Before initiating this review, I recognised that pressure ulcers in the ICU were not solely a clinical concern—they reflected broader systemic issues. Patients in intensive care are critically unwell, frequently immobile and often unable to reposition themselves. Their skin integrity is compromised by factors such as impaired circulation, nutritional deficits and the presence of medical devices.

Staff operate under considerable pressure, balancing urgent, life-saving interventions with preventative care. Routine practices, such as repositioning and skin assessments, must be prioritised alongside emergencies. Documentation is fragmented—split between paper and electronic systems—resulting in communication challenges and planning inconsistencies. Access to pressure-relieving equipment varies, and escalation pathways are not always clearly defined.

These challenges are not attributable to individuals. Rather, they are indicative of a system that does not consistently enable safe care. For this reason, I adopted a systems approach to explore how environmental conditions, tools, tasks and organisational structures interact—and where they may be misaligned.

The aim was to move beyond attributing fault and instead identify the conditions that increase the likelihood of harm and how these might be addressed.

Applying the SEIPS framework

To guide this review, I used the SEIPS model. SEIPS is a human factors framework that examines how components of a work system—people, tasks, tools and technology, physical environment, and organisational conditions—affect processes and outcomes in healthcare.[5] It supports a holistic understanding of safety by focusing on system design rather than individual performance.

Step 1: Framing the review

I began by clarifying the scope and purpose. The objective was to examine the gap between 'work as imagined' (WAI)—the protocols and guidelines—and 'work as done' (WAD)—the realities of clinical practice. This approach enabled a deeper understanding of how pressure ulcer prevention is enacted in the ICU.

A thematic review methodology was also selected to synthesise insights from multiple sources:

• patient safety incident reports
• staff interviews and informal conversations
• observations of workflow and environmental factors.

Step 2: Gathering insights

I spent time in the ICU, observing care delivery and engaging with staff across disciplines. I listened for patterns, inconsistencies and adaptations—those moments where staff had to improvise or navigate ambiguous systems.

Documentation practices were reviewed, with attention to the coexistence of paper and digital records and the implications for communication and care planning. I examined how pressure ulcer risk was assessed, how referrals to tissue viability nurses were managed, and how equipment was accessed and escalated.

Step 3: Mapping the system

Using the SEIPS framework, I mapped the key components of the ICU system:

• People: Skilled, responsive staff working under pressure.
• Tasks: Complex care routines with competing demands.
• Tools and technology: Mixed documentation systems and variable equipment availability.
• Environment: A newly established ICU with evolving workflows.
• Organisation: Gaps in escalation protocols and support structures.

This mapping revealed areas of misalignment—where expectations diverged from practice, and where staff were compensating for systemic limitations.

Step 4: Synthesising findings

The analysis highlighted several interconnected challenges:

• Absence of standardised risk assessment and escalation guidance.
• Delays in accessing specialist mattresses.
• Inconsistent documentation and communication pathways.
• Limited visibility and support from tissue viability teams.

These issues were not isolated; they reflected broader systemic vulnerabilities and opportunities for improvement.

Step 5: Developing recommendations

Based on these insights, I proposed a series of actionable recommendations:

• Standardise surface provision and mattress escalation protocols.
• Enhance visual guidance for managing pressure damage.
• Streamline access to advanced support surfaces.
• Strengthen tissue viability support and referral pathways.
• Clarify documentation expectations and risk assessment procedures.

Step 6: Sharing and reflecting

The findings were shared with ICU staff and senior leadership. Feedback was overwhelmingly positive—staff felt their experiences were acknowledged and leaders appreciated the systemic perspective. The review contributed to averting a Regulation 28 notice (Prevention of Future Deaths report) and sparked interest in applying systems-thinking more broadly.

Throughout the process, I remained grounded in curiosity. I did not begin with assumptions; instead, I asked, observed and listened. This mindset was instrumental in uncovering meaningful insights and fostering constructive dialogue.

References

1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers.. 2019.
2. Jackson D, Durrant L, Walthall H. et al. Pain associated with pressure injury: A qualitative study of community-based, home-dwelling individuals. J Advanced Nursing, 2017; 73(12): 3061-9.
3. Rubulotto F, Brett S, Boulanger C, et al. Prevalence of skin pressure injury in critical care patients in the UK. BMJ Open, 2022  ;12: e057010. doi:10.1136/bmjopen-2021-057010.
4. Parkinson E, Leming S, Elmore N, Martin S. NHS Wound Care: Rapid evidence scoping review. Health Innovation East, April 2024
5. Carayon P, Schoofs Hundt A, Karsh BT, et al. Work system design for patient safety: the SEIPS model. BMJ Quality & Safety 2006.

Related reading on the hub:

• Implementing the aSSKINg pressure ulcer care bundle – a blog by Susan Martin
• PSIRF planning – Pressure ulcer example scenario
• Application of SEIPS and AcciMap to a patient safety incident
• Patient Safety: Emerging Applications of Safety Science
• SEIPS in action

Click on the headings below to read more about each resource.

