SSKIN Care Bundle – Preventing Pressure Ulcers/Injury

Introduction

The incidence of Pressure Injuries, also known as Bedsores or Pressure Ulcers, constitutes a formidable challenge within global healthcare infrastructures. These afflictions are not merely a source of patient discomfort and extended hospitalisations; they also entail considerable financial burdens for healthcare institutions. The majority of Pressure Ulcers are thought to be preventable. The gravity of Pressure Injuries cannot be overstated, as they may result in profound and life-altering consequences, including mortality.

To combat this widespread concern, the SSKIN Care Bundle has been introduced as an extensive preventative methodology to curb the incidence of Pressure Injuries.

Historical Context of the SSKIN Care Bundle

The SSKIN Care Bundle represents the integration of research-backed protocols designed to decrease the likelihood of pressure injury in at-risk individuals. The acronym "SSKIN" encapsulates the core elements of this strategy:

• Surface

• Skin Inspection

• Keep Moving

• Incontinence/Moisture

• Nutrition

Tracing the origins of the SSKIN Care Bundle is somewhat complex. It is believed that the initial care bundle concept was implemented in a healthcare facility in Florida around 2004 and later adopted in Wales in 2009. Subsequently, its use has expanded throughout the United Kingdom.

There is a body of research that endorses the efficacy of the SSKIN Care Bundle in diminishing the prevalence of Pressure Injuries.

The primary merit of the SSKIN Care Bundle lies in its straightforwardness; it furnishes a coherent, memorable, and easily executable framework for care. Conversely, a potential shortfall is its elemental nature, which might not encompass all the intricate clinical variables involved in risk assessment and preventive strategy formulation. There exists a hazard that medical personnel might over-rely on the SSKIN Care Bundle, thereby overlooking or underestimating additional complex clinical considerations.

