Quality improvement case study

React to Red – Using a SSKIN bundle to reduce pressure ulcers in patients receiving domiciliary reablement care

A PDSA framework was used for this quality improvement project

1. Plan

Problem identified

There were patients in the community being cared for by a team of carers who were either helping to prevent hospital admission or supporting safe discharge. Pressure ulcers were being reported within this group of patients. 

Problem analysis

Most of these patients were not on the community nursing (CN)  caseloads and therefore had not been pressure damage risk assessed. The team of carers had not received any pressure damage training.

Potential solutions

To implement a SSKIN bundle check list as part of the carers daily routine in order to determine pressure damage risk or early detection of actual pressure damage. In addition, a process for referring concerns to the community nurses with a rapid response time was necessary.

Plan for solution selected

SSKIN (Skin assessment, Surface, Keep moving, Incontinence/ moisture, Nutrition) bundle check list designed. 3 hour training programme created and dates for delivery to carers agreed. Rapid referral and response process with community nurses agreed. Community nurses to keep a safety cross to monitor pressure damage (Category 1 – 4) incidents over a month.

2. Do

Implementation of solution tested – To test the SSKIN bundle model, one locality within the county was selected. Training was delivered to the carers and the SSKIN bundle check list documentation shared and issued. Community nurses were invited to attend the training for them to fully understand the carers role and process for CN referral.

The five sections of the SSKIN bundle check list was to be completed by a carer every day the patient received care. All components were to be completed if 100% accuracy was to be achieved. SSKIN bundle check lists were collected at the end of each week and sent for analysis by Tissue viability and community matron.

3. Study

Evaluation of implementation – Initial analysis found that only 40% of the SSKIN bundle was being completed. Skin inspection and Surface were frequently omitted. At the 2 weekly meetings put in place, patient choice and willingness to have their skin assessed were cited as reasons for these sections of the SSKIN bundle not being completed. Suggestions on how this could be addressed was shared with the group and communicated to the carers.

Feedback from the community nurses and analysis of the safety crosses demonstrated rapid response to concerns raised by the carers. Incident reporting saw a reduction in category 2 damage and an increase in category 1 damage.

We continued to test the process and subsequent returns demonstrated an improvement in SSKIN bundle compliance (This averaged 80 – 100%) and an overall reduction of pressure damage incidents in this locality.

4. Act

System wide implementation

Based on the results of the initial test, roll out to another locality was agreed with an aim for full county wide implementation over time.