1. Conducting a systems review of pressure ulcers in the intensive care unit

Pressure ulcers within the intensive care unit have long been recognised as a persistent and complex patient safety issue. In this blog, Patient Safety Learning's Associate Director Claire Cox shares how she adopted a systems approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model to review pressure ulcers.

2. Implementing the aSSKINg pressure ulcer care bundle – a blog by Susan Martin

In this blog, Susan Martin, a Tissue Viability Specialist Nurse at East Sussex, describes how she implemented the aSSKINg model (assess risk; skin assessment and skin care; surface; keep moving; incontinence and moisture; nutrition and hydration; and giving information or getting help) for pressure ulcer prevention into her Trust.

3. Skin Assessment: Assessing skin on patients with darker skin tones in relation to PU prevention

In this 56 minute presentation by The Society of Tissue Viability, Jacqui Fletcher looks at how wound care and pressure ulcer prevention can be improved for patients with darker skin tones.

4. PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool)

PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) is an evidence-based pressure ulcer risk assessment instrument that was developed by the University of Leeds using robust research methods. PURPOSE-T identifies adults at risk of developing a pressure ulcer and supports nurse decision‐making to reduce that risk (primary prevention), but also identifies those with existing and previous pressure ulcers requiring secondary prevention and treatment. It uses colour to indicate the most important risk factors and forms a three‐step assessment process.

5. PSIRF planning – Pressure ulcer example scenario

The Patient safety incident response framework (PSIRF) represents a new approach to responding to incidents. Under PSIRF, those leading the patient safety agenda within provider organisations, together with internal and external stakeholders (including patient safety partners, commissioners, NHS England, regulators, Local Healthwatch, coroners etc), decide how to respond to patient safety incidents based on the need to generate insight to inform safety improvement where it matters most. Key issues must first be identified and described as part of planning activities before an organisation agrees how it intends to respond to maximise learning and improvement. This guidance has been developed collaboratively between Stop the Pressure Programme, National Wound Care Strategy leads and members of the Patient Safety Team, with the support from the Patient Safety Incident Response Framework (PSIRF) Implementation and Working Groups. 

6. Embedding skin tone diversity into undergraduate nurse education: Through the lens of pressure injury

This study, published by the Journal of Clinical Nursing, explores health disparity in on-campus undergraduate nurse education through the analysis of teaching and teaching material exploring pressure injuries.

7. Measuring standards of care, not negative outcomes (Interview with Head of Nursing Quality)

In this interview, Head of Nursing Quality Gavin Porter talks about his positive, team-focused approach to improving pressure ulcer outcomes. "Counting the number of pressure ulcers doesn’t really tell you about the standards of pressure ulcer care. I wanted to look at things differently; to focus more on the interventions and good practice that helps keep patients safe."

8. Sign up to safety - pressure ulcers (Barts Health NHS Trust)

In this six minute video, Barts Health NHS Trust explains the measures frontline medical staff can take to help avoid the risk of pressure ulcers using the SSKIN acronym. 

9. This Is Nursing podcast: We don't want a good wound. We want to prevent them!

Alison Schofield, Tissue Viability Clinical Nurse Specialist, discusses the challenges facing her role in this current world of nursing, the impact of COVID-19 has had on the delivery of community tissue viability services and on people in receipt of the services in care homes and in their own homes.

10. Incidence of hospital-acquired pressure injuries and predictors of severity in a paediatric hospital

Hospital-acquired pressure injuries (HAPIs) pose significant challenges in healthcare and cause increased patient suffering, longer hospital stays and higher healthcare costs. Children in hospital face unique risks, but evidence about this remains scarce. This study in the Journal of Advanced Nursing aimed to identify and describe HAPI admission incidence and severity predictors in a large Australian children's hospital. The authors found that HAPI injuries in paediatric patients are unacceptably high. They argue that prevention should be prioritised and the quality of care improved globally. They also call for further research to develop targeted prevention strategies for these vulnerable populations.

11. Reducing hospital-acquired pressure injuries in a cardiothoracic intensive care unit

Hospital-acquired pressure injuries are a significant patient safety concern. The US Centers for Medicare & Medicaid Services tracks hospital-acquired pressure injuries as a patient safety indicator. Healthcare organisations with higher-than-expected rates may incur penalties. The aim of this study was to reduce the prevalence and incidence of hospital-acquired pressure injuries in the cardiothoracic intensive care unit.

12. Safeguarding adults protocol: pressure ulcers and raising a safeguarding concern

Pressure ulcers are a significant challenge for the patients who develop them and the healthcare professionals involved in their prevention and management. They can result in serious complications and avoidable harm, with patients with mobility difficulties at particularly risk from this. This guidance from the Department of Health and Social Care is designed to help practitioners and managers across health and care organisations to provide caring and quick responses to people at risk of developing pressure ulcers.

For more resources, see our dedicated Pressure ulcer section of the hub.

