How a 3-fold approach is making a difference to pressure ulcers in neurorehabilitation 

By Joanna Fakayode RNA, DipHe, MSc, Lead Nurse, STEPS Rehabilitation

Pressure ulcers are in the top ten causes of patient harm in the NHS in England1, affecting over 700,000 people in the UK each year2. They can have a devastating impact on individuals through associated complications such as pain, anxiety, prolonged bed rest, additional or prolonged hospital stays, delayed rehab, loss of independence, social isolation, infection, amputation and death3. Despite this, pressure ulcers are widely acknowledged to be largely preventable4. 

In neurorehabilitation, our patients are at higher risk than most5, whether due to reduced sensation and mobility from a spinal cord injury; reduced mobility and cognition due to a traumatic brain injury and polytrauma; or long-term use of a prosthesis due to amputation. Pressure ulcer prevention must always be a priority.  

As a relatively new facility, our pressure ulcer data is in its infancy and will continue to be collected. A recent review of the last two years of pressure ulcer data has shown we have had only two non-device related pressure ulcers develop in our care during this time. With 180,000 newly acquired pressure ulcers across the UK each year2, what has made the difference for us?  

The answer lies in our three-fold approach: 

  1. In—house interdisciplinary team (IDT)  
  2. Training 
  3. Reflective practice 
  1. Interdisciplinary Team (IDT): 

We are fortunate to have a highly skilled in-house IDT team. Each discipline contributes to a comprehensive, holistic approach to pressure ulcer prevention and treatment. We have seen good success with pressure ulcer prevention and healing, including those present on admission.  

A personalised pressure area care plan for each patient is created based on the NHS Improvement Pressure ulcer core curriculum 2018 – ASSKING7 (Assess risk, Support surfaces, Skin inspection, Keep moving, Incontinence, Nutrition, Give information). 

ASSKING 

Assess risk - Pressure ulcer prevention starts before the patient even arrives, with a thorough pre-admission assessment of their needs. Nurses complete a Waterlow assessment on admission to ascertain the patient's individual risk of pressure damage. Appropriate pressure ulcer prevention strategies are put in place to reduce this risk. 

Support surfaces – This begins prior to admission as any required pressure redistributing equipment is sourced from the pre-admission assessment prior to the patient’s arrival. Occupational Therapists undertake assessments of posture, seating, sleep systems and pressure redistributing support surfaces, providing personalised 24-hour postural management.  

Skin inspection – Nursing and Rehabilitation Assistant teams monitor patients’ skin to identify and act on any early warning signs of pressure damage.  

Keep moving - Physiotherapists work with complex patients on strength, range of movement and strategies to maximise their independence in repositioning for pressure relief. Effective pain management is reviewed by Rehabilitation Medicine Consultants and the Nursing team. Complemented by holistic therapies, such as Acupuncture, Solution focused hypnotherapy, Hydrotherapy, Massage and Sensory therapy. This combined approach reduces pain, anxiety, spasms, and hypersensitivity, allowing the patient to maximise their mobility and engagement in physical therapy.  

Incontinence – the IDT team works closely with the patient to support any continence needs. This may include assistance or prompting to access the toilet to support patients to regain continence where possible, provision of equipment, support with hygiene needs and skin care, application of barrier products. The Nursing team provide patient education, working with patients to achieve effective bowel and bladder management regimes and maximise their independence in these areas. 

Nutrition – A Nutritional IDT group works with the treating teams, the catering team and relevant Dietitian to support patients’ nutritional needs. This includes ensuring their diet contains the right nutrients and elements to support wound healing, muscle building, provide energy and support general good health. 

Give information – Personalised patient education and involvement in care planning is undertaken, utilising input from Speech and Language Therapists where needed. Care plans for prevention and treating any existing pressure damage are implemented and clearly communicated to the team. Referral to Tissue Viability Nurses or GP and reviews by Rehabilitation Medicine Consultants are undertaken where relevant.  

