A senior tissue viability nurse plans to ditch traditional pressure ulcer risk assessment in favour of a hand-held scanner that can detect changes in the skin invisible to the naked eye.
Glenn Smith, tissue viability and nutrition senior clinical nurse specialist at the Isle of Wight NHS Trust, is among UK nurses to trial the SEM (sub-epidural moisture) scanner.
The device was the brainchild of a US expert nurse Barbara Bates-Jensen and has been trialed by a number of health service providers, as previously reported by Nursing Times.
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The battery-operated scanner, which costs £5,835 can detect skin damage on average five days before it is visible to clinicians, according to the device’s manufacturer Bruin Biometrics.
Mr Smith told Nursing Times he believed the device, which provides a reading in seconds, had the potential to transform nurses’ approach to pressure ulcer prevention and care, and save hundreds of thousands of pounds.
“It’s a piece of information you can’t get any other way, and that’s where I think it changes things,” he said. “I don’t see why you would use a risk assessment tool of any sort, whether it is Waterlow, Norton, Braden, Purpose-T, if you can actually just measure what’s going on under the skin.”
While previously it had been drummed into nurses to “react to red”, he said the scanner allowed a change in mindset to “react before red”. Mr Smith, who is also patient safety lead at his trust, decided to explore using the SEM scanner on the back of a concerted drive to reduce pressure ulcers.
“It’s a piece of information you can’t get any other way, and that’s where I think it changes things”
The campaign included tightening up risk assessment processes, competency testing for registered and non-registered staff, learning exercises with hospital and community nurses, and investing heavily in pressure relieving mattresses.
This saw the incidence of ulcers drop by 80% but there was a stubborn proportion that remained, so Mr Smith said he was keen to try other solutions.
A small-scale trial of the SEM scanner on one medical surgical ward at St Mary’s Hospital in Newport in 2015 achieved impressive results. The two-month pilot saw all patients with a Waterlow score of 10 or above assessed using the SEM scanner.
Of the 35 patients scanned, none went on to develop a new pressure ulcer during their time on the ward. The scanner found one of the patients admitted to the ward already had incipient pressure damage, correctly predicting imminent skin breakdown.
The two scanners deployed during the trial were predominantly used by healthcare assistants, who integrated scanning into their daily care routine.
“The bit they struggled with was how it fitted into what they were already doing”
While the devices were welcomed by nurses, Mr Smith said they found it harder to get to grips with the new technology because they were so used to traditional risk assessment.
“We tend to educate nurses based on Waterlow and other risk assessment tools so they stratify patients using risk assessment,” he said. “Give them a new piece of kit and the bit they struggled with was how it fitted into what they were already doing.”
Following the trial, funding was made available for three scanners – one for the specialist tissue viability team and two others for use on the wards.
Mr Smith has since submitted a plan for two scanners on every single ward and says his goal is to eventually stop using traditional risk assessment altogether and rely on the scanners alongside nurses’ professional judgement.
“What I expect to do if we get full implementation is take the Waterlow out altogether, because I just don’t think it is a useful tool,” he said.
He stressed that the scanner itself was just a tool that provided a reading – like a blood pressure machine – and success relied on nurses taking appropriate action based on that information.
However, according to his calculations, using the scanners to spot potential ulcers and take preventative action early on, could save his trust up to £600,000 a year in cost savings – such as the cost of dressings – and revenue loss.
“It is going to change our relationship with people who sell us stuff around pressure ulcer prevention”
Meanwhile, he estimated that up to 1,420 hours of nursing time – 36 weeks in total per year – could be saved because of reduced admin for senior nurses and the fact nurses would not spend nearly as much time treating ulcers on the wards and later in the community.
As well as helping to detect ulcers early, he said the scanners had the advantage of showing how well prevention measures and pressure relieving devices were working.
Unlike a blanket Waterlow score – which will generally stay the same over a period of time – the scanner detects subtle changes in the skin day by day.
“Waterlow provides no indication in terms of supporting care but the scanners do,” Mr Smith told Nursing Times.
“One of the things we set out to measure was whether you could see a tangible change in the patient’s skin when you started putting different things in place, like re-positioning them more effectively or putting the right mattress underneath them,” he said.
SEM (sub-epidural moisture) scanner
Source: Bruin Biometrics
“The early indications were that the scanner was picking this up and showing the efficacy of things nurses and HCAs were doing within 24 hours,” he said. “It meant they were getting almost immediate feedback on whether what they were doing was making a difference.”
Mr Smith highlighted that this could help nurses assess and then only procure interventions they knew really worked.
“It is going to change our relationship with people who sell us stuff around pressure ulcer prevention, because there is nothing more powerful than using something on a patient and then scanning their skin to see if it is making a difference,” he said.
In addition, assessments of 50 patients using the scanner upon arrival at hospital found a significant proportion had invisible skin damage that had occurred at home.
Based on the scanners’ threshold deviation of greater than 0.6, all but one presented on admission with pre-existing inflammatory changes to the skin, he said. He noted that, previously, ulcers that developed would have been blamed on the trust.
“In my mind, it should change our relationship with the Clinical Commissioning Group. Why would you hold a hospital to account for pressure ulcers when the skin damage is already there when a patient arrives at the front door?” said Mr Smith.
“Using the scanner to measure pressure damage seems like a logical next step”
As part of the process to re-commission tissue viability services on the island, he said he was already talking to the CCG “about whether scanners would form part of the pressure ulcer pathway” and be used by nurses in the community as well as in hospital.
Mr Smith said he felt the devices had the potential to be used in other ways including detecting surgical site infections and leg ulcers.
“When you apply compression for a leg ulcer that should increase the drainage in the lower limbs – if you are measuring the fluid under the skin using the scanner you should see a reduction in fluid if you have applied the compression correctly,” he said.
“Conversely, it should also provide a safety mechanism because one of the risks of applying bandaging or hosiery is you can get pressure damage,” he said.
“Using the scanner to measure pressure damage as well as reduction in inflammation to me seems like a logical next step,” he added.
According to Bruin Biometrics, the SEM scanner is currently in use in nine community hospitals in the UK as well as on the Isle of Wight.