Content

Surface:	This requires a comprehensive approach is required for selecting and managing the support surface. Basic Principles: Types of Surfaces: Support surfaces include a variety of beds, mattresses, overlays, and cushions designed to redistribute pressure, reduce shearing forces, and control the microclimate around the skin. They range from foam mattresses to advanced dynamic systems/beds. Selection Criteria: Choosing the right surface depends on several factors, including the individual's risk level for pressure injury, body weight, mobility status, and the presence of existing Pressure Injuries. The surface should match the patient's specific needs to effectively redistribute pressure and provide comfort. Strategies for Implementation: Assessment and Reassessment: Regularly assess the patient's skin condition, risk level, and comfort to determine if the current support surface is adequate. Re-evaluate the needs whenever there is a change in the patient's condition or if there are signs of Pressure Injury development (skin inspection). Integration with Repositioning: While support surfaces play a crucial role in redistributing pressure, they do not eliminate the need for regular repositioning. Ensure that a repositioning schedule is followed, and educate staff and caregivers about the importance of combining both interventions. Customisation and Adaptation: Recognise that patients' needs may change over time. Be prepared to adapt or customise the support surface accordingly, especially after surgical procedures, deterioration, changes in risk profile, changes in weight, or the development of new Pressure Injuries. Education and Collaboration: Staff Training: Ensure that all healthcare providers involved in patient care are trained in the types and proper use of support surfaces as some differ, for example need weight setting for the patient. The consideration of the importance of regular skin assessments and repositioning. The local policy must be reasonable and sufficiently robust. Involving the Patient and Family: Educate the patient and their family members about the importance of the correct support surface and the role it plays in preventing Pressure Injuries. Encourage them to report any discomfort or changes in skin condition. Monitoring and Quality Control: Equipment Maintenance: Regularly check the support surfaces for any malfunctions, cleanliness, and overall integrity. Ensure that dynamic surfaces like alternating pressure mattresses are functioning correctly and that settings are adjusted as per the patient's needs. Documentation and Feedback: Keep detailed records of the support surfaces used, the rationale for their selection, and any changes made over time. Document patient feedback, skin assessments, and any pressure injuries that develop to inform future care decisions and quality improvement initiatives. NICE 2014/2015 Patients identified at high risk of developing Pressure Ulcers should be provided with high-specification foam mattresses or cushioning as a minimum. For those with existing Pressure Ulcers or extremely high risk, more sophisticated surfaces such as dynamic air-flow mattresses may be recommended. EPUAP 2019 They recommend using higher specification foam mattresses or overlays for individuals at higher risk of Pressure Ulcer development. For those at very high risk or with existing Pressure Ulcers, more sophisticated surfaces such as alternating pressure air mattresses may be necessary. The choice of surface should consider the individual's risk factors, the location and stage of any existing Pressure Ulcers, body weight, and general mobility.
Skin Inspection:	Importance of Skin Inspection: Early Detection: Regular and thorough skin inspections are crucial for the early detection of Pressure Injuries. Early stages of pressure damage might present as persistent redness, discoloration, or changes in skin temperature, texture, or integrity. Extra care must be taken with Black or Brown skin and early signs of damage can be hidden. Targeted Intervention: Identifying early signs of pressure damage allows for timely and targeted interventions, which can prevent the progression of injuries. Strategies for Implementation: Comprehensive Assessment: Inspect all areas of the skin, paying particular attention to bony prominences and areas subjected to pressure or shear. This includes the sacrum, heels, elbows, back of the head, and any other areas that might be at risk depending on the individual's position, devices present  and mobility. Frequency: The frequency of skin inspections should be guided by the individual's risk assessment. For those at high risk, inspections should occur at least once every shift or more frequently if changes are noted. Documentation: Record findings from each skin inspection, noting any areas of concern, changes from previous assessments, and any interventions made. This documentation is crucial for tracking changes over time and communicating between care providers. Education and Training: Staff Competency: Ensure that all healthcare providers involved in patient care are trained in how to conduct a skin inspection, what to look for, and how to document their findings. Patient and Family Involvement: Educate the patient and their family about the importance of skin inspections and involve them in understanding what signs to look for, especially if the patient is in a home care setting. Tools and Technology: Use of Assessment Tools: Utilise tools and scales designed to help identify early signs of pressure injury. These might include visual aids, descriptive scales, or even technological devices that can assess skin integrity. Photographic Documentation: Consider using photographs (with appropriate consent and ethical considerations) to track changes in skin condition over time. This can be particularly useful for comparing and communicating about areas of concern. Collaboration and Multidisciplinary Approach: Engage Specialists: Involve wound care specialists, dermatologists, or other professionals as needed based on the findings from skin inspections. Team Communication: Ensure that information from skin inspections is effectively communicated among all members of the healthcare team, including any changes in the patient's condition or in the care plan. NICE 2014/ 2015 Guidance on Skin Inspections Regular Inspections: NICE recommends that skin inspections should be carried out regularly, especially for individuals at high risk of Pressure Ulcers. The frequency should be determined by the level of risk and the individual's circumstances. Training and Competence: It emphasises that healthcare professionals conducting skin assessments should be trained and competent. This includes understanding how to recognise early signs of pressure damage. Documentation: Detailed records of each skin inspection should be maintained, including the date, time, findings, and any actions taken. This ensures continuity of care and helps track the patient's progress over time. Patient Involvement: The guidelines also suggest involving patients and their carers in understanding their skin condition and what to look out for, empowering them to be active participants in their care. Tools and Aids: NICE acknowledges the use of tools and scales to support skin assessments, advising that any tool used should be