This project addressed the unacceptable level and duration of avoidable skin breakdown in frail elderly people, by improving the skills of the workforce who support these people in the assessment and management of skin integrity and tissue viability. In 2014, the programme was recognised for a national HSJ award in the patient safety category.
The skin is one of the biggest and most complex organs of the body, and contains hair follicles, oil glands, sweat glands, nerves and blood vessels. As the skin ages, the dermis and epidermis thins and subcutaneous fat and tissue atrophies and is lost. Aged skin is more vulnerable to damage and stress, and also slower to heal. Wound prevalence increases with age. Residents of care homes are known to be at risk of skin problems and therefore it is important to take a proactive approach to maintaining skin integrity and assessing and treating any skin breakdown. This requires a whole system approach to care, with primary care and care home staff working with specialist colleagues in the NHS to prevent avoidable harms in relation to older people’s skin.
In Oxfordshire, a number of organisations across the system are already working to improve skin care. The first stage of the project was to carry out a current state audit into pressure ulcers, leg ulcers and other wounds both in the care home sector and in the local acute hospital. The purpose of this was to find out the prevalence of tissue viability problems from different sources in order to understand the problem better and plan an appropriate response. The average prevalence of tissue viability problems among care home residents was 9% of the total resident population, with a prevalence range of 1% to 21%. The top three reported problems were leg ulcers, skin tears and Grade 2 pressure ulcers. The dressings most commonly used in nursing homes were found to be those listed on the Oxfordshire tissue viability formulary, demonstrating that the nursing homes have adopted the recommended local guidance. There was a high use of assessment tools for pressure ulcers and wounds, but fewer than half of the homes used a validated assessment tool for leg ulcers which might explain their unexpectedly high prevalence. The majority of care home staff received less than five hours training per year in tissue viability. The average prevalence of tissue viability problems for in-patients was 38%, with surgical wounds being the highest category. Excluding these, the most common problems were pressure ulcers and leg ulcers. The largest categories of patients with these problems were admitted from their own home, with admissions from care homes being the second largest group.
The implications of these two audits are that a consistent approach to tissue viability management needs to be introduced across Oxfordshire, to minimize skin problems and manage them earlier. This needs to involve practice nurses and district nurses who support patients in their own homes, as well as those working in care homes. Work is now happening to deliver the desired changes.
A summary of the audit findings can be found here:- HIEC summary SKINintelligence eversion
The project report can be found here:-HIEC summary SKINtelligence 2 eversion