Welcome to the latest key papers and publications from the past few months focussing mainly on tissue viability in the nursing profession.
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Pressure ulcers: a clinical audit to determine compliance against the aSSKINg framework in an adult community nursing setting
Abstract: Assessment of pressure ulcer (PU) risk remains a challenge in clinical practice. The first part of this article (Martin and Holloway, 2024) discussed the evidence base underpinning the development of clinical guidelines for PUs alongside the creation of the bundle approach regarding PU prevention. This article, part two, presents the results of a clinical audit that explores compliance against a PU prevention bundle (the aSSKINg framework) in an adult community nursing setting in the south-east of England. The clinical audit was conducted between July-December 2021 and included records of 150 patients. Overall, compliance against the aSSKINg framework was poor, with only two criterion being met: equipment provision for chair and referral to the tissue viability team. Short-term recommendations are that mandatory PU training for staff in the management of PUs should be implemented, and the tissue viability nurse network should be increased. The long-term recommendation was the introduction of the aSSKINg framework as a template into the electronic patient record.
Source: Martin S. British Journal of Community Nursing, Sep 2024; 29(Sup9): S28 – S34
Nurses' views on changes to pressure ulcer categorisation: results of a Wound Care Alliance UK survey
Abstract: The Wound Care Association UK (WCAUK) is committed to supporting both the accurate and consistent delivery and reporting of pressure ulcers/injuries based on the best available research and evidence. It is known that strategic and clinical guidance to support the delivery of evidence-based care does have a significant impact. Recent proposals to change pressure ulcer categorisation led the WCAUK to undertake a questionnaire survey of its members. This article outlines the importance of evidence-based guidance on the categorisation and assessment of pressure ulcer, highlighted by the responses to published changes to pressure ulcer categorisation for nurses in England, and presents the results of the survey. The article concludes that, although the discipline of tissue viability is constantly developing, the changes must be based on evidence, and clinicians must be supported strategically and practically to implement any proposed changes. Since publication of the new guidance the document has become the subject of further discussion, following concerns raised by tissue viability nurse specialists with strategic responsibility for change, as well as generalists who are expected to implement the changes.
Source: Stephen-Haynes J. British Journal of Nursing, Nov 2024; 33(20): S16 - S22
The past, the present and the future
Abstract: Somebody asked me recently how I decide what to write about in the Editorial for BJN's Tissue Viability Supplement. I took a moment to think and gave the briefest of answers. When I reflected on it and really took the time, challenging myself, I concluded that it was a cumulative process of my experience of the past, the present and the future.
Source: Stephen-Haynes J. British Journal of Nursing, Nov 2024; 33(20): S3 - S3
The complex interplay between mechanical forces, tissue response and individual susceptibility to pressure ulcers
Abstract: Objective: The most recent edition of the International Clinical Practice Guideline for the Prevention and Treatment of Pressure Ulcers/Injuries was released in 2019. Shortly after, in 2020, the first edition of the SECURE Prevention expert panel report, focusing on device-related pressure ulcers/injuries, was published as a special issue in the Journal of Wound Care. A second edition followed in 2022. This article presents a comprehensive summary of the current understanding of the causes of pressure ulcers/injuries (PU/Is) as detailed in these globally recognised consensus documents.
Method: The literature reviewed in this summary specifically addresses the impact of prolonged soft tissue deformations on the viability of cells and tissues in the context of PU/Is related to bodyweight or medical devices.
Results: Prolonged soft tissue deformations initially result in cell death and tissue damage on a microscopic scale, potentially leading to development of clinical PU/Is over time. That is, localised high tissue deformations or mechanical stress concentrations can cause microscopic damage within minutes, but it may take several hours of continued mechanical loading for this initial cell and tissue damage to become visible and clinically noticeable. Superficial tissue damage primarily stems from excessive shear loading on fragile or vulnerable skin. In contrast, deeper PU/Is, known as deep tissue injuries, typically arise from stress concentrations in soft tissues at body regions over sharp or curved bony prominences, or under stiff medical devices in prolonged contact with the skin.
Conclusion: This review promotes deeper understanding of the pathophysiology of PU/Is, indicating that their primary prevention should focus on alleviating the exposure of cells and tissues to stress concentrations. This goal can be achieved either by reducing the intensity of stress concentrations in soft tissues, or by decreasing the exposure time of soft tissues to such stress concentrations.
Source: Gefen A. Journal of Wound Care, Sep 2024; 33(9): 620 - 628
Challenges ahead
Abstract: Happy New Year! This is an election year: I wonder what it will bring? The world of tissue viability faces many challenges and questions. Finances will remain a big challenge, whatever the outcome of the election.
