Wound care and tissue viability manual

1 Policy summary

This policy will cover all clinicians with the appropriate skills for delivering wound care. Tissue viability (TV) and wound care (WC) is the focus on reducing pressure ulcer, improving wound assessment and reducing unwarranted variations in the care of lower leg wounds (International Consensus 2013).

2 Introduction

The management of chronic wounds has been identified as a national problem and evidence of an increasing number of chronic wounds and the associated financial burden (Wound UK 2018).

NHS England responded to this new evidence with the development of a clinical reference group, which developed into a project board to oversee several ongoing work streams, as part of The Leading Change Adding Value programme (NHS 2016a).

The work streams aimed to address some of the failings highlighted and included:

• An economic case study analysis resulting in the publication of Betty’s story (NHS England 2017)
• Development of a framework for lower leg management, moved forward to “Leg Matter Campaign”
• Quality indicators for wound assessment 2017 to 2019 (CQUIN framework NHS England 2016b)
• Minimal data set (MDA) for wound assessment (Coleman et al. 2017)
• Advice for commissioners when commissioning for wound care services
• Recommendations for minimal level of education for practitioner involved in wound care: moved forwarded to pressure ulcer core curriculum (NHS Improvement June 2018)
• Stop the pressure (May 2017)
• React to RED evaluation of pilot (Lisle J, Collins J May 2017) This followed the development a training package to promote a collaborative approach to pressure ulcer prevention (Five Year Forward View NHS England 2014) and RDASH was a pilot site.
• National Institute for Health and Care Excellence (NICE) (2020) Leg Ulcer Guidance

The work of the National Wound Care Strategy Programme identified significant variations in wound care approaches. Local scoping in 2019 confirmed that this is the case in Doncaster.

A wound care alliance has been created in Doncaster with the aim to reduce variations in care. The Doncaster Wound Care Alliance consists of the following parties:

• Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBHFT)
• Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)
• Doncaster NHS South Yorkshire Integrated Care Board
• Primary Care Doncaster
• Fly Coast Medical Service Ltd (FCMS)

A joint Doncaster wound care formulary has been developed by the:

• Skin Integrity team, Doncaster and Bassetlaw Teaching Hospitals
• Tissue viability and lymphoedema services, Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)
• Podiatry foot protection service lead, Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)
• Senior medicines management, Doncaster NHS South Yorkshire Integrated Care Board

3 Purpose

The purpose of this policy is to provide guidance on wound care working within the Doncaster Wound Care Alliance framework. This includes a universal structured competency based educational programme for healthcare professionals undertaking wound care interventions, to ensure a consistent and cohesive approach for wound care interventions is provided that reflects the current evidence, local policy and pathways, whilst incorporating the national agenda. The educational programme provides three different levels of education and learning outcomes based on the complexity of the wound management required (tier 1, tier 2 and tier 3).

The complexity of the wound is divided over 4 tiers (Doncaster Wide Formulary 2025).

• Tier 1: acute healing wounds, less than 14 days old with healthy granulation and epithelial tissue managed by the general practice, district nurse, ward colleagues, or children’s community nursing service (CCN).
• Tier 2: chronic healing wounds more than 14 days old with 50% or more healthy granulation and epithelial tissue managed by the general practice, district nurse, ward colleagues, or children’s community nursing service (CCN).
• Tier 2 lower limb (LL): chronic healing leg ulcer that has had a comprehensive lower limb assessment and diagnosis within a tier 3 or 4 service previously, with more than 14 days old with 50% or more healthy granulation and epithelial tissue and managed by general practice, district nurse, ward colleagues, or children’s community nursing service (CCN).
• Tier 3: non-healing wounds 50% or more devitalised, slough or necrotic tissue managed by the general practice, district nurse, ward colleagues and a specialist service, for example, Skin Integrity team, tissue viability and lymphoedema service, vascular service, Podiatry, children’s community nursing service (CCN).
• Tier 4: complex non-healing wounds 50% or more devitalised, slough or necrotic tissue managed by a specialist service only, for example, Skin Integrity team, tissue viability and lymphoedema service, vascular service, podiatry, children’s community nursing service (CCN).

A wound may be defined as the interruption of continuity in a tissue, usually following trauma. Skin is the organ predominantly affected although any tissue, whether nerve, bone or internal organ, may be wounded.

4 Scope

This procedure is intended for use predominantly in the community, Tickhill Road Hospital site in-patient services and provides guidance for other patient areas covered by the trust.

In the North Lincolnshire and Rotherham localities tissue viability and wound care services is provided by North Lincolnshire and Goole NHS Foundation Trust and Rotherham NHS Foundation Trust. The tissue viability and wound care services provided are a combined hospital and community service.

5 Procedures

Wound care should only be provided by appropriately educated clinicians following a pathway approach approved by Doncaster Wound Care Alliance.

5.1 First to dress initiative procedure

5.1.1 Introduction

The aim of this procedure is to provide guidance for registered clinician and non-registered clinicians within the trust on the selection and application of appropriate dressings for wound care at first contact or under delegation.

The first to dress initiative is to be activated at the first contact with a housebound patient, patient attending clinic, needle exchange, day hospital or newly admitted to inpatient area that requires a wound dressing.

This procedure reflects a multidisciplinary approach to the tissue viability and wound management and follows the Doncaster community wound care formulary and associated pathways and policies version 3 (this is a live updated document).

This procedure is to ensure that patient centred wound care within the trust is provided both safely and cost effectively.

To standardise wound care practice for first contact breaches in skin integrity.

5.1.2 Scope

This procedure is intended for use predominantly in the community, Tickhill Road Hospital site in-patient services and provides guidance for other patient areas covered by the trust. However, it may also be relevant for all other in-patient services.

In the North Lincolnshire and Rotherham localities tissue viability and wound care services is provided by North Lincolnshire and Goole NHS foundation Trust and Rotherham NHS foundation Trust. The tissue viability and wound care services provided are a combined hospital and community service

5.1.3 Procedure

The purpose of this procedure is to ensure the application of the appropriate wound care dressing at first encounter of breach of skin integrity and or when priorities for wound healing change and to ensure there is no delay in supplying the appropriate wound dressing product.

The procedure acknowledges creating an environment whereby clinicians are actively involved in ensuring that quality, as well as proven, cost-effective treatments are incorporated into the care delivered and they are accountable for that care.

The procedure is not intended as a substitute for professional judgement but in support of the clinicians making an informed decision relating to the wound management at first contact, guided by the Doncaster wound care formulary appendix H and associated pathways and policies version 3 (this is a live updated document).

Details of dressing products given in tab; first to dress initiative guidance

5.1.3.1 Non-registered clinicians

The first to dress initiative allows for non-registered clinicians to apply, in defined situations, a first dressing from the core bag dressing supplies for community colleagues and ward stock for in-patient areas. The supply of dressings beyond this will be subject to assessment by a registered clinician.

The first to dress initiative can be activated at first contact with a housebound patient, patient attending clinic or hospital setting that requires a wound dressing for:

• trauma wound presenting as an abrasion or skin tear
• pressure damage presenting as a category 1 or category 2 pressure ulcer
• skin reaction to dressing produce
• skin trauma on removal of dressing product
• excoriation of skin from urinary or faecal incontinence or wound exudates
• leg ulcer care, where there is strike through of exudate through all layer of bandages
• surgical wound when a patient has been discharged from hospital with no or inadequate supply of dressing
• injection site trauma or abscess formation

Non-registered clinicians must report the first contact episode and full details of the breach of skin integrity and their action at the earliest opportunity either at report handover or by mobile phone or by SystmOne task before the end of the shift.

