Queen Elizabeth Hospital BirminghamPart of University Hospitals Birmingham

NHS Foundation Trust

Table 1 – Summary of results

Patient Ulcer Estimated Actual Debridementnumber location category category time

before afterdebridement debridement

1 pannus 3 3 2min

2 heel 3 3 1min

3 neck 3 2 1min 20sec

4 buttock 3 2 1min 15sec

5 hip 3 2 2min

6 penis 3 2 1min

7 chest 3 2 1min 30sec

8 sacrum 3 2 55 sec

9 buttock 3 3 2min

10 hip 3 3 2min

11 penis 3 2 2min 30 sec

12 left buttock 3 3 4min

13 right buttock 3 2 1min

Table 2

Category 3 and 4 hospital acquired pressure ulcer verified by Tissue Viability Service (TVS) who ensure Incident Reporting Form is completed by ward staff

Commissioners notified and involvement of Risk and Compliance unit

Root Cause Analysis completed by matron/unit manager

Duty of Candour discussion with patient/relative/carer

Documentation sent to Assistant Director of Nursing for approval

Documentation sent to Deputy Chief Nurse for approval

Action plan to the commissioners

Serious Incident Reporting Incident findings reported back topatient/family/carer

Debridement using a monofi lament fi bre pad* to

aid in the accurate categorisation of pressure ulcerJoanna Swan - Lead Tissue Viability Nurse and Rommel Orig - Tissue Viability Nurse, Queen Elizabeth Hospital Birmingham NHS Foundation Trust, UK

Introduction

Within the authors’ Trust and across the UK, accurate catagorisation of pressure ulcers has become crucial. Many UK organisations implement complex documentation and a root cause analysis when a category 3 pressure ulcer is identifi ed. The European Pressure Ulcer Advisory Panel (1) state that a category 3 pressure ulcer can contain the devitilised tissue slough, where a category 2 pressure ulcer does not.

Less experienced clinicians often categorise pressure ulcers that contain a yellow material as category 3, despite this material not being slough. For experienced clinicians some pressure ulcers that contain slough may not present as having full thickness dermal loss and therefore they question category 3 damage.

A more experienced clinician can identify these ulcers as being superfi cial in nature. Callaghan and Stephen-Haynes (2) found that when their community nurses used a monofi lament fi bre pad as part of the assessment process, they found that in 11 out of 12 cases it helped them to more accurately categorise the pressure ulcer.

Methods

Patients in an acute hospital setting were selected when the category of pressure ulcer was not clear between a category 2 and 3 and where debridement was required to assist in the categorisation process.

Debridement was facilitated by using a monofi lament pad* - as it has been reported to be a quick, simple, effective method of debridement, causing virtually no pain to the patient (3, 4).

Data was collected on a specially designed data collection form. Any imaging was taken using either digital or the Eykona 3D camera system to assist the measurement process and add accuracy and objectivity.

Results

Data on 13 patients has been collected to date and the results are summarised in Table 1.

Debridement with the monofi lament pad revealed a more superfi cial pressure ulcer in 61.5% of cases.

No more than 4 minutes of debridement was required to reveal the actual wound bed in 80% of cases.

Debridement was prematurely discontinued in 2 cases as the patients experienced heightened anxiety due to their anxiety disorders and not the monofi lament fi bre pad.

Pressure ulcers containing thicker and more tenacious slough are not suitable for a quick, one off debridement treatment with the monofi lament pad, but may respond to a number of consecutive treatments.

The monofi lament pad proved to be a very quick and easy to use debridement technique, ideal to assist pressure ulcer wound assessment at the bedside and reinforces recommendations made in the EWMA debridement document (4) which recognises that this new form of mechanical debridement is the fastest method available.

The authors are not aware of any other product that would allow this rapidassessment to take place at the bedside.

Discussion

The use of a monofi lament pad in the debridement of pressure ulcers with superfi cial slough provides clinicians with a clear view of the wound bed. This allows accurate categorisation and, therefore, the ability to provide safe and appropriate patient care.

It is the view of the authors that pressure ulcer categorisation should be based on an assessment of the depth of damage and not tissue type. When the wound bed is obscured by devitalised tissue this can be very diffi cult.

This small study has identifi ed considerable potential for cost savings by using the monofi lament debridement pad at the bedside. They include:• effective use of resources such as pressure relieving equipment based on pressure ulcer category and the level of caregiver i.e. generalist or Tissue Viability Nurse• time savings for Tissue Viability and ward nurses by not having to record as a serious incident that requires investigating – outlined in Table 2• faster wound healing progression by rapid removal of devitalised tissue

Confl ict of Interest

The monofi lament pads and the Eykona camera were provided by Activa Healthcare.

Patient

number

Ulcer

location

Estimated

category

before

debridement

Actual

category

after

debridement

Debridement

time

1 pannus 3 3 2min

2 heel 3 3 1min

3 neck 3 2 1min 20sec

4 buttock 3 2 1min 15sec

5 hip 3 2 2min

6 penis 3 2 1min

7 chest 3 2 1min 30sec

8 sacrum 3 2 55 sec

9 buttock 3 3 2min

10 hip 3 3 2min

11 penis 3 2 2min 30sec

12 left buttock 3 3 4min

13 right buttock 3 2 1min

Patient 7A 91 year old female who fell from her

armchair at home fracturing her shoulder and injuring her neck. She sustained

device-related pressure damage to her rightclavicle from the hard collar she wore.

The pressure ulcer contained slough and was categorised as a 3.

Patient 8A 58 year old male who was very ill following

a heart transplant, and had previously hadsuffered a myocardial infarction and was

severely malnourished. He developedhospital acquired sacral pressure damagewhich was covered with a stringy yellow

material and was categorised as a 3.

Patient 4An 83 year old lady who was admitted

with difficulty in breathing and possible heartfailure. On admission she was noted to have a lightly sloughy category 3 pressure ulcer

to buttock.

Before treatment with the monofilamentdebridement pad.

After 1 minute 15 seconds of treatment with the monofilament debridement pad.

Patient 6A 44 year old man who had suffered a headinjury following an assault. Known to be an

alcoholic and suffer from depression. A category 3 pressure ulcer developed as a result of incorrect catheter positioning.

Before treatment with the monofilamentdebridement pad.

After 1 minute of treatment with themonofilament debridement pad.

* Debrisoft – Activa Healthcare EPUAP 2013 Vienna, Austria, 28-30 August

References1. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel. Pressure Ulcer Treatment:

Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel. 20092. Callaghan R, Stephen-Haynes J. Changing the face of debridement in pressure ulcers. Poster presentation.

EPUAP, Cardiff, UK, 20123. Bahr S et al. Clinical efficiency of a new monofilament fibre-containing wound debridement product.

Journal of Wound Care. 20: 242-8, 20114. Strohal, R., Apelqvist, J., Dissemond, J.,et al. EWMA Document: Debridement. J Wound Care. 2013; 22 (suppl.): S1-S52

Zoom (pre-debridement)

Zoom (pre-debridement with measurement)

Zoom (post-debridement)

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Tracking page Tracking page

Patient 8Pre-debridement Post-debridement

Red 67 100Pink 0 0Yellow 33 0Black 0 0

Patient 7Pre-debridement Post-debridement

Red 57 100Pink 14 0Yellow 29 0Black 0 0