and use of resources.

Where to look

The Department of Health (2018) pressure ulcer guidance identifies that a pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence. The 4 main factors implicated are interface pressure, shear, friction, and moisture. Pressure ulcers can range in severity from patches of discoloured skin to open wounds that expose the underlying bone or muscle. NICE (2018) supports this by reporting that pressure ulcers are caused when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply. Typically, they occur in a person confined to bed or a chair by an illness and as a result they are sometimes referred to as ‘bedsores’, or ‘pressure sores’. NHS Improvement (2018) highlight that pressure ulcers can affect anyone from newborns to those at the end of life. Pressure ulcers can cause significant pain and distress for patients and can contribute to longer stays in hospital, increasing the risk of complications, including infection and they also cost the NHS in the region of more than £1.4 million every day. Many pressure ulcers are avoidable if simple knowledge is provided and preventative best practice is followed.

As part of pro-active responses to pressure ulcer developments within community services commissioned locally, the Tissue Viability nursing team at Bassetlaw CCG identified a higher than expected number of care home-acquired pressure ulcers developing. By recognising this unwarranted variation in practice, the Tissue Viability Team saw an opportunity for quality improvement, to improve outcomes of those using services locally as well as well as nationally through shared learning.

What to change

NHS Bassetlaw CCG is a member organisation consisting of 12 GP practices across Bassetlaw. The CCG is committed to working with its partners and patients and the public to improve the commissioning of services within available resources to deliver the greatest benefit for the people of Bassetlaw in terms of health outcomes and value for money for the tax payer. In April 2013 the CCG become a Statutory NHS body taking on full responsibility for the commissioning of health services for the people of Bassetlaw.

The CCG’s Chief Nurse met with families and residents affected by pressure ulcers, as well as care home staff, to identify the root causes of the ulcers as well as identify any learning to support improvements moving forwards. The findings suggested that unlike acute service staff, care home staff were not being supported or equipped appropriately with the knowledge and skills to take steps to prevent pressure ulcers from developing or support residents to minimise their risk of developing sores.

Care home staff reported to have minimal access to pressure ulcer prevention education and training. Service pressures frequently meant they could not be released to access this which was compounded by a lack of local provision of this for them to access.

To gain a deeper understanding tissue viability nurses undertook a scoping exercise with 28 care homes within Bassetlaw CCG and found that 47% of staff reported that had not had any pressure ulcer prevention training. Of those that had, many said it had been many years before, some had been shown by another carer and some said they had looked at resources online. Morale amongst care home staff appeared low, and many staff recognised that their practices were not evidence based, while they wanted to do what was best for their residents.

How to change

As a result of the scoping exercise and feedback from relatives, the dedicated Tissue Viability team for care homes was commissioned to provide support, education and training to all 28 care homes in the region.

Initially this team scoped the learning needs of all 28 care home staff and analysed pressure ulcer prevalence data available, to establish which homes to prioritise. Whilst initially concentrating on pressure ulcers, it was also apparently that other skin damage was also evident as at times staff were not recognising early skin damage and therefore early intervention and prevention was not occurring effectively. This led the team to consider the need to provide education and support more widely than how to manage pressure ulcer care and focus on a more holistic proactive and preventative approach to skin care.

The Tissue Viability Nurses developed a ‘Link Champion’ network across all 28 care homes where staff were identified from each home who attended regular network meetings to increase their knowledge, gained updates, received support and channelled this information and best practice back to their respective homes. An education and training programme was developed and rolled out across the prioritised care homes by the nursing leads. Although the training was welcomed following the initial training it became apparent that due to high demand, the level of training the Tissue Viability team were delivering could not be sustained, and they looked to develop a bespoke care home training resource package to support this more widely. This resource was called ‘React to Red’ and link champions could use this to cascade the learning across their care homes and support them to develop at their own pace, taking ownerships and leading improvements within their homes with the support of the evidence bases.

The React to Red resource contains a training DVD, competencies, a patient leaflet and poster and advice from the specialist continence service. The aim of the resource is to provide the knowledge and skills required for care home staff to feel confident in identifying, preventing and managing moisture lesions. Although primarily aimed at care homes, it is transferable to any health care setting. The resource was successfully rolled out across the Bassetlaw area and following this has been rolled out nationally across the country. The Tissue Viability team was also made permanent when the evidence demonstrated the cost effectiveness of the service.

Similar resources have been developed by the Trust in a ‘React to’ series, including ‘React to Moisture’, ‘React to Falls’ and ‘React to Feet’. These are aimed at care home staff but are also relevant to other carers and healthcare professionals and have been rolled out widely across the locality.

To support these resources the Care Home Achievement Success Event (CHASE) annual awards for React to Red have been set up in Bassetlaw to recognise care home staff achievements, which has been a huge motivator to care staff in the area.

Adding value

Better outcomes – Since the start of the initiative to November 2017 there has been an 87% reduction in avoidable pressure ulcers in the targeted care homes. There has also been an 85% reduction in pressure ulcers deemed avoidable in community services and anecdotally pressure ulcers are much smaller in size and severity. When the initiative first started there were 9 care homes that had 0% care home acquired pressure ulcers in a year, and within two years this rose to 22 homes. A change in practice has been seen of all clinicians as the approach that pressure ulcer prevention is everyone’s business has been taken.

Better experience – Staff morale has improved following the training and they report feeling confident to support residents to maximise their skin health and prevent pressure ulcers occurring. Feedback from care home staff includes:

“The reality is that many pressure ulcers are avoidable if simple knowledge is provided and preventative best practice is followed. That’s what the Tissue Viability team at Bassetlaw achieved, which is a great success and we are proud to be part of it”.

“Although we are all working towards zero preventable pressure ulcers the CHASE awards add an individual incentive…the awards give our staff an opportunity to shine. The whole focus of the awards is about the hard work and dedication of our most valuable resource -care staff and nurses. When our staff see the awards displayed, they know they are part of that achievement.”

Better use of resources – As well as reducing distress for residents, the avoidance of pressure ulcers has also reduced use and cost of dressings, with associated saved nursing time that would have previously been spent treating these. There is 100% competence amongst link champions, and evidence shows that React to Red and React to Moisture is now firmly embedded as part of new starters mandatory training. This has led to other common problems being addressed impacting on hospital admission avoidance, quality of life and financial savings. There is also clear evidence of improving leadership skills within the care home sector as a result of support from the Tissue Viability Team.

Challenges and lessons learnt for implementation

It was important to ensure resources are bespoke to the complex needs of care home settings and the staff who work within them so that differing levels of knowledge and understanding could be catered for. Challenges associated with high turnover of staff has been felt as part of this programme which meant that sustaining learning was difficult at times. By working alongside care home staff and encouraging them, sharing their learning, recognising their achievements and listening to their challenges, this supported maintaining momentum and their desire to improve continued.

For more information contact

Karen McEwan
Quality Improvement Matron
Nottingham Healthcare NHS Foundation Trust
karen.mcewan2@nhs.net