Tissue viability for people living with or at risk of frailty

As frailty can impede a person’s ability to “bounce back” after illnesses and lessen their reserves against infections, frail people are more susceptible to wounds, and complications associated with longer healing periods. While recurrent wounds are not considered a frailty characteristic, they can be an indicator that someone is frail and could prompt a review.

Relevant Legislation

Mental Capacity Act

Health and Social Care Act

Reporting of Injuries, Diseases and Dangerous Occurrences Regulation

Resources

Skills for Health National Core Capabilities for Wound Care

HWE Clinical Guidance Documents

NICE Guidance for Pressure Ulcers

Sheffield Teaching Hospital NHS Foundation Trust “It’s SSKIN” YouTube video

Pre and Post Knowledge Assessment

HCPA have developed word documents which can be used as a guide for pre and post knowledge assessments of the different levels outlines in this framework. The questions in this document can be copied into other formats such as Microsoft Forms or Excel and are a guide to the type of information you need your staff to know.

Tissue Viability Awareness Pre & Post Awareness Click here

Tissue Viability Intermediate Pre & Post Assessment Click here

Tissue Viability Advanced Pre & Post Assessment Click here

Learning Objectives

Identify

Understanding how a person’s skin should typically appear is important in supporting staff to identify when there may be a problem. Skin can show signs of infections, rashes, wounds, pressure ulcers or other medical issues, as well as being an indicator of abuse, where certain wounds may be visible. Underlying issues may affect the way a person’s skin appears so it is important for staff to understand risk factors and comorbidities relating to skin issues.

Awareness

For all staff providing care for frail people.

Staff know local protocols, policies and guidelines relating to wound care and treatment
Staff have an awareness of the anatomy and physiology of the skin and the importance of maintaining its integrity
Staff understand the definition of a wound and can differentiate between skin tears and other wounds
Staff understand red flags for wounds including skin tears and lower leg ulcers (including diabetes, pressure ulcer, skin infection and deterioration)
Staff are able to provide initial wound care including completing an initial wound assessment, wound and skin cleaning
Staff understand how and when to use simple low-adherent dressing with sufficient absorbency where appropriate,
Staff can manage wounds conservatively until red flags have been managed
Staff know the signs of significant arterial insufficiency and to refer for urgent vascular care
Staff know the signs of a pressure ulcer and who to alert
Staff are able to offer advice on pressure ulcer management including prevention and early signs
Staff understand how different skin tones may present different symptoms for wounds (i.e. blanching may be less apparent, skin may appear a greenish hue rather than yellow etc.)
Staff know referral routes for assessment and how to refer

Assessment

Being able to understand the level and progression of skin problems is important in understanding the correct treatment required for a pressure ulcer

Awareness

For all staff providing care to people living with frailty.

Staff can conduct a SSKIN Assessment
Staff can conduct a STARR assessment
Staff understand pressure ulcer risk management and can recognise the ulcer categorisation including understanding of next steps such as escalation
Staff can follow a skin tear pictorial guide and understand next steps including escalation

Intermediate

For non-specialist healthcare professionals.

Non specialist healthcare professionals are able to conduct a holistic lower leg ulcer assessment (PMH and drug history, Comprehensive assessment including psychological needs, Wound assessment, Lower limb assessment including ABPI (‘Doppler’)/ vascular assessment, Ability to self-manage)

Advanced

For staff responsible for Pressure Ulcer Categorisation.

Staff understand how to carry out Pressure Ulcer Categorisation and necessary next steps including referral

Management Options (Prevention)

It is important that staff understand what preventative measures are available and have an understanding of the benefits of compression, to prevent further deterioration.

Awareness

For all staff providing care to people living with frailty.

Staff understand the use of compression for patients with venous disease and are able to apply compression stockings as advised by prescriber
Clinical staff are able to identify those at risk of skin tears and know what actions to take that can reduce the risks
Nonclinical staff are able to identify those at risk of and early signs of pressure ulcers
know how to treat these and when to refer

Advanced

For staff responsible for people with venous disease.

Staff understand compression for wound management of patients with venous disease and are able to advise a person when and how to use this

Management Option (Post-Wound)

Being able to manage a wound is critical to the recovery of the person. It is important that staff can identify the best on-going management strategies to ensure that wounds are dealt with in a timely manner.

Awareness

For all staff providing care for people living with frailty.

Staff know red flags for a Skin Tear and whether a referral or 999 call is necessary
Staff know basic life support and first aid
Staff understand how and when to clean a skin tear
Staff are able to conduct a skin tear and wound assessment
Staff know next steps for skin tears classified as Type I-Iia (Assess for Frailty and 24-48 hour follow up)
Staff know next steps for skin tears classified as Type IIb-III (Same day referral)
Non-clinical staff understand the differences between dressings and how to apply and when to refer
Staff understand their responsibilities within the skin tear pathway including knowing when to refer
Staff know Leg Ulcer Red Flags
Staff understand amber flags relating to Ulcer Care and understand how to manage these before referral
Staff know that a person with a wound may find the results of investigations and diagnosis difficult to understand or accept and can provide support as needed
Staff understand that wounds may be a result of safeguarding issues, recognising particular at-risk groups and take appropriate action when there are grounds for concern
Staff have an awareness of the wound healing process and other factors which can affect healing
Staff recognise the signs of wound deterioration and know how to report the deterioration or ask for advice
Staff are able to contribute to wound therapies as instructed
Staff can demonstrate a general knowledge of infection prevention and control techniques and protocols
Staff have a working knowledge of local and, where appropriate, national wound care protocols and guidance
Staff understand the wound healing process and other factors which can affect healing
Staff understand ongoing management of a healed Venous Leg Ulcer

Intermediate

For staff responsible for ongoing management of wounds.

Non-specialist staff understand pathway 5 (Lower leg ulcer management), when to use this and what their responsibilities are
Staff are able to conduct immediate and necessary intervention for leg ulcer management
Staff can recognise how deteriorating and/or complex wounds can impact mental health and identify when this is relevant.
Staff understand ongoing management of a healed ulcerated foot
Staff understand ongoing management of a healed Arterial Leg Ulcer
Staff understand ongoing management of a healed Mixed Leg Ulcer

Advanced

For non-specialist clinical staff providing wound care.

Staff know how to apply first line light compression
Nurses can conduct 24–48-hour review including knowing how to document findings and signs of infection
Clinical staff understand the skin tear pathway and their responsibilities and when to refer if needed. Staff know where to find this pathway if needed
Staff can carry out a holistic leg ulcer review
Staff can identify venous disease/ oedema
Clinical staff are able to conduct a holistic patient assessment
Staff can interpret the results of relevant diagnostic investigations, formulate a diagnosis and determine the appropriate treatment and care management plan for noncomplex wounds
Staff recognise when the results of diagnostic investigations are incomplete or do not identify the reasons for non-healing and can seek advice from a senior member of the multi-disciplinary team
Staff can plan for post-diagnostic follow up, recognising the needs of families and carers providing care and support for individuals at high risk of wound deterioration, making onward referral as required