If any of the following red flags are identified, seek immediate guidance from registered clinician, if inpatient for single point of access for appropriate service:

• nature and extent of the injury is uncertain
• there is a history of head injury or the patient reports loss of consciousness
• there is persistent bleeding
• suturing is required
• foreign body is present in the wound
• tetanus prophylaxis maybe required
• there is any uncertainty of the appropriate management

It is the non-registered clinicians responsibilities to:

• observe the wound and patient and report back to the registered clinician accurately and promptly
• only undertake wound care as specified within competencies framework and as guided by this procedure
• record actions accurately in the patient’s care plan using SystmOne
• identify training needs in relation to wound care: undertake initial education using tier 2 pressure assessment training
• continue to seek ongoing support and education as needed to ensure safe practice
• will follow the wound cleansing pathway and follow the wrap pack guidance

5.1.3.2 Registered clinician responsibilities

The first to dress initiative allows for a registered clinician to apply a first dressing and the first change of dressing without the need for a prescription. This may be at either first contact or where a different dressing product is required as a result of changes to the wound.

5.1.3.3 Infection control

The first to dress dressing stock will be part of the core bags for all community clinicians and dressing cupboards for inpatient areas, should be kept in according to the trust infection prevention and control specifically waste management.

5.1.3.4 Professional accountability: community

Registered clinicians follow own code of practice.

5.1.3.5 Wrap pack

Included within your wrap pack are a range of simple to apply dressing to ensure initial first to dress patient wound safety.

5.1.3.5.1 Step 1: prepare

1. Identify the wound and select the most appropriate dressing from your wrap.
2. Wash hands and ensure patient is comfortable.
3. Open dressing pack, try not to handle the contents of the pack too much.
4. Open the selected dressing onto the dressing pack, ensuring you do not touch the dressings.

5.1.3.5.2 Step 2: cleanse

1. Use alcohol gel to decontaminate hands and apply gloves within pack.
2. Cleanse the wound using the Irripod solution and the gauze.

5.1.3.5.3 Step 3: treat

Apply the selected dressing, ensuring you do not touch the part of the dressing which will touch the wound.

5.1.3.6 Suggested dressing

Suggested dressing for intact skin: Medi Derma S or Comfeel plus transparent.

Suggested dressing for broken skin: Urgotul Absorb Barrier.

5.1.3.7 Housebound procedure

1. Is the patient housebound?
   • Yes: refer into single point of access for district nurse review in 5 to 7 days on 03000 218 996.
   • No: refer to patients GP or practice nurse.

All dressings can remain in place for up to 7 days, however may need changing more frequently.

5.1.4 Wound care formulary

Pathway based formulary giving guidance for assessment, planning, implementing and evaluation of wound care. Doncaster Wound Care Formulary

5.2 Pressure ulcers, prevention, detection and treatment procedure

5.2.1 Introduction

A pressure ulcer is localised damage to the skin and, or underlying tissue, usually over a bony prominence (or related to a medical or other device) resulting from sustained pressure (including pressure associated with mechanical force of shear). The damage can present as intact skin or an open ulcer and maybe painful (EPUAP2019).

Pressure damage is common in many health settings, affecting all age groups, and is costly in both terms of human suffering and resources. Most pressure damage could be prevented and it is important to have prevention and educational strategies in place based upon the best available evidence.

5.2.2 Scope

This procedure is intended for use predominantly in the community, Tickhill Road Hospital site in-patient services and provides guidance for other patient areas covered by the trust. However, it may also be relevant for all other in-patient services and the need for a pressure ulcer risk assessment will be determined by the physical assessment on admission, in line with the policy minimal standards for the physical assessment, examination and ongoing care of in-patient in mental health and learning disability service.

In the North Lincolnshire and Rotherham localities tissue viability and wound care services are provided by North Lincolnshire and Goole NHS Foundation Trust and Rotherham NHS Foundation Trust. The tissue viability and wound care services provided are a combined hospital and community service.

5.2.3 Procedure

For the prevention and management of pressure ulcers. Following the structure of stop the pressure (ASSKING):

• A: assess the risk to pressure injury
• S: surface look at all the surface the person comes in contact with
• S: skin inspection for early detection
• K: keep moving or assist to change position Incontinence or moisture management
• I: incontinence or moisture management
• N: nutrition a heathy diet and hydration
• G: giving information at a level that enables the person to make informed choices and participate in care planning (Royal Marsden 2020)

Individual care plans will be developed from the nursing assessment, taking into account the patient needs, preferences and legal requirements. This personalised prevention plan may include a pressure-relieving device.

Pressure relief equipment is supplied in the community in partnership with the providers of community loan equipment for the prevention and management of pressure ulcers.

5.2.3.1 Assessment of pressure ulcer risk

The qualified nurse will perform an initial risk assessment in first episode of care, on admission to inpatient areas within 6 hours for planned admissions and at first visit for community patients. (This may be extended up to 12 hours if the patient’s mental health state will not allow it to be undertaken within 6 hours). If the clinical presentation of the patient is high risk for example immobile, unconscious or critically ill then prevention strategies must be implemented immediately.

Risk assessment is a fundamental part of preventing pressure ulcers and prescribing care. Many pressure ulcer risk assessment scales have been developed, but these represent only one part of the process. Individual’s risk of developing a pressure ulcer can change over a short or long period of time. It is linked with the general health and wellbeing of the individual in the majority of cases; however small changes in care or routine can dramatically increase risk. Once recognised these factors should be removed if possible or reduced as much as possible.

The trust supports the use of Pressure Ulcer Programme of Research Tool Purpose T version 2 adapted from University of Leeds and Leeds Teaching Hospitals NHS Foundation Trust as the pressure ulcer risk assessment tool and is supported by the NWCSP (2022).

Completion of Purpose T will give a direction for care planning:

• green pathway: on assessment no pressure ulcer identified and not currently at risk
• amber pathway: on assessment no pressure ulcer but at risk and primary prevention pathway with care plan to minimise or eliminate risk within principles of skin, surface, keep moving, incontinence or moisture, nutrition
•  red pathway: pressure ulcer category 1 or above or scarring from previous pressure ulcers with care plan for secondary prevention to minimise or eliminate further risk within principles of skin, surface, keep moving, incontinence or moisture, nutrition and a management care plan for treatment of pressure ulcer

Review risk assessment in line with care plan notification, for example, in line with complexity score in the community, with changes in clinical condition for example patient becomes unwell, develops incontinence or reduction in mobility or nutrition.

All patient’s prevention or treatment management. Patients with identified risk factors may require referring to other members of the health care team. Referrals to a dietician for all grade 3 and above pressure sores, physiotherapist, occupational therapist or continence advisor should be made where appropriate.

Risk status can increase or decrease; both may require changes in care.

5.2.3.2 Surface

5.2.3.2.1 Pressure relieving devices

Support surfaces for beds and chairs must reflect the patient’s pressure ulcer risk and ability to change position. If a patient cannot reposition independently then consider the use of dynamic mattress systems where two hourly repositioning is not feasible.

Devices (mattresses and cushions) come in two main types; those that reduce pressure by spreading the weight and increasing the surface area, and those that relieve pressure by removing the pressure at frequent intervals. Decisions about which pressure redistributing device to use should be based on an overall assessment of the individual and not solely on the basis of scores from risk assessment scales.

Consider smoking status and suitability of equipment and refer to fire service for advice (a risk assessment is in development but not available as yet, in the meantime if support required contact the tissue viability and lymphoedema service (TVALS) or Nottingham Rehabilitation Society (NRS).

Pressure relieving equipment does not replace the need for repositioning and should be used as in conjunction with repositioning and skin inspection regime that suits the patient and circumstances.

Pressure relief equipment is supplied in the community by the community loan equipment loans service. Details of equipment provided and ordering procedures are included in the online Nottingham Rehabilitation Society (NRS) IRIS electronic catalogue. If the patient lives outside the geographical area, contact Nottingham Rehabilitation Society to ask for guidance on who to contact to order equipment.

Only authorised staff with an individual personal identification number (PIN) can order equipment via Nottingham Rehabilitation Society. Staff must attend training before they are issued with a requisition number and will be expected to attend periodic refresher training to retain their Requisitioner status.

Within the Doncaster in-patient area pressure relieving equipment is available on the ward.