validated and appropriate for the specific patient group. Both the National Institute for Health and Care Excellence (NICE) and the National Pressure Injury Advisory Panel (NPUAP) offer guidance on skin inspections as a crucial component of Pressure Injury prevention and management. Here's what each generally advises: NPUAP/EPUAP 2019 Guidance on Skin Inspections Frequency and Thoroughness: NPUAP/ EPUAP advises that skin inspections should be conducted at least daily for at-risk individuals and more frequently if the risk is higher. This should increase when devises are in place. The entire skin surface should be inspected, with particular attention to bony prominences and areas under medical devices. Early Detection: The focus is on the early detection of any signs of pressure injury, including non-blanchable erythema, warmth, coolness, hardness, or discoloration. The NPUAP/EPUAP emphasises the importance of recognising these early signs to prevent the progression of injury. Education and Training: Similar to NICE, NPUAP/EPUAP recommends that all healthcare providers involved in patient care should be educated about pressure injury risks and prevention strategies, including how to conduct effective skin inspections. Patient-centred Care: NPUAP/EPUAP encourages involving the patient and their family in the care process, educating them about the risks of pressure Injuries and how they can contribute to prevention efforts.
Keep Moving:	The "Keep Moving" precept within the SSKIN Care Bundle is pivotal in the prophylaxis of pressure injuries. It is predicated on the understanding that immobility and sustained pressure are primary aetiological factors for the development of such injuries. The physiological rationale for movement is to enhance circulation, stimulate tissue viability, and prevent the deleterious effects of unrelieved pressure on skin integrity. Implementation of Movement Strategies: Individualised Repositioning Regimens: Repositioning schedules should be customised to the individual's specific risk factors, including the degree of mobility impairment and the presence of existing Pressure Injuries. A multidisciplinary approach, involving input from nursing staff, physiotherapists, and occupational therapists, is recommended to devise a repositioning protocol that is both efficacious and respectful of the patient's comfort and dignity. Encouragement of Autonomous Movement: For patients capable of self-movement, encouragement and facilitation of regular, independent shifts in position should be a standard practice. The empowerment of patients to participate actively in their own care can be facilitated through education and the provision of assistive devices as necessary. Education and Empowerment: Healthcare Provider Expertise: A key component of the "Keep Moving" principle is the education and training of healthcare providers in the proper techniques for patient mobilisation and repositioning, as well as the use of assistive devices. Patient and Caregiver Involvement: Patients and their caregivers should be educated on the critical importance of movement in Pressure Injury prevention. They should be provided with guidance on how to safely implement movement strategies, recognising the signs of skin compromise, and understanding when to seek assistance. Monitoring and Adaptation: Continuous Assessment: Regular assessment of the skin, particularly after repositioning, is essential to ensure that the strategies employed are effectively preventing Pressure Injury. Observations should be meticulously documented and communicated across the care team. Responsiveness to Patient Feedback: The comfort and feedback of the patient regarding movement and repositioning should be closely monitored. Adjustments to care plans should be made in response to the patient's experiences and preferences, ensuring a patient-centred approach. NICE 2014/2015 Guidance on Movement Assessment of Mobility: NICE guidelines recommend assessing the mobility of patients as part of their initial risk assessment for Pressure Ulcers. This includes evaluating the patient's ability to change positions and the need for assistance or motivation with movement. Encouraging Movement: The guidelines advise encouraging and assisting patients to move and change positions regularly. This should be tailored to the individual's needs and abilities. Use of Equipment: NICE also suggests considering the use of equipment such as hoists or slide sheets to aid movement for those who cannot move independently. Staff Training: Healthcare professionals should be trained in manual handling techniques to ensure safe patient movement and the prevention of Pressure Ulcers. Repositioning Schedules: For patients who are unable to reposition themselves, NICE recommends implementing a repositioning schedule and suggests a  minimum of 4 hourly recommendation for high risk patients.  There is a lack a supportive evidence base for 2 hourly repositioning and the schedule should be documented and reviewed regularly. NPUAP/EPUAP 2019 Guidance on Movement Repositioning: NPUAP/EPUAP emphasises the importance of repositioning patients to redistribute pressure, particularly for those who are at high risk of Pressure Injury development. Individualised Care Plans: The panel recommends that repositioning strategies be individualised based on the patient's condition, the level of risk, and the support surface in use. Consideration of Patient Comfort: Repositioning should consider patient comfort, and adjustments should be made based on patient feedback. Education on Movement: NPUAP/EPUAP advises educating the care team and the patient (when possible) about the importance of movement in preventing Pressure Injuries. Frequency of Movement: The frequency of movement and repositioning should be determined by a risk assessment and the patient's specific clinical needs.
Incontinence /Moisture:	The "Incontinence/Moisture" aspect of the SSKIN Care Bundle is essential, given that excessive moisture can significantly undermine skin integrity, making it susceptible to breakdown and infection. It is not just incontinence that poses a risk; perspiration, wound exudate, and other bodily fluids can also contribute to a moist environment detrimental to skin health. Strategies for Moisture Management: Timely Incontinence Care: Implement a proactive incontinence management plan, which may include regular toileting schedules, the use of absorbent products, and skin barriers to protect against moisture. Skin Care Regimen: Establish a skin care regimen tailored to maintain dryness and protect skin integrity. This should involve gentle cleansing, avoiding harsh soaps, and the application of moisture barriers or emollients where appropriate. Product Selection: Choose incontinence products and skin care items that are appropriate for the individual's skin type and condition. Products should be effective in maintaining dryness without causing irritation. Education on Products: Educate staff and caregivers on the correct use of incontinence products and skin care regimes, including when to change products and how to apply skin protectants. Education and Collaboration: Multidisciplinary Approach: Engage with continence specialists, and other healthcare professionals to address underlying causes of incontinence and develop comprehensive care plans. Patient