Not so long ago, it was a sore point, but now the North-East is leading the way… Peter Barron gets under the skin of a health service success story

IT is an uncomfortable statistic that more than half of patients admitted to hospital are at a high risk of going on to suffer from painful skin conditions, such as bed sores, ulcers and blisters.

That’s why it is vital for the NHS to find the best ways of managing what comes under the general term of “pressure damage” – an injury caused when the skin above a bony area such as a heel, elbow or hip comes into constant contact with some kind of surface like a mattress or chair.

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An ageing population makes the challenge even greater because the skin becomes more vulnerable as we get older, and with illness, malnutrition, and reduced mobility also having an adverse effect on the body, our skin is at huge risk of breaking down.

“The skin is an important barrier to infection so the more it can be protected, the less chance there is of complications and pain,” explains Joanne Todd, associate director of nursing for County Durham and Darlington NHS Foundation Trust.

The good news is that County Durham and Darlington NHS Trust is now being officially recognised as leading the way on the issue, with one of the lowest rates in Europe for pressure ulcers acquired in hospitals.

Despite the fact that more than 50 per cent of patients admitted to hospitals in the County Durham and Darlington NHS Foundation Trust area are at “high or very high risk” of pressure damage, there hasn’t been a single case recorded in the trust’s hospitals the last 16 months. In fact, many in-patient areas have not had a single patient develop pressure damage for more than six years.

And that’s proof of the progress made in the past 15 years under the leadership of tissue viability matron Carol Johnson, who saw the need for change, was backed by the senior managers of the trust, and then supported by her tissue viability nurses.

Carol set out to overhaul all elements of prevention, including the streamlining of wound dressings, introducing pressure- relieving equipment, educating frontline staff and patients, and reviewing policies and procedures. A formal risk assessment was established for each patient in the form of a “skin inspection” within six hours of admission. How great was the risk of pressure damage and what could be done to prevent it? They were the questions asked and what was considered a pioneering step several years ago is now standard practice across the trust.

Crucially, a much more sophisticated approach to the types of mattresses used by the trust was also adopted. With so many different conditions to treat, it was important to give each individual patient, including babies and children, the right mattress. “Pressure reduction” mattresses – designed to minimise the risks of skin damage – were made standard. For particularly vulnerable patients, specialist “pressure-relieving” mattresses can now be accessed quickly via a central loan facility.

Nearly a third of the mattresses used in the trust are replaced annually to ensure that they maintain adequate pressure-reducing properties. In addition, the trust is replacing the bedside armchairs across all nine of its sites with improved pressure-reduction chairs, with more than 700 installed so far.

Meanwhile, an extensive education programme has spread the expertise of the Tissue Viability Team across all wards and services, including those working in community care known as WRENS (Wound Resource Education Nurses). Their upskilling has played a vital role in the transformation.

Underpinning it all is a zero tolerance approach to any pressure damage caused while a patient is in the trust’s care. Any tissue damage must be reported so a review can be carried out and lessons learned. It adds up to a strategy which has put County Durham and Darlington ahead of the game with the rest of Europe catching up.

It is testament to the trust’s success that Carol Johnson was drafted in to help develop national guidance and research by Nice (the National Institute for Health and Care Excellence). A natural problem solver, Carol works with specialists across the trust’s services, identifying patient groups at higher risk of developing pressure damage. She then recommends specific dressings which are applied automatically, to prevent problems developing.

Further proof of its reputation for the effective management of pressure damage is that the trust now has an agreement to provide the tissue viability service for the Tees, Esk and Wear Valleys NHS Foundation Trust, which provides a range of mental health and learning disability services for people living in County Durham and Darlington, the Tees Valley and most of North Yorkshire.

The progress is irrefutable and, while Carol’s vision is fully acknowledged as having inspired the improvements, Senior tissue viability nurse Karen Wilkinson believes the sustained success is down to a “major cultural shift”. “There is real teamwork at the heart of the changes,” she says. “We’ve come such a long way because the expertise has been shared across every aspect of the trust – with the result being increased patient comfort and early recognition of patients at risk of pressure damage and requiring early interventions.”

In what may be viewed as a particularly unglamorous, yet hugely important, area of the NHS, the reasons for success are clearly much more than skin deep.