Source: Stephen-Haynes J. British Journal of Nursing, Feb 2024; 33(4): S3 - S3
Key issues in an election year
Abstract: A General Election is an opportunity. So important is the government to the delivery of the NHS that, as a nurse, the coverage will be compelling viewing and listening for me. The productivity of the NHS is under scrutiny and there can be no doubt that there is a need to deliver better outcomes for the people of the UK.
One important issue is the lack of a clear strategy on social care, which has led to a crisis that has impacted the NHS. This needs to be a priority. Another issue is patients waiting on trolleys. In 2023, 35 000 patients waited for 12 hours on hospital trolleys every month in England (Lee, 2024). Working in tissue viability, my concern, apart from people waiting in discomfort or pain, is that this poses a significant challenge to pressure ulcer prevention.
Source: Stephen-Haynes J. British Journal of Nursing, Jun 2024; 33(12): S3 - S3
At a glance: pressure injuries
Abstract: Pressure injuries, also known as pressure ulcers or ‘bed sores’, are caused by prolonged pressure on the skin and underlying tissues and are common in healthcare settings. They result from a variety of factors including pressure, moisture and friction, with a higher risk among older adults, post‑surgical patients and those with limited mobility or long‑term conditions. These injuries can extend hospital stays and significantly impact patient recovery and mortality risk. Prevention includes regular repositioning, the use of pressure‑relieving devices, skin care and nutritional support. The National Institute for Health and Care Excellence provides guidelines to mitigate these risks through systematic risk assessments and targeted interventions. Early detection and specialist care by a multidisciplinary team are crucial to improving patient outcomes. Consistent pplication of prevention strategies are needed to reduce incidence, improve patient care and alleviate the economic burden of thesex injuries on the NHS.
Source: Williams L. British Journal of Nursing, Nov 2024; 33(20): S24 - S30
Integration of the aSSKINg framework into the electronic patient record: a quality improvement project
Abstract: Assessment of pressure ulcer (PU) risk is important in clinical practice and the need to document it in the patient's record is paramount. Despite national and international guidelines highlighting the need to document PU risk, nursing documentation remains variable. The first article in this series discussed the evidence base underpinning the development of clinical guidelines for PUs, alongside the creation of bundle approach for PU prevention. The second article presented the results of a clinical audit exploring compliance against a PU prevention bundle (aSSKINg framework) in an adult community nursing setting in the South East of England. This final article in the series presents the results of a quality improvement project that involved a clinical audit following the implementation of the aSSKINg framework into the electronic patient record (EPR). The aim was to improve nursing documentation for patients with PU risk. The clinical audit was conducted in two parts, with a pilot phase running between 6 February 2023 and 15 April 2023. After the template implementation into the EPR, a follow-up audit was undertaken between 1 November 2023 and 31 January 2024. Overall compliance against the aSSKINg framework improved, especially the completion of the PURPOSE-T on the first visit, full skin assessment and repositioning advice. Following the pilot phase, the aSSKINg template was rolled out in a phased approach to the adult community nursing, enhanced care home matrons and urgent community response teams.
Source: Martin S. British Journal of Community Nursing, Dec 2024; 29(Sup12): S16 - S21
Using a prognostic medical device for early identification of pressure ulcers: protocol for study design
Abstract: Background: An objective, physiological measurement taken using a medical device may reduce the incidence of pressure ulcers through earlier detection of problems signs before visual signs appear. Research in this field is hampered by variations in clinical practice and patient-level confounders.
Aim: The authors outline key considerations for designing a protocol for a study to assess the efficacy and safety of a prognostic medical device in reducing pressure ulcer incidence in a hospital, including comparators, randomisation, sample size, ethics and practical issues.
Method: Key issues relating to methodology and ethics are considered alongside a theoretical protocol, which could support future researchers in wound care trials.
Source: Keltie K. British Journal of Nursing, Jun 2024; 33(12): S8 - S18
Tissue viability and care of malignant wounds in patients near the end of life
Abstract: Skin changes at the end of life are common and can be attributed to a variety of factors. These changes can impact the appearance, texture and overall health of the skin, and can affect the person's comfort and overall wellbeing. It is important for health professionals to address these skin issues by providing appropriate skin care, pain management and emotional support. This article, the third in a series on palliative and end-of-life care, discusses risk assessment and monitoring of pressure ulcers, caring for malignant wounds and the importance of individualised care in a multiprofessional team.