and Caregiver Education: Provide education to patients and caregivers about the importance of skin care and moisture management, including techniques for proper hygiene and the use of protective products. Monitoring and Adaptation: Regular Skin Assessments: Include moisture-related skin assessments as part of the routine skin inspection protocol. Look for signs of excessive moisture, such as maceration, and take prompt action to address any issues. Feedback and Tailored Interventions: Be attentive to the patient's feedback regarding the comfort and efficacy of incontinence products and skin care routines. Adapt interventions as necessary to align with the patient's needs and preferences. NICE 2014/2015 Guidance on Incontinence and Moisture Management NICE provides detailed guidance on managing incontinence and moisture as part of pressure ulcer prevention strategies, including: Assessment of Incontinence: Conduct an initial assessment and regular re-assessments of incontinence issues, as part of the overall risk assessment for Pressure Ulcers. Management Plans: Develop individualised care plans for managing incontinence that minimise skin exposure to moisture. This may include the use of absorbent products and skin barriers. Skin Care: Recommend specific skin care regimens that address the needs of patients at risk of skin damage due to moisture. This includes gentle cleansing, pat drying, and the application of emollients. Product Selection: Use high-quality absorbent products and skin care items that maintain skin integrity while controlling moisture. The choice of products should be based on a thorough assessment of the patient’s needs. Education: Provide training for healthcare professionals on the prevention and management of skin damage due to moisture and educate patients and their caregivers on the importance of skin care and the correct use of protective products. NPUAP/EPUAP 2019 Guidance on Incontinence and Moisture Management NPUAP/EPUAP’s recommendations regarding incontinence and moisture management include: Regular Skin Inspection: Advise regular inspection of skin for early signs of moisture-associated skin damage, especially in areas frequently exposed to moisture. Skin Cleansing: Encourage prompt cleansing of the skin after episodes of incontinence using gentle cleansing agents that minimise irritation and dryness. Moisture Barriers: Recommend the use of moisture barriers, creams, or ointments to protect the skin from excessive moisture. Individualised Interventions: Suggest individualised incontinence care interventions, including scheduled toileting programmes, appropriate use of incontinence products, and catheter care where applicable. Assessment Tools: Utilise validated tools for assessing the risk of moisture-related skin damage and implement interventions based on the assessment findings.
Nutrition:	The "Nutrition" segment of the SSKIN Care Bundle is predicated on the principle that adequate nutritional support is crucial for maintaining skin integrity and facilitating the healing process. Malnutrition or specific nutrient deficiencies can greatly impair the body's ability to resist and repair tissue damage, making nutrition an integral part of Pressure Injury prevention. Nutritional Strategies for Pressure Injury Prevention: Nutritional Assessment: Conduct comprehensive nutritional assessments for each patient, considering factors such as age, medical conditions, current dietary intake, and potential for malnutrition. Utilise tools and scales validated for nutritional risk screening (such as the MUST scoring system). Individualised Nutritional Plans: Collaborate with dieticians to formulate tailored nutritional plans that address the specific needs and preferences of the patient, ensuring they receive the necessary macro- and micronutrients to support skin health and recovery. Hydration Management: Recognise the importance of adequate hydration in maintaining skin elasticity and preventing breakdown. Monitor fluid intake and output, adjusting fluid administration as per the patient's hydration status and clinical needs. Education and Multidisciplinary Involvement: Staff Training: Educate healthcare staff on the signs of malnutrition and dehydration and their implications for Pressure Injury risk. Ensure they understand the protocols for implementing nutritional interventions. Patient and Caregiver Engagement: Involve patients and caregivers in the nutrition care process, educating them about the importance of nutrition and hydration in Pressure Injury prevention and overall health. Multidisciplinary Collaboration: Establish a collaborative approach that involves dieticians, nurses, physicians, and other relevant healthcare professionals to address the multifaceted aspects of nutritional care. Monitoring and Ongoing Adjustments: Continuous Nutritional Re-evaluation: Regularly reassess the patient's nutritional status and the effectiveness of the nutritional plan, making adjustments as needed based on changes in their condition or response to nutritional interventions. Documentation and Communication: Maintain meticulous records of nutritional assessments, plans, and outcomes. Ensure clear communication among the care team regarding any changes to the nutritional strategy. NICE 2014/2015 Guidance on Nutrition NICE offers comprehensive guidelines on nutritional support for the prevention and management of Pressure Ulcers: Nutritional Screening: Conduct regular nutritional screening for all patients using validated tools, with specific attention to those at high risk of Pressure Ulcers. Individualised Nutritional Care Plans: Develop individualised care plans addressing nutritional needs, taking into consideration the patient’s preferences and clinical condition. Dietary Intake and Supplementation: Ensure adequate dietary intake, monitor and consider supplementation if required. This includes protein, vitamins, and minerals essential for skin integrity and wound healing. Hydration: Monitor and support adequate hydration, as it is crucial for maintaining skin elasticity and preventing breakdown. Multidisciplinary Approach: Involve a multidisciplinary team, including dieticians and SALT to assess, plan, and manage the patient’s nutritional and swallowing needs. Education: Provide education to healthcare professionals, patients, and caregivers about the importance of nutrition and hydration in Pressure Ulcer prevention. NPUAP/ EPUAP 2019 Guidance on Nutrition The NPUAP/EPUAP  also emphasises the role of nutrition in Pressure Injury prevention: Assessment: Recommend a comprehensive nutritional assessment for patients at risk of Pressure Injuries, considering factors like body mass index (BMI), weight loss, and dietary intake. Nutritional Support: Advise on the importance of providing adequate caloric intake and nutritional support, including protein, to promote tissue repair and maintenance of skin integrity. Interdisciplinary Care: Encourage an interdisciplinary approach to patient nutrition, involving collaboration between nurses, physicians, and dieticians. Patient-centred Care: Focus on patient-centred nutritional interventions that align with the individual’s needs, goals, and treatment plans. Re-evaluation: Recommend regular re-evaluation of nutritional interventions and their effectiveness, with adjustments as necessary.

