Keywords: Pressure ulcer/SKIN Bundle/

Prevention

Nursing Practice
Innovation
Pressure ulcers

This

article has been double-blind

peer reviewed

A systematic approach helped to reduce the incidence of pressure ulcers at a health

board in Wales, and changed staff views that they were inevitable in some patients

Using the SKIN

Bundle to prevent
pressure ulcers
In this article...
 ost and prevalence of pressure ulcers
C
Development of the SKIN Bundle and how it can be used to
help prevent pressure ulcers
How the SKIN Bundle was implemented at Cardiff and Vale
University Health Board

Authors Joy Whitlock is quality and safety

improvement manager; Sian Rowlands is
solicitor and clinical governance manager
primary care; Gemma Ellis is consultant
nurse in critical care and Cardiff University
lecturer; Alison Evans is pressure ulcer
programme manager and Cardiff
University lecturer; all at Cardiff and Vale
University Health Board.
Abstract Whitlock J et al (2011) Using the
SKIN Bundle to prevent pressure ulcers.
Nursing Times; 107: 35, 20-23.
Every year up to 20% of patients in acute
care in England and Wales are affected by
pressure ulcers, which can lead to serious
harm and death if left untreated. This
article discusses the development of the
SKIN Bundle, a pressure ulcer prevention
initiative, and its implementation at Cardiff
and Vale University Health Board, and how
it is being used to help prevent pressure
ulcers and improve patient care.

ressure ulcers are painful and

debilitating
and,
if
left
untreated, can lead to serious
harm and death (National
Patient Safety Agency, 2010). Up to 20% of
patients in acute care in England and

Wales are affected by pressure ulcers every

year, and older people in intensive care
units who develop pressure ulcers have a
two- to four-fold increased risk of early
death (NPSA, 2010; Vanderwee et al, 2007).
The cost to the NHS of treating pressure
ulcers and related conditions is up to 4bn
a year, with the most severe cases ranging
from 11,000 to 40,000 per person.
Since 2005, the NPSA has received
around 75,000 reports of patient safety
incidents relating to pressure ulcers, yet a
growing body of evidence suggests these
are largely preventable (NPSA, 2010).
Box 1 outlines some key facts about
pressure damage; reducing such damage is
a high priority across Wales.

Box 1. Pressure
ulcers: key facts
Skin integrity can deteriorate in hours
Frequent assessment prevents minor
damage from becoming major ulcers
Risk is predictable factors include
advanced age, immobility, sensory
problems, incontinence, poor nutrition,

20 Nursing Times 06.09.11 / Vol 107 No 35 / www.nursingtimes.net

This article describes the implementation of the SKIN (Surface, Keep moving,
Incontinence, Nutrition) Bundle assessment tool an initiative to reduce the incidence of pressure ulcers at University
Llandough Hospital, Cardiff and Vale University Health Board (C&V UHB). The SKIN
Bundle was piloted on the hospitals critical
care unit between May 2009 and April 2010.

Background

The SKIN Bundle was developed in 2004 at

St Vincents Medical Centre, a 528-bed hospital in Florida, US. It was introduced in
Wales in 2009 through Transforming Care,
a ward-based programme for Wales that
aimed to improve patient care by reducing
circulation problems and dehydration
Wet skin is more vulnerable to skin
disruption and ulceration, but dry skin
can also be affected
Continual pressure, especially over
bony prominences, increases risk
Pressure-relieving surfaces such as
mattresses or special cushions are
effective in preventing pressure damage

Source: Reddy et al (2006)

Nursing Practice
Innovation

5 key
points

Up to one in five
inpatients have
pressure ulcers,
which costs the
NHS up to 4bn a
year to treat
Risk factors
include age,
immobility,
incontinence and
poor nutrition
The SKIN
Bundle can
help prevent minor
skin problems from
becoming major
pressure ulcers
Its aims
include
identifying all
patients at risk and
significantly
reducing pressure
ulcers acquired in
hospital
The Model for
Improvement
can help the spread
and sustainability
of the SKIN Bundle

