Stop the Pressure in community nursing: taking the role of carers seriously

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Tissue Viability Nurse and Pressure Ulcer Prevention Project lead, Siobhan McCoulough, explains how some simple steps have led to a reduction in pressure ulcers in Hounslow and Richmond Community Healthcare NHS Trust.

How treating pressure ulcers in community care differs to hospital care treatment

Much of the work and advances in pressure ulcer prevention has been focused on hospital care where round the clock nursing presence allows regular monitoring and turning. 

In community care, we don’t have this capacity; we don’t do daily skin inspections. As a result of this the SSKIN 5 simple steps to prevent and treat pressure ulcers guide, an integral part of the Stop the Pressure campaign, hasn’t been easy to adapt. 

To develop a community approach, I looked at work from Coventry and Warwickshire Partnership NHS trust and from my research identified that it can take only 20 minutes for a pressure ulcer to take hold. In the community, it is not nurses but carers who do most of the skin care so the key to improvement is how we engage carers, how we access them, and teach them to be able to identify early stage pressure damage.

Local challenges

In my part of North West London, many of the carers, whether relatives or employed carers, do not speak good English which makes it more difficult to engage with them. 

To counter this challenge, I developed a visual poster prompt. On the same model as the nationally recognised community meningitis campaign, this visual prompt made it easier to demonstrate the steps carers need to take to identify and monitor skin pressure.  

We then developed a community engagement programme to support carers. This included setting up carers champions and focus groups which looked at the issues of prevention. From the feedback, it was identified that there was very little understanding of the causes and how to identify pressure ulcers. We also surveyed a leading care agency (we received a 100% return rate) and it was clear that informal and formal carers wanted and needed training.

There has been a CQUIN for offering this training to nursing homes only, however, I currently have a business case for joint commissioning (CCG and local authority) of an internally accredited training for domiciliary carers, and to note that joint commissioning for prevention comes under the Five Year Forward View, alongside 2015 NICE quality indicators for pressure ulcers.

visual poster for identifying pressure ulcers

Visual prompt poster for identifying pressure ulcers.

The results: what level of reduction has been made

In one 3 month period in 2015, we achieved a 14% reduction in grade 2 ulcers, 30% in grade 3, and 50% in grade 4. Our evaluation has demonstrated a strong link to our carers engagement, training and awareness programme. This needs to be sustained however if it is to continue each year due to the turnover of care staff. 

It is not just a quality issue, but also delivers substantial savings in terms of avoiding costly more acute care. A 20% reduction saves £250,000 in my area of London over a two year period. 

Training carers is a patient safety standard

I saw a patient last week, whose wife is the main carer. They hadn’t really had any contact with any services apart from their GP.  When I was called in, there was already a significant Grade 3 pressure ulcer on his heel which was infected. We are now training his wife who checks the skin daily, and she told me that if she had known, she would have called the nurse sooner. 

The work my pressure ulcer multi-disciplinary team has done in Hounslow and Richmond won a European Pressure Ulcers Advisory Panel award last year.  It was great for the team to get this recognition, but my message is that it is relatively straight forward but committed work. It is not always the great set piece medical breakthroughs which can lead to significant improvements in patient care. 

Siobhan McCoulough (second from left) and her pressure ulcer prevention project team with their award at the ceremony in Belgium.

Siobhan McCoulough (second from left) and her pressure ulcer prevention project team with their award at the ceremony in Belgium.

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