5.2.3.2.2 Equipment selection

Before equipment is chosen existing support surfaces (bed, chair) should be examined for suitability. Lack of support and bottoming out from an old mattress or cushion could be causing the pressure damage.

All vulnerable patients, including those with a category 1 to 2 pressure ulcer should receive, as a minimum provision, a high specification foam mattress and the ulcer should be closely observed for deterioration.

The level of equipment support should be increased (stepped up) when:

• the patient is showing signs of pressure damage
• as a first line preventative strategy for persons identified at elevated risk
• the patient’s condition deteriorates

The level of support should be decreased (stepping down) when:

• the patients condition improves
• mobility improves
• post operatively (over 24 hours)
• following successful rehabilitation

Adverse incident reports using the reporting system Ulysses system (IR1s) should be raised to report the:

• equipment failures
• non-compliance with manufacturer’s instructions
• misappropriate use of equipment, for example, allocated equipment is not with the named patient
• prescribed pressure relief equipment is not available in a timely manner

There are three principles of action when selecting a pressure relief device for pressure ulcer prevention and, or management:

• reducing or relieving pressure
• preventing damage to the skin
• improving tissue resistance

Decisions about support surfaces should be made following a holistic assessment of a person’s risk, comfort and general health state.

Patient movement in and out of bed should be considered as air mattresses can restrict movement.

Assessment should be ongoing throughout an individual’s episode of care and the type of pressure relief support changed to suit any alteration in risk.

Patient may choose not to use any therapy products because of their personal circumstances in particular those that wish to continue sleeping with their partner.

A full conversation about risk and consequences should be discussed with the patient. If you believe the patient has capacity to make decisions about their care and treatment of the pressure ulcer you should ask the and patient to sign informed refusal form, within the consent to care and treatment policy. The risks and consequences need to be revisited on a regular basis and the person capacity ability to consent reconsidered.

Where there are concerns about the person capacity a mental capacity assessment should be undertaken and recorded on the MCA1 questionnaire on SystmOne in line with the Mental Capacity Act (2005) policy.

If the outcome is the person has capacity, then you proceed with informed refusal process, if they lack capacity then a best interests decisions to whether they should receive the treatment against their wishes should be carried out and recorded on best interests decision record (MCA2).

A bed rail risk assessment should be completed and appropriate bed rails supplied.

5.2.3.2.3 Electric profiling beds

Electric profiling beds reduce skin damage by:

• making movement easier for the patient, carers and staff to perform, reducing friction and shear
• use of the knee break prevents sliding down the bed reducing friction and shear
• allowing patients to change their own position
• it is vital that an environmental check be carried out to ensure space is available as these beds a larger than a standard divan and require additional space for functionality
• for patients with category 4 pressure injury the profiling bed base is supplied with a pressure relief mattress replacement system
• equipment and mattresses available in the in-patient areas should be cleaned in line with latest guidance from infection prevention and control
• equipment allocated from community loan equipment services should be returned at the end of allocation for cleaning and decontamination
• healthcare professionals are responsible to ensure that equipment prescribed for patient is documented on electronic record and checked this remains in working order
• healthcare professionals have a duty of care to their patients when using pressure reducing or relieving equipment to ensure it is used safely and appropriately. Information leaflets provided should be read and adhered to and all healthcare professionals should be able to trouble shoot routine and minor equipment failures
• most pressure reducing or relieving systems are fitted with visual and, or audible alarms and informal and formal carers should be informed of whom to contact should the alarms be activated
• prescribed equipment should be monitored for safe and effective working order at each community visit and reassessment of appropriate allocation in-line with at risk status or pressure ulcer management plan as a minimum in line with patients community complexity score review
• foam mattresses should be checked for collapse of foam (bottoming out use both fists to lean weight on mattress and test to feel base of bed frame) and integrity of cover on at least a monthly basis
• mattress with a ripped or torn cover through to the foam need to be condemned and replaced this is due to the risk of contamination to the foam
• pressure relief system covers that are ripped or torn also require replacement because of risk of contamination
• electrical equipment requires an adequate electrical supply and should be plugged directly into the electrical socket. Consider the safe positioning of trailing wires either around or under the bed. All wires should be secured and neatly placed

All manual handling tasks should consider the whole picture and assessed using the ergonomic framework of; task, load, individual, environment and equipment provision. Giving consideration to the environmental factors for example, space around the bed and mattress.

All equipment provided by Nottingham Rehabilitation Society, cleaning instructions for all equipment is provided on delivery for patients family and clinicians to follow.

5.2.3.2.4 Seating pressure relief

• The benefits of a pressure redistributing device should not be undermined by prolonged chair sitting.
• When sat in a chair 70% of your body weight is spread over 8% of your surface area. This means that seating increases the risk of pressure damage. Poor seating increases the risk even more.
• When planning to sit a patient out of bed consider the following points:
  • the severity and location of any pressure ulcers
  • the patients’ ability to sit comfortably in an armchair and reposition themselves
  • ergonomics of the chair, for example, height, depth, width, position of armrests
  • ease of transfer from bed to chair and the use of appropriate moving equipment
  • posture, mobility, comfort and support.
  • functions required when sitting, for example, eating or washing
  • patient choice and psychological consideration.
  • a patient considered at high risk who is provided with an alternating pressure mattress but who sits out should also have their seating assessed and suitable equipment provided
  • Patients should be advised of the risk of prolonged chair sitting so they can make informed choices about it
  • National Institute for Health and Care Excellence (NICE) recommend restricting the time spent seated to a maximum of 2 hours at a time for high-risk patients
  • Advice should be sought from the multidisciplinary team (occupational therapists, physiotherapists, wheelchair services) if seating is a problem

Treatment of the skin therefore depends on the state in which it is found, rather than routine procedure. The following principles in caring for the skin:

• keep it clean
• do not let it remain wet
• do not let it dry out
• prevent accidental damage
• skin inspection can take place during routine care taking into account patient consent, preferences, privacy and dignity
• refusal to allow skin inspection should be documented, and the risks fully explained to patient and carers

Skin assessment for individual identified at risk should be carried out after each position change; this will allow the practitioner to guide decisions on the length of time between each position change. Completion of repositioning chart will assist in care planning for assessment of pressure areas identified as high risk.

In the community when working in partnership with other agencies, the compliance and documenting of turns and repositions and the effectiveness of the regime, to be reviewed and recorded at each visit.

Patient should have a turning or re-positioning regime and pain assessment related to the pressure ulcer or its treatment. Manage pain by eliminating or controlling the source and offer pain relief as appropriate. Seek specialist advice if necessary. Document all findings in electronic records.

Where a red area is noted, apply light finger pressure for 10 seconds if the area blanches, goes pale, on removal of finger there is no damage to micro, circulation. If the area remains red, non-blanching erythema of intact skin, a category 1 pressure ulcer is indicated and further action is required.

Correct positioning and support is important to minimise friction and shear whether in bed, chair and wheelchair. This includes the use of pillows to keep bony prominences apart (for example knees, heels or ankles). However, care should be taken to ensure that these do not interfere with the action of any other pressure relieving equipment in use. Patients at risk of developing pressure ulcers because of the time spent sitting in a chair should be encouraged to sit in a chair, which is of the correct height in addition to the use of a pressure relieving device.

5.2.3.3 Keep moving

Individuals, where appropriate should be encouraged to reposition themselves if this is possible.

Consideration should be given to the prescribing of TOTO (this is lateral turn equipment that is placed on the bed base between the bed frame and the mattress or pressure relief system) to provide assistance with a turning and repositioning regime.

The use of the 30-degree tilt has been found to be beneficial to the patient. It involves the patient being positioned at a 30-degree angle using pillows, rather than at a 90-degree angle which would place them directly onto their hip and therefore at increased risk. (Preston 1988).

5.2.3.4 Incontinence

Where incontinence and, or moisture to the skin is identified as a risk factor advice can be sought from the continence specialist services.