Source: Russell J. Nursing Times, Jul 2024; 120(8): 44-47
Q&A approach to lower limb and leg ulcer management
Abstract: Here, Georgina Ritchie, director of education, Accelerate CIC, explains why she and colleagues decided to write a book on lower limb and leg ulcer management using a Q&A approach in order to tease out and explore the most relevant themes in this area of practice. [...]along with the important chapters on clinical assessment and management, we bring critique and synthesis to public health and the social determinants of health and how they affect patients with lower limb conditions. Interventions aimed at early management of CVI include a spectrum of approaches, including recommendations for lifestyle changes such as weight loss, increased physical activity, promoting good skin care and hygiene, and compression therapy. Early identification and referral to an appropriate specialist team for a patient suspected of having an atypical leg ulcer is essential and can assist in preventing unnecessary wound deterioration, managing the symptoms effectively, decreasing the risk of complications and improving quality of life for the individual.
Source: Anonymous. Journal of Community Nursing, 2024; 38(3): 63-66
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Frailty and the ageing skin: understanding skin tears
Abstract: The impact of ageing on the body and its association with skin harm and frailty in relation to multimorbidity, comorbidity and polypharmacy is clearly described in the literature. The ageing population globally brings with it the challenge for healthcare professionals of managing individuals with increasingly complex and inter-related needs. This article considers ageing skin and skin tears within the context of frailty as a syndrome. It discusses what frailty is understood to be, how to recognise and assess for it, and how to consider risk and prevention of harm to the skin of the ageing person with frailty.
Source: Sandoz H. Journal of Communty Nursing, Oct 2024; 38(5): 20-22, 24-26
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Content of a wound care mobile application for newly graduated nurses: an e-Delphi study
Abstract: Background: Wound care represents a considerable challenge, especially for newly graduated nurses. The development of a mobile application is envisioned to improve knowledge transfer and facilitate evidence-based practice. The aim of this study was to establish expert consensus on the initial content of the algorithm for a wound care mobile application for newly graduated nurses.
Methods: Experts participated in online surveys conducted in three rounds. Twenty-nine expert wound care nurses participated in the first round, and 25 participated in the two subsequent rounds. The first round, which was qualitative, included a mandatory open-ended question solicitating suggestions for items to be included in the mobile application. The responses underwent content analysis. The subsequent two rounds were quantitative, with experts being asked to rate their level of agreement on a 5-point Likert scale. These rounds were carried out iteratively, allowing experts to review their responses and see anonymized results from the previous round. We calculated the weighted kappa to determine the individual stability of responses within-subjects between the quantitative rounds. A consensus threshold of 80% was predetermined.
Results: In total, 80 items were divided into 6 categories based on the results of the first round. Of these, 75 (93.75%) achieved consensus during the two subsequent rounds. Notably, 5 items (6.25%) did not reach consensus. The items with the highest consensus related to the signs and symptoms of infection, pressure ulcers, and the essential elements for healing. Conversely, items such as toe pressure measurement, wounds around drains, and frostbite failed to achieve consensus.
Conclusions: The results of this study will inform the development of the initial content of the algorithm for a wound care mobile application. Expert participation and their insights on infection-related matters have the potential to support evidence-based wound care practice. Ongoing debates surround items without consensus. Finally, this study establishes expert wound care nurses’ perspectives on the competencies anticipated from newly graduated nurses.
Source: Gagnon J. BMC Nursing, May 2024; 23: 331
Managing hypergranulation in wounds
Abstract: Normal wound healing follows four distinct phases: haemostasis, inflammation, proliferation and finally, maturation. If any barriers to healing occur within these four phases, the healing process will be delayed or may even stall (Mitchell, 2021). One of the common barriers to healing is hyper or overgranulation, or 'proud flesh'. Hypergranulated wounds can cause concern to both patients and healthcare professionals, and, although common in wound care, there is a limited evidence base and currently no guidelines for management. This article discusses the causes of hypergranulation, with suggestions on how it can be managed.
Source: Brown A. Journal of Community Nursing, Feb 2024; 38(1): 24-27
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Effectiveness of interventions to enhance shared decision‐making in wound care: A systematic review
Abstract: Aims: To explore the effectiveness of interventions to enhance patient participation in shared decision‐making in wound care and tissue viability.
Background: Caring for people living with a wound is complex due to interaction between wound healing, symptoms, psychological wellbeing and treatment effectiveness. To respond to this complexity, there has been recent emphasis on the importance of delivering patient centred wound care and shared decision‐making to personalise health care. However, little is known about the effectiveness of existing interventions to support shared decision‐making in wound care.