2
3

4
5

Pressure ulcers can

cause serious harm

pressure ulcers, among other things. After

the initiative was implemented successfully at Abertawe Bro Morgannwg University Health Board, learning was shared
across all health boards in Wales through
the All Wales 1,000 Lives Campaign.
C&V UHB used the Institute for Healthcare Improvements (IHI) Model for
Improvement plan, do, study, act to test
and implement the bundle through faceto-face collaboration and through sharing
and learning across the organisation. After
training in virtual mentoring from the
Safer Patients Network (tinyurl.com/saferpatients), web and telephone conferencing
technology was also used to mentor staff at
six sites implementing the SKIN Bundle
across the UK.

Implementing the SKIN Bundle

A faculty was established to develop and

deliver the pressure ulcer reduction programme, with personal coaching and
mentoring provided by the IHI. The programme used a mini collaborative model
of three learning events:
Session 1 introduced the SKIN Bundle
and model for improvement methodology, including measurement;

Session 2 was about sharing progress

and increasing learning about pressure
damage and nutrition, and introducing
what reliability means and how it can
be achieved;
Session 3 was an opportunity for
everyone to share, learn and celebrate
success, and learn about sustainability
and spreading the model more widely.
The model provided face-to-face
learning events at the health board, and virtual technology to six organisations across
the UK. It helped teams who attended the
collaborative learning events to:
Establish a reduction in pressure damage
as a main organisational priority;
Appoint an executive lead to ensure
ward teams are released to attend
collaborative events, and to address any
barriers promptly;
Involve other experts, such as dietitians
and tissue viability nurses, in the
learning;
Use the model for improvement and
underpin the learning with improvement science;
Get the balance right between what to
do and how to do it;
Establish a local clinical team this
includes a team leader, a champion to
start the improvement programme as
well as dietitians, physiotherapists and
tissue viability nurses;
Bring together the acute, community and
independent sectors of the health board.
All teams established a baseline of pressure ulcer incidents at the start of the initiative, and a pressure ulcer safety cross was
used to measure the number of days
between incidents (NHS Wales, 2010).
The aims of the SKIN Bundle are

Box 2. Aims of the

SKIN Bundle
To identify all patients at risk of
developing pressure damage
To reliably implement prevention
strategies identified by the National
Institute for Health and Clinical
Excellence (NICE, 2005)
To reduce the number of hospitalacquired pressure ulcers by 20% by
April 2012 across the whole of Cardiff
and Vale University Health Board
(each clinical team has set its own
goal, with most aiming for a reduction
of at least 50%)
To develop a reusable model for
implementing quality improvement
programmes

22 Nursing Times 06.09.11 / Vol 107 No 35 / www.nursingtimes.net

Fig 1. skin bundle

assessment tool
D/T

Waterlow
At risk? *Yes/No

N/T

Surface

Mattress
Repose boots
TEDs/heel
check

Keep moving

Position change
_______ hrly

Improved
moisture
management

Yes/No
Barrier cream
Consider
Flexiseal

Nutrition and
fluids

*WAASP
> 7 High Risk
NG/TPN/ Food chart
*Weight, Appetite, Ability to eat,
Stress fractures, Pressure ulcers

outlined in Box 2. Using the IHI Model for

Improvement, the elements of the Bundle
were tested, compliance was measured
and the data reviewed. Changes continued
to be made until compliance reached 95%.

SKIN Bundle assessment tool

A SKIN Bundle assessment tool (Fig 1) was

developed to help critical care staff achieve
reliability in:
Evaluating and documenting risk
assessments;
Ensuring all patients receive the most
appropriate care;
Documenting deviations from best
practice, for example when patients
withhold consent to interventions.
By using the tool to audit practice, staff
were also able to monitor what they were
doing well and what they needed to
improve. Other visual cues, communication tools and decision aids have been developed throughout the organisation to ensure
the SKIN Bundle is delivered effectively.