Do you have a resource or story to share on pressure ulcer care or prevention? the hub is designed for frontline staff, patients, managers, and anyone else else with an interest in patient safety, to come together and share their insights.

You can sign up today for free for full access to our library of resources and all of the benefits on offer to our members. 

The pressure injury prevalence rate in a cardiothoracic intensive care unit was above the National Database of Nursing Quality Indicators benchmark. The current standard of care—use of the Braden scale for pressure injury risk assessment and the SKIN (surface, keep turning, incontinence care, and nutrition) care bundle—may not adequately address the needs of the intensive care unit population. In addition, cardiac patients present a special challenge because of their disease process and the mechanical support devices used to treat patients in cardiogenic shock, which place them at risk for the development of hospital-acquired pressure injuries.

Methods

A performance improvement project was carried out in the cardiothoracic intensive care unit to reduce the prevalence and incidence of hospital-acquired pressure injuries. A preintervention convenience cohort was compared with a postintervention cohort. The intervention consisted of use of the Cubbin-Jackson scale, an intensive care unit–specific risk-assessment tool, with linked interventions to prevent pressure injuries.

Results

The preintervention and postintervention cohorts consisted of 102 patients each. The pressure injury prevalence and incidence rates decreased by 67.84% and 36.43%, respectively, from before to after the intervention.

Conclusion

The use of an intensive care unit–specific risk-assessment tool with linked interventions to prevent pressure injury can help reduce hospital-acquired pressure injuries in an intensive care unit.

The aim of this protocol is to provide a national framework, identifying pressure ulcers as primarily an issue for clinical investigation rather than a safeguarding enquiry led by the local authority. Indicators to help decide when a pressure ulcer case may additionally need a safeguarding enquiry are included.

In addition to this protocol the Department of Health and Social Care has published an accompanying adult safeguarding decision guide, body map and proforma as appendices, which can be found here.

The incidence and prevalence of pressure ulcers continues to rise in England despite national and international guidance. When I was considering what to do for my MSc dissertation as part of the Wound Healing and Tissue Repair programme at Cardiff University, I wanted to explore how we were doing as an organisation. As a Tissue Viability Nurse Specialist, I was familiar with aSSKINg, which is a pressure ulcer care bundle, although we had yet to implement it within our organisation.

Data collection

A clinical audit to determine the organisation's compliance against the aSSKINg framework for pressure ulcers seemed like a good place to start. I completed the required clinical audit paperwork and started collecting data from adult community nursing caseloads in the East locality.  The Trust is large and, as I was a single auditor, one locality was chosen to determine our compliance. 

I adapted a data collection tool from another clinical audit undertaken in acute trusts for a community setting. The audit covered the period July to December 2021 and I had access to 3000 patient records alongside clinical incident reports. Overall, 418 patients were identified as having a pressure ulcer in the audit period. Pre-audit work to determine if the data collection would be successful involved removing 20 patients and checking the data collection tool. I subsequently completed a pilot audit in another locality (West) and further amendments were made to the data collection too.  Of the remaining 398 patients in East, they were randomised using a number generator app and 150 patients were randomised to audit. 

Baseline data and aSSKINg pilot

The baseline data from the audit highlighted a need for improvement and I made the recommendation that an aSSKINg template was required in the electronic patient record to reduce the variations in care and improve documentation. 

A digital nurse specialist, a digital configuration analyst and I built the initial template. I identified six community nursing teams Tust-wide who wanted to participate in the pilot and the pilot started on the 6 February 2023. Alongside the pilot sites we made adjustments to the template.  Due to the overwhelming success of the pilot, I closed it on the 15 April. This is demonstrated in the table below. 

The feedback from the pilot site was that they found it helpful in that everything relating to pressure ulcers was in one place and they knew they had documented everything correctly. The Operational Leads fed back that they found it easier to locate information when completing clinical incident reports. 

Next steps

Following success of the pilot, the aSSKINg template has started to be rolled out Trust-wide. I decided, in discussion with other clinicians, that the roll out would be done gradually. The reason for this was to allow staff time to digest the changes and feel supported by the Practice Development Nurses, the digital team, their local tissue viability team and myself. 

Overall, the rollout is successful and teams are engaging with the change. There is a noted improvement in the overall documentation and early evidence that the variations in care are reducing. 

My advice to anyone thinking about doing something similar is to have good stakeholders involved, and to roll out a programme like the aSSKINg template care plan slowly as that has helped us to iron out any issues early on.

Have you implemented a new initiative in your organisation? Have you improved patient safety where you work? We would love to hear from you and share on the hub your journey. If you are a member, you can share directly on the hub or please contact content@pslhub.org to discuss further.

• Holistic management on venous leg ulceration
• Active treatment of non-healing wounds in the community
• Addressing skin tone bias in wound care: Assessing signs and symptoms in people with dark skin tones
• Care of the person with diabetes and lower leg ulcers
• Post operative wound care: reducing the risk of surgical site infection

You can access all of the Best Practice Statements via the link below.

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