Reducing the incidence of pressure sores and shearing damage for bed-bound individuals

MHANZ 23rd March 2012

Melanie Sturman-Floyd, MSc, RGN.Moving and Handling Consultant

What are pressure ulcers and shearing damage?

• A pressure sore/decubitus ulcer is a local injury to the skin or underlying tissue over a bony prominence, caused by prolonged, sustained pressure.

• Shearing damage is caused by pulling/tearing of the tissue.

Pressure and Shear

Pressure – presses tissue together

Shear – pulls/tear tissue

Shear and friction – cause pressure sores

Blood vessel

Shear between skin layers

Skin layer 3 (dermis)Skin layer 2 (cutis)

Skin layer 1 (epidermis)

Why does the pressure damage occur?

• Poor Nutrition• Dehydration• Poor Circulation• Incontinence• Old Age• Immobility• Insufficient Moving/Turning in Bed, Chair or Wheelchair• Poor Moving and Handling Techniques • Unsuitable Mattress

Common Pressure Ulcer Sites

• The areas most effected are:

• Back of heels

• Sacrum

• Sometimes scapula area

• Hip, when the patient is lying in the foetal position.

Pressure Ulcer Classification Grade 1.European Pressure Ulcer Advisory Panel. Pressure Ulcer

Treatment Guidelines

Non-blanchable erythema (redness) of intact skin.Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.

Pressure Ulcer Classification grade 2

• Partial thickness skin loss involving epidermis, dermis, or both.

• The ulcer is superficial and presents clinically as an abrasion or blister.

Pressure Ulcer Classification Grade 3

• Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.

Pressure Ulcer Classification Grade 4

• Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss.

In which environments do pressure sores occur?

• 20 % service users in acute care (large hospitals)

• 30 % people in community (own home and community hospitals)

• 20 % people in nursing/residential homes

The annual cost of pressure ulcers in the UK

References:

Bennett G., Dealey C. & Posnett J. The cost of pressure ulcers in the UK. Age and Ageing. 2004; 33(3): 217-218.

Vanderwee K, Clark M, Dealey C et al. (2007). Pressure ulcer prevalence in Europe: a pilot study. Journal of Evaluation in Clinical Practice. 13(2):227-235.

Phillips L, Buttery J Exploring pressure ulcer prevalence and preventative care. [Journal Article] Nursing Times 2009 Apr 28-May 4; 105(16):34-6.

EPUAP (2009) European Pressure Ulcer Advisory Panel. EPUAP Review 2009; 10(1):1-28.

The cost is 1.4 -2.1 billion/year = Mental Health orCommunity Health Services Budget

The cost per service user ranges between £11k – £40k

Section A: Total number of pressure ulcers                  

 

How many pressure ulcers does your organisation treat? (enter a number and press ENTER)

  350 

       

                 

Section B: Pressure ulcers by grade                  

 

How many pressure ulcers of each grade does your organisation treat?

Grade 1 122         

  Grade 2 144  

     

            Grade 3 45         

The default numbers are based on percentages Grade 4 39         

from the academic research study. Please overwrite              

if you are confident your numbers are different. Total 350  (Total of section B must be the )  

               same as the number in section A)  

Section C: Results: Estimated cost of pressure ulcer care at 2008/09 prices    

(rounded to the nearest thousand £s)                  

  Central estimate  Lower range   Higher range     

                       

Grade 1 177,000   143,000   214,000      

                         

Grade 2 862,000   699,000   1,044,000      

                         

Grade 3 449,000   363,000   543,000      

                         

Grade 4 552,000   447,000   668,000      

                         

Total 2,040,000   1,652,000   2,469,000      

                         

Section D: Potential savings if the number of pressure ulcers is reduced            

                         

  Enter a planned percentage reduction                

  in the green box, to see the impact on                

  number of ulcers, and cost pressures:  

A reduction of 25% in pressure ulcers would mean 88 fewer pressure ulcers and a potential cost saving of £510k

   

      25%      

               

                         

                         

                         

Pressure ulcer productivity calculator

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_116669

How can pressure damage be reduced?

• Activate the Service User when Possible• Improved Nutrition and Hydration• Pressure Relieving Mattresses and Cushions• Improved Standard of M/H Equipment• Reduce friction and shearing with equipment and

manual handling techniques.• Well-Trained Staff• Change position regularly.

Preventative approach – Cost-benefits

• Activate service user whenever possible• Work with minimal force• Reduce carer’s injuries• Reduce cost of care

Reducing the incidence and risk of pressure sores and shearing damage for bed-bound individuals.

•An equipment evaluation conducted by: •Melanie Sturman-Floyd MSc RGN•Norfolk County Council & MSF Manual Handling & BackCare •www.manualhandlingconsultancy.co.uk

The Thesis

“Does leaving a leave in bed positioning system under a person lying in bed exacerbate or increase the incidence of pressure ulcers?”

• Other questions asked.

“Does leaving a leave in bed positioning system reduce the number of carers for moving and handling tasks?”

“Does leaving a leave in bed positioning system increase patient comfort?”

Study Inclusion

• 110 clients evaluated.• Criteria for inclusion, predominately

bedbound, tissue viability mattress.• Require assistance with moving and

handling activities.• Support provided by family or employed

handler.

Introduction of equipment.

• Balance between managing manual handling risks and pressure ulcer incidence.

• Discussed with Tissue Viability Nurse.• No previous research.• Wendy Lett systems introduced.• Record types of tissue viability mattresses used.• At start of trial record pressure ulcer incidence.• At start of trial record number of patient handlers.• At start of trial measure and record handler

perceived rate of exertion.

Findings

• Pressure ulcer incidence – start of trial 79 clients had pressure ulcers,

• Grades Start 6 weeks 12 weeks• Grade 1 25 5 2• Grade 2 3 2 1• Grade 3 2 2 0• Grade 4 1 1 0

Projected costs of pressure ulcer management for N79 at start £88,000 and at end of study £9,000.

Reducing handler costs and manual handling injuries

• Reducing carer costs• Introducing system enabled a reduction of carers for 28 clients. Cost

at start of trial £711,349, Cost at end of study was £422,276.

• Reducing manual handling injuries• 232 carers were asked to rate perceived rate of exertion, at start of

trial range was 14-17, (high risk). Changing technique and introducing the leave in systems reduced range to 5-9, (low risk).

• Using systems with bariatric clients – reduces manual handling effort from positioning slide sheets.

• Using systems with clients who have complex behavioural needs – reduces challenging behaviour.

• Increased patient comfort and facilitated transfers/independence.