As per pathways within the Doncaster Wound Care Formulary September 2022, to be reviewed July 2024. Skin care pathway for incontinence associated dermatitis (IAD) and moisture associated skin damage (MASD).

5.2.3.5 Nutrition

Malnutrition and dehydration are risk factors for the development of pressure ulcers.

To help achieve healthy nutritional status for the patient:

• promote a healthy balanced diet
• encourage staying hydrated; aim to have 6 to 8 drinks (1.5 litres) per day, this could include water, tea, coffee, milk and, or juice
• if appetite is poor; encourage an enriched diet with high calorie snacks and drinks (high in fat and sugar), for example, milky drinks and dairy based puddings
• if overweight or obese advise to follow healthy eating guidance, for example, have the right portion size, choose low fat dairy foods, avoid high sugar foods, for example, biscuits, cakes, chocolate, fizzy drinks, sweets. However, if a person is identified to be at risk of malnutrition following screening (for example, 5 to 10% or more weight loss in the last 3 to 6 months), avoidance of these foods may not be appropriate in the first instance. Please refer to the must template and care plans available for guidance
• if a patient is unable to eat independently consider suggesting purchasing adapted cutlery or crockery to support independence, provide assistance prompting encouragement or feeding when needed
• if patient is in own home and unable to eat independently
• refer onto the relevant service if these are the primary reasons for low intake, for example, dentist, speech and language therapy, mental health team, GP

All patients on initial assessment should have nutritional assessment completed using must assessment tool. All patients who are nutritionally compromised should have a plan of appropriate nutritional support or supplementation that meets the individual needs and is consistent with overall goals of therapy. Referral to the dietetic service should be made as appropriate. Patient’s receiving late stage (last 12 weeks) palliative care should be provided with the nutrition in palliative care leaflet (must page 1).

5.2.3.6 Giving information

Education for staff within the trust.

Pressure ulcer awareness education tier 1,2 and 3 This will form part of the professional role requirements training, tier level to be decided by service manager.

These learning objectives are based on the recommendations from the national wound care strategy programme core capabilities Framework for England (2021).

This framework is used by the Doncaster Wound Care Alliance. The framework has been designed to cover all health and social care settings. It is up to the practitioner and their employer to determine which tier of knowledge and skills they need to achieve within their current role.

The capabilities are cumulative; therefore, a health or care practitioner working at tier 3 will be able to demonstrate the capabilities at tier 1 and tier 2 as well as those at tier 3. The tiers do not relate to specific roles or pay grades.

5.2.3.6.1 Pressure ulcer awareness education tier 1

Capabilities that require a general knowledge and understanding of wound care and the skills which support provision of care, the focus being on pressure ulcer risk.

We propose this could be achieved by awareness e-learning including information on wound photography and supported by leaflets which may be provided to the patients or carers.

This e-learning awareness video will include:

• react to red principles for adult services
• pressure ulcer prevention principles for children, including a public health agency for children’s service leaflet. Using the ASSKING framework it will aid practitioners to identify the risks to skin integrity and give them the knowledge to provide health promotion advice to keep the skin healthy.

E-learning on electronic staff record (ESR) pressure ulcer awareness, caring for skin and preventing pressure ulcers

Learning objectives:

• care of skin and prevention of pressure ulcers
  adhere to local protocols, policies, guidelines, and relevant regulatory frameworks relating to wound care and treatment; see first to dress initiative procedure
• understand common terms
• identify who is most at risk of developing a pressure ulcer
• know when to react to at risk skin
• understand the ASSKING bundle and how to use it
• know where to get help

Posed target audience: clinical staff who see patients or clients who would follow health promotion advice or who have carers or parents who can follow the advice and give the direct care. For example, health visitors, those who would not directly provide first line physical health care.

5.2.3.6.2 Pressure ulcer awareness education tier 2

Capabilities that enable the provision of wound care independently and with a degree of critical analysis. Using the see treat and refer on model.

We propose this could be achieved by a more comprehensive E learning, which builds on the tier 1 content. Supported by the provision of the wrap pack on completion of the e-learning.

This e-learning will include:

• pressure ulcer risk factors
• caring for skin
• importance of pressure ulcer prevention
• identification of pressure damage
• taking the first steps to protect the pressure ulcer (using the wrap pack)
• giving health promotion advice on how to protect the skin. Following the first to dress principles of “see treat refer on”
•  referring on to the appropriate service for ongoing risk assessment and wound care
• IR1 reporting

Learning objectives, tier 1 plus:

• understand the anatomy and physiology of the skin, the importance of maintaining its integrity
• be able to recommend and carry out agreed wound management techniques and therapies within the scope of practice
• make timely and appropriate wound management referrals
• have a comprehensive knowledge of local and regional wound care protocols and guidance (wound care formulary)
• know where to refer onto for ongoing care and treatment

Proposed target audience: clinical staff who see patient or clients who would be at risk of pressure ulcer damage but would be unable to follow health promotion advice and would require more clinical assistance. They would follow the first to dress policy, provide first line care, following the “see, treat, refer on” pathway. They would be provided with the core wrap pack for first line dressings. They would not provide ongoing wound care and advice, for example, specialist nurses and allied health professionals.

5.2.3.6.3 Pressure ulcer awareness education tier 3

Capabilities that require a high degree of autonomy and complex decision-making, an ability to lead wound care practice, enabling innovative solutions to enhance people’s experience and improve outcomes.

This is a face-to-face taught session which focuses on the risk assessment, avoidance of risk and if a pressure ulcer develops the care, treatment, reassessment, reporting and duty of candour process. This is part of the wound care alliance training programme for district nurses.

This will be rolled out to the physical health wards by learning and development in 2023. This formal teaching session includes:

• holistic assessment of any at risk patient
• preventative strategies to keep skin healthy
• use of pressure relieving equipment
• pressure ulcer grading and wound care following the Wound care alliance formulary
• working as part of a multidisciplinary team to keep the patients skin safe
• IR1 reporting and duty of candour process

Learning objectives, tier 1 and 2 plus:

• construct, oversee and advise upon the development of wound care management plans in collaboration with the multidisciplinary team, which include specific review dates
• develop care plans that take account of the individual’s needs, goals and wishes, local service availability and relevant guidelines, ensuring that the management plan considers all options that are appropriate for the care pathway
• have a comprehensive knowledge of the wound healing process and other factors which can affect healing
• engage in the critical review of own and others’ practice, learn from them and share the learning with colleagues and networks

Proposed target audience: clinical staff who wound care and wound dressings are part of their core role. They would provide ongoing wound care and advice to patients cares and families. They would follow the Doncaster wound care formulary and have access to a dressing store, equipment provision. For example, district nurses, physical health in patient areas, hospice staff and tissue viability and lymphoedema service.

Individuals who are willing and able should be encouraged, following education and guidance, to inspect their own skin and pressure points. Where practicable the patient and their family or carers should be involved in the inspection process. Any education or guidance should be recorded and supported with written information. This should include the importance of reporting to the healthcare professional any areas of concern.

Patient or carers or family can be directed to under pressure video on YouTube for visual information on the formation of a pressure ulcer and their prevention and detection.

Patient or carer or family information to compliment the video is available in leaflet format react to RED.

See appendix E react to RED leaflet for patient and carers: for patients presenting with poor nutrition the trust produce a leaflet with suggested food items to support an enriched diet.

See appendix F food first: for patients who may present with challenges because of dementia the trust produce a leaflet with suggested food types and techniques to assist the patient achieve a nutritionally balanced diet.

See appendix G eating, drinking and swallowing awareness in dementia

It is important to give relevant information in a way that patient can understand to make significant decisions about their health and welfare. Staff will record in the appropriate document or care plan the patients and carers understanding and comprehension of pressure ulcer prevention and, or management plans.

This to include information on the patient’s capacity to understand the information to ensure informed choice. The patient’s capacity to be recorded on completion of mental capacity form if appropriate (Mental Capacity Act form on electronic record).