Design: Systematic review of interventional studies to enhance shared decision‐making in wound care or tissue viability. This was reported following the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines 2020.
Methods: Interventional primary research studies published in English up to January 2023 were included. Screening, data extraction and quality appraisal were undertaken independently by two authors.
Data Sources: Medline, EMBASE, Cochrane Central Register of Controlled Trails (trials database), CINAHL, British Nursing Index (BNI), WorldCat (thesis database), Scopus and registries of ongoing studies (ISRCTN registry and clinicaltrials.gov).
Results: 1063 abstracts were screened, and eight full‐text studies included. Findings indicate, interventions to support shared decision‐making are positively received. Goal or need setting components may assist knowledge transfer between patient and clinician, and could lower short term decisional conflict. However, generally findings within this study had very low certainty due to the inconsistencies in outcomes reported, and the variation and complexity of single and multiple interventions used.
Conclusions: Future research on shared decision‐making interventions in wound care should include the involvement of stakeholders and programme theory to underpin the interventions developed to consider the complexity of interventions.
Implications for the profession and patient care: Patients setting out their needs or goals and exploring patient questions are important and should be considered in clinical care.
Source: Clemett V J. Journal of Clinical Nursing, Apr 2024; 33(8): 2813-2828
Effectiveness of specialised support surface modes in preventing pressure injuries in intensive care: A systematic review and meta-analysis
Abstract: Background: Patients in intensive care units (ICU) are at an increased risk of pressure injuries. In ICUs, specialised support surfaces are an intervention often used to prevent pressure injuries. This systematic review and meta-analysis aimed to ascertain the effectiveness of different specialised support surface modes for preventing pressure injuries to adult ICU patients.
Methods: Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, PEDro, Cochrane Library, Clinicaltrials.gov and eligible paper references were searched for appropriate studies. Studies were included if they investigated both dynamic support surface modes low-air-loss (LAL) and alternating pressure (AP), involved adult ICU patients (≥18 years old), and investigated pressure injury incidence. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Mixed Methods Appraisal Tool (MMAT) checklists were used for reporting and quality assessment. Risk ratios (RRs) with 95 % Confidence Intervals (CIs) were used to summarise pressure injury incidence. The pooled RR was calculated with the random-effects model using the Mantel-Haenszel method. Further secondary analysis examined length of stay (LoS) and severity of illness.
Results: The four included studies involved 3,308 patients. These studies were heterogeneous in design. When AP surface mode was compared with LAL surface mode, there was no significant difference in the occurrence of pressure injury (8.9 % versus 10.9 %, RR 0.64). Mattress mode also had no direct association with length of stay and severity of illness.
Conclusion: This systematic review and meta-analysis found no significant difference in the effectiveness of LAL and AP support surface modes in preventing pressure injuries in adult ICU patients.
Implications for clinical practice: Clinicians should remember that mattresses are just one element within strategies to prevent pressure injuries in ICUs. The equivocal findings of this systematic review highlight the complexity of preventing pressure injuries and underscore the importance of holistic nursing care.
Source: Lane B. Intensive and Critical Care Nursing, Aug 2024; 83: 103713
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Research topics on pressure injury prevention and measurement tools from 1997 to 2023: A bibliometric analysis using VOSviewer
Abstract: Objectives: To identify and visualize studies on pressure injuries in intensive care units, prevention of pressure injuries and measurement tools, and reveal the global trends in this field.
Research methodology/design: Descriptive and bibliometric analysis method study.
Setting: Data were obtained from the “Web of Science Core Collection” database on July 12th, 2023. For bibliometric data, the Web of Science database was searched with the keywords “intensive care unit,“ ”pressure injury,“ ”prevention,“ ”risk assessment tools,“ and critical care.” Performance analysis, scientific mapping, and bibliometric analyses were completed using the VOSviewer (1.6.15) software program for a total of 326 publications.
Main outcome measures: Publication, cluster, link and network map on pressure injury, prevention and risk measurement tools.
Results: As a result of the analysis, the most used keywords were “pressure injury,” “pressure ulcer,” “critical care,” “pressure ulcers,” “intensive care unit,” and “pressure injuries.” The journal with the highest number of publications (n = 55) was “Journal of Wound Ostomy Continence Nursing”, the highest number of articles (n = 47) was published in 2022, the most active institution was “Queensland University of Technology Qut” (20 articles), the country that published the most was the United States of America (171 articles), the institution that provided the most funding was the “National Institutes of Health NIH USA” (20 articles), and Cox J. was the author who published the most articles.
