Tissue Viability

Introduction
Mittens are used to facilitate necessary interventions safely in patients who lack the mental capacity adhere to them. A serious incident (SI) occurred at our Trust when a patient, with delirium, developed pressure ulcers to their wrists as a result of prolonged use of mittens. A subsequent investigation revealed that there had been inadequate skin checks and insufficient documentation, from the medical team, directing the use of mittens.

Method
A multidisciplinary QIP was initiated: • For the Medical team: An electronic “Mittens Request Form” was created. This included fields to document a mental capacity assessment, the best interest decision and a link to apply for Depravation of Liberty Safeguards. There was also a prompt to prescribe mittens on the electronic drug chart. • For the Nursing team: A pre-existing electronic mittens checklist form was updated to confirm that a daily skin check had been completed. The outcomes of the SI report and changes above were communicated to the department. After the QIP, a notes review was completed for all patients over the age of 65 years who had a mittens checklist completed before and after the interventions. Notes were assessed for documentation of a mental capacity assessment, communication of a best interest decision, prescription of mittens and completion of a daily skin assessment.

Results
Documentation of a capacity assessment improved from 9% to 47%. Communication with relatives improved from 0% to 35%. Prescription of mittens, on the drug chart, improved from 0% to 24%. Documentation of a daily skin assessment Increased from 0% to 94%

Conclusions
This QIP brought about improved documentation of best interest decisions related to mittens and ensured regular skin checks. The next stages will involve expanding the QIP to other departments within the hospital and reinforcing messaging about communication with relatives and prescription of mittens.

Aims:

i) Develop and test a theory-based diagnostic instrument to assess barriers and facilitators accurately and prospectively; and ii) survey barriers and facilitators to the delivery of skin hygiene care in care homes.    

Background:

There is an ageing population and an increasing number of people residing in care homes. As skin ages it become vulnerable to dryness, itching, cracks, and tears. These are experienced by many older people and cause discomfort, compromised quality of life, skin breakdown, increased dependency, longer hospital stays, and greater financial and human costs. These problems can be prevented through adequate skin hygiene care, however despite best practice guidance, concordance may be sub-optimal.  

Methods:

Barriers and facilitators identified from a literature review and pilot study were categorised in a Delphi survey of experts (psychology or skin health) (n=8) to the Theoretical Domains Framework. This model was tested in three rounds for face validity (n=38), construct validity (n=235), and test-retest reliability (n=11).  Barriers and facilitators were surveyed in round two. 

Results:

A 29-item valid and reliable instrument resulted (χ2/df=1.539, RMSEA=0.047, CFA=0.872).  Key barriers were delivering skin hygiene care to agitated or confused residents, pressure to rush or engage in other tasks from colleagues, high workload, and difficulties meeting often unrealistic expectations of relatives. A key facilitator was knowledge of how to perform effective skin hygiene care. 

Conclusions:

This study identified a comprehensive list of barriers and facilitators to skin hygiene care including barriers previously unreported.  

Relevance to clinical practice:

Efforts to improve care tend to be based on information giving. However, our work illustrates that barriers other than knowledge need to be addressed.  Use of the SHELL-CH Index will allow identification of barriers and facilitators in local contexts and this understanding will support the development of interventions tailored according to need.