2. Training 

Staff education forms an essential part of pressure ulcer prevention and healing1. Over the years we have employed various methods to promote Pressure Ulcer awareness including:  

  • Formal training on induction for all new clinical and therapy staff  
  • Yearly refresher training 
  • Pressure ulcer workbooks  
  • Pressure ulcer board game and quizzes 
  • Drop-in sessions for staff and patients on STOP THE PRESSURE days 
  • Training for external care teams taking over care for clients on discharge home 

Training is based on the NICE Clinical Guideline [CG179] Pressure ulcers: prevention and management6 and The International Guideline created by EPUAP/NPIAP/PPPIA3. 

Training includes awareness of increased risk for people with darkly pigmented skin due to risk of delayed detection3 and the signs to check for.  

3. Reflective practice:  

Reflection is essential to improving practice. It is the process through which we identify areas for learning and development on personal, professional, and organisational levels to improve client care and service delivery8. Over the last few years there are several ways we have employed this strategy in relation to pressure ulcer prevention.  

All pressure ulcer development is escalated through incident reporting, investigated, and any actions indicated through reflection are implemented. This has led us to recognise the factors of this 3-fold approach that have contributed to success with prevention of non-device related pressure ulcers. We plan to build on this with an IDT review of therapeutic device related pressure ulcers. 

Our in-house IDT allows us to be responsive to patients’ changing needs and risk factors, creating a unique personalised approach for each patient. Reviews of each patients’ pressure ulcer risk, care plan and pressure redistributing equipment occur throughout their stay. Wounds are monitored for signs of improvement or deterioration and referrals to Tissue Viability or GP are made as needed.

If a patient’s risk of pressure ulcer development or deterioration increases, as indicated by Waterlow risk assessment, changes in health, presentation or condition, or measurements of wound tracking, size, and depth, the nurses alert the patient to their increased risk and involve them in reviewing their care and repositioning plan.

If this necessitates a period of increased bed rest the nurses co-ordinate with the patient’s interdisciplinary treatment team, who make changes to the patient’s therapy timetable to fit around pressure relief needs.

In addition, they shift the focus of the patient’s rehabilitation to activities that could be done from bed, however still work towards the patient’s rehabilitation goals. This may include increasing holistic therapies such as psychology, art therapy, or neurologic music therapy, alongside working bed based physical activities like upper limb function or Speech and Language Therapy.  

The new plan is clearly communicated to the IDT and continually monitored and reviewed. Further changes are implemented as necessary, with the aim of gradually increasing skin tolerance when sitting out with a graded approach. 

Patient’s repositioning charts are monitored, and feedback provided to the team. Staffing levels and skills mix are regularly reviewed to meet changing patient needs.  

Conclusion 

Our 3-fold approach of responsive in-house interdisciplinary input, pressure ulcer awareness training and reflective practice has proven effective in pressure ulcer prevention and healing. Using this approach we have seen improvements in all pressure ulcers, including those present on admission of all categories, with 60 per cent fully healed and many others healing well on discharge. 

References:  

  1. National Wound Care Strategy Programme 2024. Pressure Ulcer | National Wound Care Strategy Programme  
  1. Wood, J., Brown, B., Bartley, A., et al. (2019) Reducing pressure ulcers across multiple care settings using a collaborative approach. BMJ Open Quality 8(3), e000409.  
  1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019. 
  1. Office for Health Improvement and Disparities 2022. Pressure ulcers: applying All Our Health - GOV.UK (www.gov.uk) 
  1. Alito, A., Portaro, S., Leonardi, G., Ventimiglia, C., Bonanno, F., Fenga, D., Sconza, C., & Tisano, A. (2023). Pressure Ulcers-A Longstanding Problem: A 7-Year Neurorehabilitation Unit Experience of Management, Care, and Clinical Outcomes. Diagnostics (Basel, Switzerland), 13(20), 3213. https://doi.org/10.3390/diagnostics13203213 
  1. NICE National Institute for Health and Care Excellence. Pressure ulcers: prevention and management Clinical guideline [CG179] 2014. Overview | Pressure ulcers: prevention and management | Guidance | NICE 
  1. NHS Improvement - Pressure Ulcer Core Curriculum 2018. Pressure-ulcer-core-curriculum.pdf (england.nhs.uk) 
  1. Nursing & Midwifery Council. Supporting information for reflection in nursing and midwifery practice 2024. supporting-information-for-reflection-in-nursing-and-midwifery-practice.pdf (nmc.org.uk) 
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