Sally Sore - a doll making a difference

Pressure ulcer prevention

Developing a pressure ulcer for a patient is a devastating outcome for them and the healthcare professionals caring for them. While a few are unavoidable, those that  are avoidable can indicate that care being delivered falls short of what would be reasonably expected. 700,000 people are affected by pressure ulcers each year; 80 – 95% of these are quoted to be avoidable, and each additional pressure ulcer adds additional costs of care to £4000.

Finding new, exciting and innovative ways to teach pressure ulcer prevention is a constant challenge to Tissue Viability teams.

Sally Sore  is a pressure ulcer prevention teaching aid used at University Hospitals Coventry and Warwickshire NHS Trust to provide education to staff in a ‘hands on’, practical way and to raise awareness of pressure ulcer prevention. Sally Sore is used to educate staff in many areas related to pressure ulcer prevention. These include:

• 30 degree tilt
• Use of slide sheets
• Skin assessment
• Intentional rounding
• Heel elevation/ prevention

The 30 degree tilt is a repositioning technique that can be achieved by rolling patients slightly onto either side using pillows for support. The traditional 90 degree lateral rotation of patients is not recommended as it can result in complete anoxia to weight baring areas and so, may contribute to pressure ulcer development. This position is also very restrictive as patients are unable to reach drinks and it could limit social interaction when positioned away from other patients.

Sally doesn't sit still!

The Tissue Viability team attend all clinical areas and provide short training sessions using Sally Sore to provide practical demonstrations to as many staff as possible. Sally Sore promotes discussion of pressure ulcer prevention and the visibility of the team within clinical areas gives staff the opportunity to ask questions and discuss any issues regarding pressure ulcer prevention.

Sally tours clinical areas on a ‘mock’ bed and with the help of specially made appropriately sized equipment such as leg troughs, pillows, anti-embolic stockings, bandages and slide sheets, allows staff the opportunity to practice pressure ulcer prevention techniques such as skin assessment, heel elevation and the 30 degree tilt repositioning technique with the support and supervision of the Tissue Viability Team.

She wears a T-shirt showing a poem to high light the importance of using two slide sheets when repositioning patients. Miniature slide sheets are used to demonstrate the correct repositioning technique. Two slide sheets should be rolled out beneath the patient from head to heels and the top sheet used to slide the patient up the bed. This education supports the mandatory moving and handling training provided by UHCW Trust.

At UHCW skin assessments should be carried out within six hours of admission to hospital, on transfer and at least daily thereafter for patients with a pressure ulcer risk score of 10 or above. Using Sally Sore, the Tissue Viability Team are able to identify ‘at risk’ areas and demonstrate methods of pressure ulcer prevention such as heel elevation and regular repositioning.

An intentional rounding chart is completed for all in-patients at UHCW which incorporates the ASKIN bundle (Care bundle for prevention of pressure ulcers). Sally Sore is used to reiterate the importance of documenting actions carried out in relation to all sections of the ASKIN bundle.

In conjunction with link worker days, annual moving and handling training and bi-annual pressure ulcer prevention training Sally Sore on tour has helped further raise awareness of pressure ulcer prevention in an enjoyable, interactive way.

At UHCW though we have managed a sustained reduction in avoidable hospital acquired pressure ulcers, we have yet to eliminate these entirely which is the trusts and the tissue viability teams ambition. As a result the costs associated with patients sustaining avoidable harm are high and the physical, psychological and social impact to the patient often immeasurable.

Sally Sore allows the team to ensure that the message of pressure ulcer prevention can be delivered in a fun but meaningful, educational way on the formal teaching sessions, but is more widely used within clinical practice in ward and dept based teaching sessions. This method could be replicated across the UK and worldwide for the benefit of patients at risk of pressure ulcers everywhere.

Challenges

The number of staff that requires training in pressure ulcer prevention on an ongoing basis is huge in any large organisation. Staff turnover, use of agency staff and access to formal education sessions for some clinical areas can be challenging. Sally Sore fills these gaps in education with staff who may otherwise find it difficult to maintain their knowledge.

The use of teaching dolls is nothing new; most organisations use resus Annie dolls to teach effective CPR. We ourselves have also used a doll at UHCW to teach effective skin tear prevention (Terry Tear). The principle could therefore be replicated with topics of education in tissue viability and perhaps wider than this.

Sally Sore gets some unusual looks from some healthcare professionals around the organisation. However resus Annie’s are usually used in a controlled clinical teaching environment not touring the wards on a mock bed handing out education and staff information leaflets! It is through this method though that the team have found Sally Sore on tour is the most beneficial. Confining her just to classroom teaching limits the number of accessible staff and minimises the fun aspect of the teaching method.

Challenging the concept of how education should be delivered to be effective, persevering with this innovative method has meant that all staff have benefitted including hard to reach groups of staff such as our medical colleagues.

Visual and interactive teaching methods are more ‘sticky’ easier to recall, and more memorable. People didn’t previously chat as much about pressure ulcers, but they chat about Sally Sore within the organisation. In addition Sally Sore’s twitter page has allowed colleagues around the world who follow her to benefit from the messages on pressure ulcer prevention she shares.

Outcomes to date

In conjunction with various trust wide high profile campaigns (such as react to red skin and 100 days free), link worker days, monthly pressure ulcer prevention study days and annual handling and moving training, Sally Sore on tour has helped us to further raise awareness of pressure ulcer prevention in an enjoyable, interactive way across UHCW NHS Trust.

In the past few years over 1000 members of staff have been educated using Sally Sore at UHCW. This being part of the overall pressure ulcer prevention strategy has assisted the team in reducing the number of hospital acquired avoidable pressure ulcers. In addition Sally’s twitter page has over 300 followers including nurses, TVNs, university lecturers, matrons, practice facilitators, deputy chief nurses and even the nurse director of monitor Ruth May.

Although we have managed a sustained reduction in avoidable hospital acquired pressure ulcers, we have yet to eliminate these entirely which is the trusts and the tissue viability teams ambition.

As well as over 1000 staff at UHCW meeting and being educated, Sally Sore has also been introduced to many health professionals via her Twitter page @SallySore. Sally has interacted with other tissue viability teams during visits to other organisations and at Wounds UK 2015, student nurses at a national conference, directors of nursing from the UK as well as colleagues from Japan on an international visit to our hospital.  Sally is highly thought of in regards to the message she is conveying to staff in practice about eliminating pressure ulcers.

Conclusion

The Tissue Viability team would ideally like everyone across the UK to benefit from Sally Sore for use in teaching pressure ulcer prevention in an innovative fun way. Sally Sore could be developed into “Sally Sore in a box” and sold to NHS organisations, care homes, district nurse bases, nursing homes etc.

She has not yet been used to deliver education to patients, friends and family; however patients and family would benefit from an awareness of pressure ulcer prevention such as skin assessment and repositioning, especiallly if being cared for by non-professionals.

Sally Sore could also be the face of a national campaign to educate the general public of those patients at risk of pressure ulcers.

Sally Sore also has her own Twitter page @SallySore to promote her activities and she is included in the quarterly tissue viability newsletter.