Discussion

Eighteen clinical teams have attended the

internal mini collaborative sessions; a further six have received virtual mentoring. All
teams are using the IHI Model for Improvement to test and implement changes, and
are displaying the pressure ulcer safety
cross to measure and monitor days between
events. Tips, tools and techniques have
been shared among collaborative members.
More than 95% compliance with the
SKIN Bundle is now being achieved in an
increasing number of areas (Fig 2), and the
number of days between pressure ulcer
events has also increased (Fig 3).

Nursing For more articles on pressure ulcer care,

Times.net go to nursingtimes.net/woundcare
Fig 2. Compliance with the SKIN Bundle
100
96
92

88

Spread too early

before reliability
was achieved

84
80
76
72

Implementation
and spread
throughout unit

PDSA cycles on
different elements of
the bundle commenced
to achieve process
reliability

-2
0
0
9
6
-2
0
0
9
7
-2
0
0
9
8
-2
0
0
9
9
-2
0
0
9
10
-2
0
0
9
11
-2
0
0
9
12
-2
0
0
9
120
10
2
-2
01
0
3
-2
01
0
4
-2
01
0
5
-2
01
0
6
-2
01
0
7
-2
01
0
8
-2
01
0
9
-2
01
0
10
-2
01
0
11
-2
01
0
12
-2
01
0

68

Month

Days between pressure ulcers

Fig 3. Days between pressure ulcers

100
80
60

PDSA cycles
testing elements
of the SKIN Bundle
Implementing
the SKIN Bundle
Goal = 50

40
20

4/
2/
20
0
9
5/
10
/2
0
0
9
5/
18
/2
0
0
9
6/
1/
20
0
9
7/
10
/2
0
0
9
7/
14
/2
0
0
9
8/
28
/2
0
0
9
9/
13
/2
0
0
9
10
/4
/2
0
0
9
11
/3
/2
0
0
9
2/
24
/2
01
0
4/
30
/2
01
0
6/
28
/2
01
0
9/
15
/2
01
0
12
/2
3/
20
10
3/
18
/2
01
1

not yet fit for purpose and, therefore,

likely to fail. We learnt from this experience, and have reinforced the need to
ensure reliability before implementation
and spread of an initiative.

Conclusion

The SKIN Bundle is a simple, holistic

approach to ensuring all patients receive
the appropriate care to prevent pressure
damage. Using the pressure ulcer safety
cross to measure incidents of pressure
damage transformed attitudes staff
went from accepting pressure damage as
inevitable for some patients to scrutinising care to ensure everything was being
done to prevent pressure ulcers from

occurring. The IHI Model for Improvement is a simple and reusable model for
introducing rapid change, resulting in
sustained improvement. NT
References
National Institute for Health and Clinical Excellence
(2005) Pressure Ulcers: The Management of
Pressure Ulcers in Primary and Secondary Care.
London: NICE. www.nice.org.uk/cg29
National Patient Safety Agency (2010) NHS to
Adopt Zero Tolerance Approach to Pressure
Ulcers. London: NPSA. tinyurl.com/NPSA-ulcers
NHS Wales (2010) 1000 Lives Plus. Pressure Ulcer
Safety Cross. tinyurl.com/safety-cross
Reddy M et al (2006) Preventing pressure ulcers: a
systematic review. Journal of the American Medical
Association; 296: 974-984.
Vanderwee K et al (2007) Pressure ulcer
prevention in Europe: a pilot study. Journal of
Evaluation in Clinical Practice; 13: 2, 227-235.

www.nursingtimes.net / Vol 107 No 35 / Nursing Times 06.09.11 23

Spl, Al Grant

The bed selection decision algorithm to

help acquire the correct mattress and bed
for patients has been simplified, leading to
more appropriate selection and use of less
expensive beds; in addition, the use of barrier cream has been standardised to ensure
consistent practice and to reduce waste.
Due to staff enthusiasm and belief in
the value of the SKIN Bundle in the pilot
area, the tool was spread more widely
before we had achieved reliability. Fig 3
shows the delay in improvement days
between pressure ulcers where the SKIN
Bundle was spread too quickly (month 9).
Spreading a tool before good compliance
is achieved in the testing phase can lead to
the implementation of something that is