Staff will record in the appropriate document or care plan efforts to re-enforce the principles and activities needed for an effective management care plan.

When a patient or principle carers decline to take on board the recommendations relating to pressure ulcer prevention or management, for example, use of pressure relief equipment, limit the time spent sitting in a chair.

After explanation of the advice provided, the potential benefits and the probable risks of not following the recommendations they should be given the opportunity to record their preferences by completing the informed refusal form available on TPP SystmOne.

The issues covered by the informed refusal form need to be revisited at least monthly, to ensure the accurate records of patient’s preferences and choices.

5.2.3.7 Guidelines for specialist patient groups

5.2.3.7.1 Critically ill patients

Consider the need to change support surfaces for patients who cannot be turned for medical reasons such as spinal instability, for example, spinal cord compression and haemodynamic instability.

Consider more frequent small shifts in position to allow some re-perfusion in patients who cannot tolerate frequent major shifts in body positions, for example, utilise 30-degree tilt techniques.

Prevent shear injury with the use of slide sheets for any repositioning move.

If patient presents with a pressure ulcer or wound, document the number of dressings and their position if filling undermining areas to ensure they are correctly removed at next dressing change. Do not pack tightly as this will cause additional pressure.

5.2.3.7.2 Bariatric obese patients

Ensure adequate assistance to fully inspect all skin folds. Pressure ulcers may occur in unique locations, such as beneath folds of skin and in locations where tubes and other devices have been compressed between skin folds.

Pressure ulcer develops over bony prominences, but may also result from tissue pressure across buttocks and other areas of high adipose tissue concentration.

Consider the use of pillows or other positions devices to off load large skin folds and prevent skin on skin pressure, for example, Kerrapro.

Ensure the correct fit of the bed that supports the weight of the individual and ensures sufficient width to allow turning and patient does not rest up against side rails of the bed when turned from side to side.

5.2.3.7.3 Patient receiving palliative care

Complete a comprehensive assessment of patient’s health status and combine this with patient’s preferences in turning, including whether they have a position of comfort after explaining the rationale for turning.

Establish a flexible repositioning schedule based on the patient’s preference and tolerance and the pressure redistributing characteristics of the support system. Individualise the turning and repositioning schedule, ensuring it is consistent with the patient’s goals, wishes, administration of prescribed analgesia, current clinical status and combined co-morbidity conditions as medically feasible. Document turning and repositioning as well as the factors influencing these decisions, for example, patient wishes, medical need.

Comfort is of primary importance and may supersede prevention and wound care for patients who have been diagnosed as being the final stages of dying or who have conditions causing them to have a single position of comfort. If appropriate offer prescribed medication to the patient 20 to 30 minutes prior to a scheduled position change for patients who experience significant pain on movement.

Consider the following factors in repositioning:

• protect the sacrum, elbows, and greater trochanters, which are particularly vulnerable to pressure
• use positioning devices such as pillows as necessary to prevent direct contact on bony prominences and to avoid having the patient lie directly on a pressure ulcer (unless this is the position of least discomfort and the patients’ preference)
• use heel protectors and, or suspend the length of the leg over a pillow to float the heel away from the bed surface
• use a chair cushion that redistributes pressure on the bony prominences and increases comfort for patients who are seated
• ensure the family and carers understand the goals for the patient’s plan of care

For pressure ulcer care, pain management, odour control and exudate management are the main aspects closely related to supporting the patient’s comfort. Select extended wear dressings to reduce pain associated with frequent dressing changes. If consistent with the treatment plan provide opioids and, or non-steroidal anti-inflammatory medications 30 minutes prior to dressing changes or procedures and afterwards as prescribed.

Skin changes at end of life, located predominantly on coccyx or sacrum usually shaped like a pear, butterfly or horseshoe. They are a variety of colours including red, yellow, or black, are sudden in onset, typically deteriorate rapidly and usually indicate the death is imminent.

5.2.3.7.4 Spinal cord injured patients

Specialist wheelchair assessment services should individualise the prescription of a wheelchair and seating support surface and associated equipment for posture, pressure re-distribution and consideration for transfers for lifestyle needs.

Use of a wheelchair is imperative for spinal cord injured individuals, but sitting will need to be restricted when pressure ulcers are present on sitting surfaces. Ideally ischial pressure ulcers heal in an environment where the ulcers are free of pressure and mechanical stress.

Total bed rest may be prescribed to create a pressure free wound environment. However, this approach comes with potential physical complications, for example, muscle wasting, deconditioning, respiratory complications, psychological harm, social isolation and financial challenges if a period off employment is required.

Deconditioning is a complex process of physiological changes following a period of inactivity, bed rest or sedentary lifestyle. It results in functional losses in such areas as mental status, degree of continence and ability to accomplish activities of daily living. It is frequently associated with hospitalisation in the elderly. The most predictable effects of deconditioning are seen in the musculoskeletal system and include diminished muscle mass, decreases of muscle strength by two to five per cent per day, muscle shortening, changes in periarticular and cartilaginous joint structure and marked loss of leg strength that seriously limit mobility.

This creates a challenging dilemma for the patient and clinician to provide a balance between the physical, social and psychological need against the need for total pressure off loading. Consider referring to the surgeon for an opinion regarding surgical intervention.

Further information from the spinal injury association.

5.2.3.7.5 Patients with dementia

Older people in general are at higher risk of pressure ulcers, particularly if they have difficulty moving. Dementia increases this risk further, especially as it progresses. Pressure ulcers are linked to dementia because of various associated problems:

• mobility as people with dementia may have difficulty changing position without help. This can include problems with walking, transferring between bed and chair, or repositioning themselves. Their movement may also be restricted by others for fear of falls
• frailty as a result of loss of protective fat and muscle loss and thinning skin
• poor diet and dehydration which reduce the strength and healing capacity of the skin
• incontinent because of the damage to the skin that can be caused by moisture
• poor blood supply with conditions such as diabetes
• agitation or restlessness with the behavioural rubbing often over heels and elbows
• medications that may cause sedation or drying of skin
• communication as the person may be less able to tell someone they are in pain When assisting a person with dementia to wash or dress take the opportunity to assess the skin at pressure points

Further information on Alzheimer’s.

5.2.4 Categorisation of pressure ulcers

5.2.4.1 Assessing the ulcer

All patients who present with a pressure ulcer should receive an initial and ongoing pressure ulcer assessment.

Pressure ulcers should be graded using the classification system in the European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance (2014) classification system of pressure ulcer categories.

Establish the root cause of the pressure ulcer: if noted on transfer onto community caseload, or reason for first community visit or on admission to the in-patient area defined as inherited pressure ulcer; if developed whilst on active community caseload or an in-patient on the ward defined as trust acquired.

• Category 1: non-blanchable erythema of intact skin. Discolouration of the skin warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.
• Category 2: partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.
• Category 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
• Category 4: full thickness tissue loss with exposed bone tendon or muscle extensive destruction. Often includes undermining and tunnelling. The depth varies by anatomical location.

Deep tissue injury (DTI): intact skin with localised area of persistent non-blanchable deep red, maroon, purple discolouration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin colour changes. Discolouration may appear differently in darkly pigmented skin. This injury results from intense and, or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss.

Unstageable pressure injury: full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough and eschar are removed a category 3 or category 4 will be revealed.

Unstageable and deep tissue injury (DTI) should be reviewed by a clinician with appropriate skills on a weekly basis to help identify a definitive pressure ulcer category (needs to be graded within 10 days).

Moisture lesions: presents as intact skin with a history of incontinence or perspiration. Area blanches on finger pressure test. Moisture associated skin damage (MASD) should be counted and reported in addition to pressure ulcers. Where skin damage is caused by a combination of moisture associated skin damage and pressure, it is reported on the category of pressure damage.

5.2.4.2 Pressure ulcer and moisture lesion differentiation

Medical device related pressure ulcer: a pressure ulcer that results from use of devices designed and applied for diagnostic or therapeutic purposes.