Conclusion

The SSKIN Care Bundle represents a significant advancement in the interdisciplinary approach to pressure injury prevention. By integrating key components—Surface, Skin Inspection, Keep Moving, Incontinence/Moisture, and Nutrition—into a cohesive framework, it offers healthcare providers a structured protocol to mitigate the risk of pressure ulcers. The bundle's simplicity facilitates its adoption and memorability, which is crucial in fast-paced clinical environments.

However, the true strength of the SSKIN Care Bundle lies in its flexibility and adaptability. As healthcare landscapes evolve and patient populations become more complex, the bundle serves as a foundational tool that can be augmented by advanced technologies, ongoing education, and personalised patient care strategies.

It is imperative that healthcare institutions not only implement the SSKIN Care Bundle but also commit to continuous evaluation and improvement of its components in light of emerging evidence and patient feedback.

Looking forward, the potential of the SSKIN Care Bundle to significantly reduce the incidence of pressure injuries hinges on a culture of prevention, rigorous training, and research-based practice. As such, the medical and nursing community should continue to engage in research to refine each element of the bundle, ensuring it remains at the forefront of patient care.

Moreover, institutions should foster an environment where feedback mechanisms are in place, allowing for the dynamic integration of clinical insights into practice.

In summary, the SSKIN Care Bundle stands as a proactive healthcare strategy, embodying a holistic and patient-centric approach to the prevention of pressure injuries. Its comprehensive framework underscores the importance of clinical vigilance and robust, structured gold standard care.

Authors

Scott Harding-Lister

Scott is a qualified nurse and solicitor. He was a senior nurse within the NHS before leaving to pursue a career as a solicitor in City practices. In 2013 he set up Apex Health Associates and the expert witness practice has gone from strength to strength. Scott is a medico-legal expert, a nursing expert, and head of practice at Apex.

Jane Collins

Jane Collins is one of the senior team of experts at Apex Health Associates.  Jane has been with the practice for many years.  Jane is both a clinician and an academic.  Our Head of Practice noted "she is an excellent expert, she knows what she is doing and her opinions are sound"