Tissue Viability are helping to #stopthepressure

The Tissue Viability Team at UHP are here to work with patients who have particular needs in terms of skin integrity, wounds and pressure ulcers. Lead Tissue Viability Clinical Nurse Specialist, Siobhan Mccoulough, writes about the different models of care and the importance of aSSKINg ahead of Stop the Pressure Day on 19 November.

Two of the Tissue Viability Team – Siobhan and Emma

The SSKIN bundle has been identified as a key process/intervention in pressure ulcer prevention which has been tested widely since its development in the Ascension Hospital system in 2004 in the USA and more recently across the UK in programmes such as the 1000 Lives campaign, Transforming Care in Wales and Stop the Pressure Collaborative across the Midlands and East of England. The bundle methodology was designed to facilitate consistency in practice.

This developed a blueprint for change in pressure ulcer prevention. Part of this blueprint involved defining and prioritising best known evidence and practices, into a ‘bundle of care’. 

The original SSKIN care bundle focusing on four key aspects of preventative care: Surface, Skin inspection, Keep moving, Incontinence, and Nutrition.

This above model has been in use as a gold standard for prevention and management of pressure ulcers. Initially brought over to the UK in 2004, it was launched first in Wales in 2009, Scotland in 2011 and adopted by NHS England in 2012. It has slowly been incorporated into acute settings in England . It has shown great results for not just reducing the amount of pressure ulcer incidences but raising awareness of the main components needed to be risk assessed and monitored for the at risk resident/patient.

This model is often benchmarked while investigating pressure ulcers as routine, such as root cause analysis. If any of the above SSKIN care components were not included in the individual’s care plan, or there are clear gaps in this model, it may indicate improvement is needed in the care setting.

As a CQC specialist advisor it is this model that I use first as a benchmark when checking care records and practices.

I have been completing root cause analysis for pressure ulcers in the community and long-term care settings for many years. As a tissue viability nurse and investigator clear emerging themes and gaps come up time and time again. When meeting with colleagues here in the UK and looking at international research, these challenges are similar. 

One of these challenges is that the risk assessment completed may not have been holistic and did not incorporate all of the above model of prevention. Whilst the Waterlow, Braden are tools for risk assessing, the research shows that they do not allow for individualised care planning and our dated assessment tools. The updated Purpose T assessment tool developed in Leeds University by Dr Suzanne Coleman uses up-to-date research methods to develop its tool.

However none of these tools will tell you that your resident will refuse to be repositioned due to pain or not wanting to lie on their side etc, or that they tend to lean on their left elbow for most of the day. This must come from your observations and interventions explored. 

The other is where the resident has full capacity or reduced capacity and there is an informal or formal carer in place that information must be given to them so that they understand their own risks to their skin, thus being able to make informed decisions with their care plan. Or that the carers fully understand how to prevent a pressure ulcer and know the early stages, such as non-blanching erythema (Category 1 Pressure ulcer), so that they can report.

It is great, therefore, that the NHS improvement updated recommendations have included two more letters to the acronym SSKIN, namely A – Assessment and G – Giving information.

The new recommended guidelines therefore are as below:









NHS trusts in England have been implementing the SSKIN bundles since 2012. The aSSKINg update has been implemented at UHP and the below video explaining these principles will be mandatory for all clinical new starters as part of their mandatory training.

A aSSKINg UHP video by the Tissue Viability Team can be found below:

The full brief of the NHS improvement recommendations including the ASSKING model is found below:

Whatever stage you are at for pressure ulcer prevention care planning, don’t forget to share your journey and successes at #stopthepressure on Twitter which is the national # for improvement, support and sharing of information.

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