When sacral ulcers do not show signs of healing when appropriate wound dressing and appropriate pressure relief is achieved, give consideration to other causative factors:

• medication, for example, nicorandal
• incontinence dermatitis, defined as an irritant dermatitis
• underlying medical condition, for example, renal failure
• consequence of medical condition, for example, cancer

For pressure ulcer presenting on lower limbs a Doppler or Medi ABPI or vascular assist and complete lower limb assessment blood supply before considering use of debriding wound care products as directed for treatment aims for limb necrosis in “Wound management guideline with TIMES”.

This is all recorded within the skin individual plan of care (IPOC).

TIMES is a wound assessment guide:

• T: tissue
• I: inflammation or infection
• M: management of exudate
• E: edge of wound
• S: surrounding skin

See appendix K wound management guideline (TIMES).

5.2.5 Documentation of pressure ulcer

Document the origin, length, width, depth, wound bed presentation and category (using the above classification system) in the patients care plan.

Follow minimum data guidance (appendices to be added) complete the skin individual plan of care (wound care integrated pathway of care individual plan of care) and record variances as they present.

Healing pressure ulcers should not be reverse graded. A category 4 pressure ulcer does not become a category 3 as it heals it should be described as a healing category 4 pressure ulcer. Reasons for deterioration in a pressure ulcer should be noted and if not expected a thorough reassessment should be undertaken.

All pressure ulcers within the trust category 2 or above must be reported using the trust’s safeguard electronic incident reporting system (IR1) recognising the occurrence of pressure ulcers as adverse events. The details of the incident registration number to be recorded as a reminder in the patient’s electronic records on patient home page.

Trust acquired category 3 and category 4 to be investigated by systematic judgement review with root cause analysis (RCA). The author of the report will present findings to the trust pressure ulcer systematic review panel to establish if there was a no lapse in care but lessons learnt or lapse in care which is followed up with injury being logged as serious incident within full investigation to timeline. Duty of candour process needs to commence.

The simple fact that a person at risk has a pressure ulcer, even a category 3 or category 4, or multiple pressure ulcers, more than 3 or 4 at a lower category or mixed categories, is not in itself a reason to suspect abuse or neglect. There are a number of factors to help decide whether it potentially indicates neglect or whether it indicates a need for care providers to improve practice.

These factors include:

• the person’s physical health and existing medical conditions
• any skin conditions the person may have
• any other signs of neglect, such as poor personal hygiene
• the appropriateness of their care plan and whether it has been properly carried out
• the person’s own view, and the views of their family and friends, on the treatment and care

Consider these factors against The Care Act, Three Point Check (for section 42 enquiry)

The safeguard duty applies to any adult who:

• has need for care and support (whether the authority is meeting any of those needs)
• is experiencing, or is at risk of, abuse or neglect
• as a result of that need is unable to protect themselves from either the risk of or the experience of abuse or neglect

Staff will record in the appropriate document or care plan the patients and carers understanding and comprehension of pressure ulcer prevention or management plans. This to include information on the patient’s capacity to understand the information to ensure informed choose. The patient’s capacity to be recorded on completion of mental capacity form (Mental Capacity Act form).

Staff will record in the appropriate document or care plan the distribution of patient or carer information.

Staff will record in the appropriate document or care plan efforts to re-enforce the principles and activities needed for an effective management plan.

When a patient or principal carers decline to take on board the recommendations relating to pressure ulcer prevention or management, for example, use of pressure relief equipment, limit the time spent sitting in a chair. After explanation of the advice provided, the potential benefits and the probable risks of not following the recommendations they should be given the opportunity to record their preferences by completing the informed refusal form available on TPP SystmOne.

The issues covered by the informed refusal form need to be revisited at least monthly, to ensure the accurate records of patient’s preferences and choices.

5.2.6 Treatment of pressure ulcer

A patient with a pressure ulcer will also require preventative care plan as well as a wound treatment plan for pressure ulcer management. Patients with pressure ulcers should receive an initial and ongoing holistic assessment. This section of the policy should be used in conjunction with wound management guidelines.

Referral to tissue viability and lymphoedema service (TVALS) should be made when:

• patient has a category 3 or category 4 pressure ulcer
• patient presents with a deteriorating pressure ulcer
• patient presents with a difficult to manage pressure ulcer
• patient presents with concerns regarding neglect or safeguarding contributing issues to pressure ulcer development
• if patient refuses treatment seek advice from the tissue viability and lymphoedema service

5.2.6.1 Liaison between care settings

Pressure ulcer prevention and management is complex, frequently crosses care and professional boundaries and benefits from a multidisciplinary and collaborative approach to care.

Sharing information and documentation will ensure continuity between care settings and ensure an appropriate package is instigated.

When possible, communication should take place prior to transfer and, or discharge ideally the information should include:

• patient’s level of risk
• any equipment used
• skin condition
• plan of care, for example, moving and handling plan, member of multidisciplinary team involved
• relevant social and cultural information including communication needs
• wound dressing regimes
• wound dressing supplies for one change, to allow time for further supplies to be arranged

5.3 Wound photography using smartphone or digital device

5.3.1 Aim

This procedure has been prepared to ensure best practice and standardisation of digital wound photography with a smartphone or digital device across the organisation.

5.3.2 Scope

The target audience for this procedure are frontline clinicians who have an organisation owned smartphone or digital device and are directly involved in providing wound care. Clinicians completing the risk assessment where skin damage has been identified.

5.3.3 Procedure

Digital imaging should be a standard part of wound assessment but not undertaken so frequently that it places unnecessary burden on patients, carers or health and care professionals.

Digital images should be recorded as part of the wound dressing procedure before a dressing is applied or after a dressing is removed. Removing a dressing for the sole purpose of taking an image should be avoided.

5.3.3.1 Principles

• Digital imaging must only happen if the patient, their legal representative or parental guardian gives valid consent.
• Where there are concerns about the patients capacity a mental capacity assessment should be undertaken and recorded on the MCA1 questionnaire on SystmOne in line with the Mental Capacity Act (2005) policy.
• Matters of privacy, dignity and safeguarding should be practiced in accordance with existing trust policies.
• Digital imaging by clinicians should only be undertaken using digital devices owned and approved by Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH). Where possible, devices used to capture digital wound images should be encrypted.

Images should be sharp, clear and well formatted (centred, at an appropriate angle) free of extraneous details and with a plain background

5.3.3.2 Assessment

Patients with any wounds or tissue damage will have an initial and ongoing assessment of their wound using the trust recognised wound assessment tool on SystmOne skin individual plan of care (IPOC). This assessment should be supported by digital wound photography.

All wounds or tissue damage should be photographed on the initial assessment.

This includes all grades of pressure sores, surgical wounds, leg ulcer, abrasion, blister, burn, skin graft, skin tears, diabetic foot ulcers, sinus wound, bite wounds including insects, laceration, fungating wound, haematoma or any alteration in the skin that may cause concern.

The wound should be re-photographed:

• monitored during the healing process at least every 4 weeks
• if there are any significant changes or concerns regarding the wound
• to show the patient their wound to promote compliance with treatment
• to record changes that could have implications for treatment prior to commencing new treatment
• to promote supportive assessment

5.3.3.3 Risk management

Precautions are required to reduce risk of cross infection caused by using digital devices in multiple care settings (refer to the Infection prevention and control manual).

General Data Protection Regulation (GDPR) will not be compromised. Identity of the patient will be protected at all times.

Written consent must be obtained for the specific purpose of education or publication as part of an academic paper (the tissue viability and lymphoedema service (TVALS) only if the digital image is for a purpose other than the persons treatment or care.

5.3.3.4 Consent

The clinician is responsible for ensuring the patient or parental guardian has given informed consent before any photography takes place. This consent will be documented in the patient’s clinical record (refer to the consent to care and treatment policy).

If the patient lacks capacity to give consent a decision should be made in their best interests and recorded in the patient notes.