Conclusion: This study highlights popular fields of research in pressure injury prevention and risk measurement tools aimed at improving quality of care in intensive care units.
Implications for Clinical Practice: The bibliometric analysis method used in the study can lead nurses to conduct research to prevent pressure injuries in critical care patients and develop risk measurement tools to overcome deficiencies such as prevention tools and objective risk measurement tools in this field.
Source: Azizoğlu F. Intensive & Critical Care Nursing, Feb 2024; 80: 103557
Introducing playing games and a fun element to help deliver wound care education
Abstract: According to Tamara Chilver, author and home-schooling mum: "fun + learning = the best educational experience." This article describes how the tissue viability team in Glasgow set about introducing a fun element into wound care education. The article also includes practical guidance on some of the games played by delegates at the education sessions.
Source: Hodgson H. Wounds UK, 2024; 20(4): 72-75
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Integrated lymphoedema and tissue viability service: improving patient and wound outcomes
Abstract: This article will focus on the integration of tissue viability and lymphoedema services to improve outcomes for patients with leg ulceration. It will highlight why there is a need for lymphoedema specialist knowledge within the care of patients with leg ulceration and how the services are closely aligned. Lymphoedema can adversely affect wound healing and the article will provide case studies that highlight how developing a hybrid tissue viability and lymphoedema clinician or integration of the specialists can provide effective patient-centred care at reduced cost. The article offers potential strategies and suggestions on how to address inequalities in care and how to improve service provision.
Source: Stanton J. British Journal of Community Nursing, Apr 2024; 29(Sup4); S19-S26
The utilisation of a negative pressure wound therapy clinical decision tree in an acute care setting tissue viability service
Abstract: The aim of this case series and service evaluation was to demonstrate the beneficial clinical and economic outcomes of the utilisation of a negative pressure wound therapy (NPWT) clinical decision tree within routine practice. A total of 16 retrospective anonymised complex wound case studies were referred to the tissue viability nursing (TVN) service. Patients received NPWT as inpatients, as per routine practice. Data was reported as an aggregated cohort, with further stratification by wound type. Descriptive statistics were utilised. The most prevalent wound type was dehisced surgical wounds (n=10; 62.5%) located on the abdomen (n=9; 56.25%). Risk of contamination (43.75%) and exudate management (43.75%) were the most common rationales for choosing traditional NPWT (tNPWT). Seven patients (43.75%) were discharged from hospital still requiring NPWT, with five (71.4%) having wound criteria suitable for single use NPWT (sNPWT). Using tNPWT and sNPWT alongside a clinical decision tree can assist in optimising NPWT delivery to patients within an acute care setting.
Source: Leek K. Journal of Wound Management, Apr 2024; 25(1): 2-9
Oxygen Saturation or Tissue Oxygen Determinations on Skin Whose Viability is at Risk
Abstract: The triad of ischaemia, neuropathy, and infection are among the principal causes of lower extremity wounds that are commonly prevalent in patients with diabetic foot (DF) a condition in which peripheral arterial disease commonly co-exists. The prevalence of this condition is increasing globally and with it, the mounting costs of its management. One aspect of management is saving limbs and or digits, a crucial part of this process is assessing tissue viability of skin which is a focus of this review: there are other aspects which are well described in the literature. Amputations are offered to limit the damage resulting from acute/chronic ischaemia. Holstein measured skin perfusion pressure using a radioisotope clearance technique to describe critically ischaemic skin; he found 30 mm Hg as the threshold above which healing may reliably be expected. Recent advances in vascular surgery and related technology have informed evidence-based advice to revascularize and save limbs; in practice, this may leave a wound in the distal skin unhealed; managing these raises questions of tissue viability. Much effort has been made to manage, prevent and to better understand these lower extremity wounds using measurements of tissue oxygen, oxygen saturation and skin imaging. The measurement techniques and their relevant merits are examined in this article. Advances in wound management systems and protocols can also facilitate the repair processes, and those which can have a particular impact on restoring or maintaining tissue perfusion are also discussed in the article.
Source: Richardson M. International journal of Lower Extremity Wounds, 2024; Mar 23(1): 55-62
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Sharing the journey ... of setting up a Tissue Viability Service in NHS Tayside: the first year
Abstract: Last year’s Wounds Scotland conference saw a number of healthcare professionals share their journey of implementing changes to the way we deliver healthcare. Here, Jane Nicoll describes setting a new tissue viability service.
Source: Nicoll J. Wounds UK, Feb 2024; 20(1): 25-26
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