5.3.3.5 Taking photographs

• Continue to follow aseptic non-touch technique procedure.
• Care will be taken to protect patient identity by ensuring that faces or any other obvious features are obscured, for example, face, tattoos, birthmarks.
• Patient dignity and modesty will be protected by ensuring minimum patient skin exposure. Genitalia will be covered to preserve dignity. If damage is around or on genitalia and safeguarding is a concern, clinical judgement will be used.
• The wound and surrounding skin (in particular the perineum) will be cleansed if indicated prior to the photograph being taken.
• Follow-up photographs will be taken with the patient in a similar position to previous photographs.
• Follow-up photographs will be taken from a similar angle and distance so that photographs can be compared objectively.
• During image capture, avoid physical contact with the patient and prevent the camera or device from coming into contact with the wound or other potential sources of infection.
• Ensure that each photo has clear identification with the NHS number, patients date of birth, date of photograph, location of wound, if possible use the sterile ruler from the dressing pack.

In the event of not being able to use the sterile ruler, there is an option to use the “paint” application to record the patient’s details in a text box. This option should only be used if the wound is in a difficult location, or if there is difficulty taking the photograph.

• As needed, if the patient should be helped into a neutral position which they can comfortably hold, it may be necessary to seek additional assistance from another professional or carer or to separate skin folds to fully view the wound.
• Where possible, move the camera or the device, rather than the patient.
• When taking subsequent images, see to replicate the same positioning, surroundings, and lighting of the original image.
• Email photograph from Organisations mobile device to personal NHS email account. Check email has been received, delete from trust mobile device. Download the photograph from personal email onto desktop, go into patient record on SystmOne, click record attachment, click attach file, click desktop to locate appropriate photograph, select, this will then add to patients record. Delete photo from desktop and delete email containing patients photograph. Please see below for guidance on uploading photographs.
• Records attachment video guide

See appendix M for printable simplified recommendations for taking images.

5.3.4 Storage of photographs

Photographs will be stored in the patient’s main clinical record. This will be the SystmOne electronic patient record whenever possible. The photograph will be uploaded at the earliest opportunity and added as an attachment in the communication folder.

Photographs should be deleted from the camera or mobile device as soon possible after the picture has been added to the clinical record.

Photographs must not be stored on laptops or computers.

No other record of the photograph will be retained unless there is a specific intention for its use as stated within the consent to care and treatment policy.

5.3.5 Quality improvement

The quality of digital imaging should be monitored as part of the process for supervision, clinical record keeping and Radar process.

6 Training implications

6.1 Tissue viability and wound care for community colleagues, clinical skills and development

• Colleague groups: registered nurse, registered nurse associate, health care assistant.
• Wound care alliance modules of training:
  • aseptic technique, removal of clips and sutures (8 hours)
  • TIMES (8 hours)
  • wound healing (8 hours)
  • wound cleansing (8 hours)
  • skin tears (8 hours)
  • tier 1 and 2 bandaging (4 hours)
  • pressure ulcers (4 hours)
  • negative wound pressure (6 hours)
  • delayed healing (4 hours)
  • wounds with simple wound infection (8 hours)
  • diabetic foot wound (8 hours)
  • leg ulcers including ankle brachial pressure index (ABPI) (8 hours)
• Delivery method: practical and face to face for all training.
• Training delivered by whom: community practice educators.
• Where are the records of attendance held: electronic staff records (ESR) system.

It is each person’s professional responsibility to ensure their knowledge is updated accordingly as part of his or her personal professional development plan. A refresher and updates of skills should be completed 3 yearly.

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

No issues have been identified in relation to this policy.

7.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1). No issues have been identified.

8 Other associated documents

• Royal Marsden NHS Trust Manual of Clinical Procedures
• Doncaster Wound Care Formulary
• Infection prevention and control manual
• Consent to care and treatment policy
• British National Formulary
• Nursing and Midwifery Council Code of Professional Practice 2015
• Physical health policy

9 References

• Coleman, S., Nelson, E. A., Vowden, P. et al. (2017) Development of a Generic Wound Care Assessment Minimum Data Set. Journal of Tissue Viability. 26 (4) 226 to 40.
• Furlong W (2015) Recommended frequency for ABPi review for patients wearing compression hosiery. British Journal of Nursing Volume 24, Number 20.
• Guest JF, Ayoub N, McIlwraith T. (2015) Health economic burden that wounds impose on the National health Service in UK BMJ Open 5 (12).
• Guest JF, Vowden K, Vowden P (2017) the health economic burden that acute and chronic wounds impose on an average clinical commissioning group and health board in UK J Wound Care 26(6) 292 to 303.
• International Wound Infection Institute (2016) Wound Infection in Clinical Practice.
• International Consensus (2013) Making the Case for Cost-Effective Wound Management
• Leg Ulcer infection; antimicrobial prescribing (NG152)
• NHS England (2016) A Framework for nursing, midwifery and care colleagues, Leading Change, Adding Value.
• NHS Improvement (2018) Pressure ulcer; core curriculum.
• National Wound Care Strategy Programme (2024) Pressure Ulcer Recommendations and Clinical Pathway
• PSIRF NHS England (2024) Patient Safety Incident Response Framework
• NHS Right Care scenario (2017) The variations between sub-optimal and optimal pathways; Betty’s story: Leg ulcer wound care.
• Wounds International (2016) Wound Infection in Clinical Practice: Principles of best practice.
• Wounds UK (2018) Best Practice Statement; Improving holistic assessment of chronic wounds.
• Wounds UK (2020) Best Practice Statement: Management of lower limb skin tears in adults. Wounds UK, London.
• Wounds UK (2018) Best Practice Recommendations for the prevention and management of skin tears in aged skin.
• Mobile devices, social media, the internet and digital content, appropriate and acceptable use procedure
• Royal College of Nursing (RCN) position statement: Nursing staff using personal mobile phones for work purposes.
• K Jacob (2019) Best practice for capturing and presenting accurate wound image. Wound Uk Journal Vol:15 Issue :01
• Estacado, N and Black, J (2019) Ten top tips: wound photo documentation. Wounds International, 10(3), page 8 to 12.
• Use of digital images for wound care

10 Appendices

10.1 Appendix A responsibilities, accountabilities and duties

10.1.1 Chief executive

The chief executive retains overall responsibility for the development and implementation of trust policies.

10.1.2 Director of nursing and allied health professionals

Is the executive lead for safeguarding.

10.1.3 Deputy chief nurse and allied health professionals

The deputy director of nursing is responsible for the development, review and monitoring of this policy.

10.1.4 Clinical nurse specialist in tissue viability

Clinical nurse specialist in tissue viability providing expert professional advice on tissue viability and wound care to other professionals, multi-disciplinary groups, patients and carers. Advising on complex issues relating to tissue viability and lymphoedema and treatments and interventions, delegating responsibility to trust colleagues as appropriate

• To report any breaches in policy compliance through the trusts electronic reporting system, Radar and to the Health Safety and Security Committee.
• Leading in the investigation of identified breaches of tissue viability and contributing to serious incidents (SIs) reports as required
• Managing the Tissue Viability and Lymphoedema team of registered nurses and health care assistant.

10.1.5 Tissue viability and lymphoedema services (TVALS) registered nurses and healthcare assistants

Tissue viability and lymphoedema services (TVALS) registered nurses and healthcare assistants who deliver tissue viability, wound care and lymphoedema management to patients in their preferred place of care.

10.1.6 Tissue viability and lymphoedema service (TVALS)

Wound care and lymphoedema advice can be obtained from the tissue viability and lymphoedema service (TVALS). The normal hours of service are 8:30am to 4:30pm, Monday to Friday. The service can be contacted via phone on 01302 566 999.

Referral to the service can be processed through SystmOne by completion of the tissue viability and lymphoedema service referral form. Referral can be made by any healthcare professional or social care professional.

10.1.7 Service managers and modern matrons

Service managers and modern matrons includes ensuring that all colleagues are aware of the manual and adhere to policies, procedures and guidance.

• Identifying training needs and ensuring colleagues are appropriately trained in tissue viability and wound care issues.
• Ensuring colleagues have protected time to attend training and educational sessions in tissue viability and wound care.
• Ensuring compliance with the audit requirements of the policy.
• Identification of learning from incidents.

10.1.8 Registered nurses and clinicians

Registered nurses and clinicians must only work within their competency.

It is the registered nurses responsibility to

• undertake initial and ongoing assessment of wound, surrounding peri-wound tissue and associated conditions
• following the identified pathway plan, implement and evaluate and record in the appropriate documentation. Monitor wound progress by reassessing a healing wound after 3 dressing changes by healthcare assistant and support workers or more frequently if wound is deteriorating or static
• provide support to healthcare assistants and support workers through the competencies for skin assessment and wound care
• continue to ensure support and education as required to ensure safe practice

10.1.9 Registered nursing associates

Following a plan of care assessed by a registered nurse provide wound care following the wound care formulary pathways. Record and report any change in condition of wound to registered nurse.

Complex wounds should have a clear care plan to follow and escalation plan in place.

10.1.10 Healthcare assistant and support worker

Following a plan of care assessed by a registered nurse provide wound care following the wound care formulary pathways. Record and report any change in condition of wound to registered nurse, dependent on area of practice.

Wound care of complex wounds should not be delegated to healthcare assistant and support worker. The definition of a complex wound is:

• deteriorating category 3 and category 4 pressure ulcer
• deep cavity wound
• fistulae and deep sinus wounds
• deteriorating lower leg wounds that require anything but conservative or palliative care
• infected or dehisced surgical wounds

Wound care should not be delegated to healthcare assistants and support workers if the wound presents with a significant risk of developing a complicated such as pain or risk of haemorrhage.

10.1.11 Rotherham and North Lincolnshire Localities: Rotherham care group and North Lincolnshire care group.

The principles of the tissue viability and wound management policy and procedures are upheld within the trust care setting but the localities’ tissue viability and wound care services is provided by Rotherham NHS Foundation trust and North Lincolnshire and Goole NHS foundation trust.

10.2 Appendix B monitoring arrangements

10.2.1 Pressure ulcer risk assessment

• How and who by: local audit.
• Reported to: Safeguarding Assurance Group.
• Frequency: annually.

10.3 Appendix C skincare protocol for incontinence associated dermatitis (IAD) primary care

Refer to appendix C: skincare protocol for incontinence associated dermatitis (IAD) primary care (staff access only)

10.4 Appendix D pressure ulcer risk primary or secondary evaluation tool (Purpose T)

Patients wearing prescribed anti-embolic stockings for up to 23.5 hours a day, they require removal, for a maximum of 30 minutes in a 24-hour period to allow the legs and feet to be washed and skin condition and integrity observed.

Document all findings:

• staff should be aware of the following signs on the skin which may indicate early development of pressure ulcers.
• persistent erythema (redness)
• non-blanching hyperaemia previously identified as non-blanching erythema (redness)
• blisters
• discolouration
• localised heat
• localised oedema
• localised induration

Assessment should involve a thorough inspection of the skin, and this should include finding out about the patients’ baseline skin tone following the skin tone tool (adapted from Ho and Robinson, 2015). Patients with darkly pigmented skin have a high melanin concentration in the skin, which makes it difficult to detect erythema, the main indicator of pressure damage. There are other signs and symptoms that can be observed:

• purplish or bluish localised areas of skin
• temperature change, initial warmth due to the inflammatory response which will become cooler as tissue death occurs
• localised oedema due to the inflammatory response
• localised induration due to excessive inflammation and necrosis (Wounds UK 2021)

Full assessment of skin areas can often involve removal of clothing, surgical appliances and mobility aids. Assessment should not only be visual as pressure ulcers can often be felt as soft and boggy. Persistent redness (erythema) does not always lead to ulceration but must be closely observed.

Other causes of skin damage and redness may be from incontinence rather than pressure incontinence associated dermatitis (IAD), any area of abnormal skin should be examined by a registered nurse and documented.

10.5 Appendix E react to RED patient and carer leaflet

Refer to appendix E: react to RED patient and carer leaflet (staff access only).

10.6 Appendix F food first

Refer to appendix F: food first.

10.7 Appendix G eating, drinking and swallowing awareness in dementia

Refer to appendix G: eating, drinking and swallowing awareness in dementia.

10.8 Appendix H prevention of medical device-related pressure ulcers (MDRPU)

Refer to appendix H: prevention of medical device-related pressure ulcers (MDRPU).

10.9 Appendix I debridement larval therapy pathway

Refer to appendix I: debridement larval therapy pathway (staff access only).

10.10 Appendix J Doncaster community wound care formulary

Refer to appendix J: Doncaster community wound care formulary.

10.11 Appendix K wound management guideline (TIMES)

Refer to appendix K: wound management guideline (TIMES) (staff access only).

10.12 Appendix L repositioning schedule

Refer to appendix L: repositioning schedule (staff access only).

10.13 Appendix M preparation for taking images of wounds

1. Explain to the patient why you wish to take a digital image and seek their verbal consent. Document consent in their notes.
2. Before starting, ensure everything necessary is to hand and if assistant is needed there are sufficient staff.
3. Ensure the imaging device is functioning correctly and has sufficient power and storage capacity or memory.
4. Make sure the patient is in a comfortable position, with the entire wound visible but private and personal body parts (for example, genitals, breasts) and identifiable features (such as face, tattoos or birthmarks) covered. If there are previous images, seek to replicate the previous positions.
5. Where possible use an uncultured pale or neutral background, ideally non-reflective and neutral grey or surgical drape or sterile sheet with no personal identifying items or other people visible. Ambient natural light is ideal. Avoid extremes of light or dark and minimise shadows. If flash is used document use.
6. Decontaminate your hands, put on a disposable apron from the wound care dressing pack, remove the dressing and cleanse the wound, surrounding skin and any skin or clothing that will be visible in the digital image unless this is needed for legal or safeguarding purposes. Remove gloves and decontaminate your hands.
7. Decide how many images will be needed. The recommended minimum is an image of the wound plus an image of the site of the wound, for example, leg, abdomen. Instructions for taking images of wounds
8. Use a single-use disposable measuring scale or an auto-scale (if available on the device).
9. If the digital imaging device does not automatically immediately upload the image to the patient’s digital clinical record, a patient identifier, for example, the patients initials or NHS number should be visible either within the image or at the beginning and end of the image sequence.
10. Scales with colour control patch to take account of variation of skin tones are recommended.
11. Aim to take a clear, close-up photograph of the wound. Hold the camera or device at a distance so that you can photograph the whole wound if possible:
    • if the wound is long, you may need to take more than one image to capture the whole wound
    • for some sites, for example, the heel, it may be easier to use a mirror to view the wound (do not use the camera flash if a mirror is used)
    • gentle tension on excess body tissue or the separation of skin folds may be necessary to reveal the depth of a cavity or you may need to lift the leg to photograph the heel or separate toes
12. Where possible, point the camera or device directly at the wound, for example, straight in front of the wound and not at an angle.
13. Allow the device to focus on its own (auto-focus). If needed, focus manually. This can usually be done by tapping the screen or pressing down the button slightly. You may need to move the camera or device further away if it cannot focus.
14. Check the images on the display screen. It should be in focus, unblurred well-lit and ideally with no shadows over the wound. You can try taking a picture with and without the flash (if available) to see what looks best. It is very important that the photo does not show any identifiable features, such as patients face and tattoo. If you need to take another photo until you are happy that you have a clearest photo possible.
15. Delete unsuccessful photos as you go along so you are only left with the ones that you want.
16. Decontaminate your hands and equipment before and after taking the photos.

Page last reviewed: May 29, 2026
Next review due: May 29, 2027

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