The incidence rates of comorbidities such as pressure ulcers, which result in mobility issues and weight loss, increase with an aging population. A pressure ulcer has been defined as localised damage to the skin and its underlying tissue caused by pressure and shearing forces (Clinical Practice Guidelines, 1993). The cost of treating a pressure ulcer can vary from £1214–14 108, depending on wound severity and its associated complications, thus representing a significant burden to the NHS and social care services (Dealey et al, 2012). Pressure ulcers can affect one in 20 community patients (McGinnis et al, 2014) and are associated with poor health-related quality of life, such as the exudate and odour from a wound and its effects on function (Gorecki et al, 2009). Two factors can contribute to the development of pressure ulcers: poor mobility and lying in bed for prolonged periods of time (Lindgren et al, 2004).
Air-alternating pressure-relieving mattresses and cushions are designed to prevent pressure damage in patients who are at very high risk of developing pressure ulcers and their associated complications. The National Institute for Health and Care Excellence (NICE) guidance advises the use of high-specification foam mattresses for adults with a pressure ulcer or the use of a dynamic support surface if a foam mattress does not suffice (NICE, 2014). A large majority of patients on the community nursing caseload in Sheffield are treated using air-alternating pressure-relieving equipment, as they are at risk of developing a pressure ulcer.
Managing the risk of fire while providing the best pressure ulcer prevention
Elderly persons with decreased mobility and dementia are at risk of death in a residential fire (Runyan et al, 1992). Fatal dwelling-house fires account for 10% of all accidental deaths in the UK and approximately one-quarter of people killed in house fires are over 75 years of age (Elder et al, 1996).
Patients who smoke cigarettes while being treated on air alternating equipment are at increased risk of being victims of accidental fire from cigarette debris. The pump in the air-alternating equipment will increase oxygen flow to the fire (like a pair of bellows), which, in turn, increases the risk of the fire igniting at lower temperatures. A fire will then burn faster and reach higher temperatures as a result of the increased flow of oxygen. Many patients who are house- or bed-bound also use oil-based emollients, making them susceptible to risks of fire damage as these creams are flammable. The Medicines and Healthcare products Regulatory Agency (MHRA) has noted at least 50 deaths by fire in 2018 that involved the use of emollients (MHRA, 2018).
People living alone and at a higher risk of developing pressure ulcers, with a maximum of four care visits per day, do not have an adequate frequent turning schedule as would be planned, for example, in a hospital or care home. In these instances, providing air-alternating equipment ensures that pressure areas are relieved when turning is not possible, significantly reducing the risk of pressure damage developing or deteriorating.
Community nursing teams must balance both pressure and fire risk and often, the immediate threat is from pressure damage, which can cause serious long-term complications if not adequately prevented. For example, Category 4 pressure damage can result in: infection, increased bed rest, reduction in quality of life, osteomyelitis, which, in some instances, can result in the death of the patient. Clinicians involved with patients in these circumstances express how difficult it is to make the decision to provide air-alternating equipment if there are fire risks.
The need for a comprehensive assessment
It is extremely difficult to provide air-alternating equipment in the home of a patient who refuses to stop smoking. Clinicians are aware of the need to prevent pressure ulcer damage, which would significantly increase the risk, if alternating equipment was not provided. However, the clinician must also consider the fatal scenario where the patient accidentally sets fire to their bedding and is unable to escape. There is also the risk of the fire affecting others in the house who may have limited mobility or ability to escape; or the fire might spread to other houses or flats.
Any risk assessment should also cover other heat sources where air alternating equipment is being used, such as: candle use, electric blankets, having an open coal or log fire near the equipment, or placing hot electrical items such as hairdryers or straighteners on the air mattress. Patients with hoarding tendencies also have a significant fire risk if they have an open fire.
South Yorkshire Fire and Rescue (SYFR) can issue flame retardant resources following assessment by a member of the SYFR staff. However, in February 2021, SYFR issued a warning:
‘there is a common misconception that flame retardant resources such as bedding or throws issued by SYFR, in conjunction with airflow products will stop a fire from happening; this is not the case. The flame retardant resources will delay ignition; however, if a heat source punctures the air flow product, this will increase ignition and fire spread due to the added air being released’.
SYFR also advise that practitioners should be aware of this when creating care plans or undertaking risk assessments. In a scenario where a fire does occur, patients who require air-alternating equipment who have limited mobility would find it extremely difficult to either put it out or escape from it. There have been occasions where SYFR have fitted a sprinkler system into the homes of patients who refuse to stop smoking and are a risk to themselves and others (for example, living in a shared building, with a row of terraces, ir where someone else is living in the house).
Despite explaining the risks and benefits, the individual may choose to continue smoking or have other fire risks in the property. In instances where a patient smokes, clinicians will advise the patient to stop, not to smoke while using alternating equipment, and will refer the patient to SYFR. Clinicians also refer to the Tissue Viability Team (TVT) for advice on weighing the benefits and risks of providing air-alternating equipment. If the patient has family members, they are consulted by the team to try and reach an agreement about the patient smoking; for example, only smoking while someone is in the house. However, the community nursing team are not able to control this.
There can be a delay in ordering equipment while clinicians discuss the risks with the multidisciplinary teams (MDTs) and nursing teams. Any delay in ordering alternating equipment can result in significant deterioration to the skin and underlying tissues.
There is no set escalation procedure for this difficult decision of managing pressure ulcers versus avoiding fire risks. The risk of providing air-alternating equipment to someone with a fire risk has been scored at the highest possible consequence due to death from fire—‘catastrophic’ based on the Trust Local Risk Categories (Table 1). The other risk categories are ‘insignificant’, ‘minor’, ‘moderate’ and ‘major’.
Table 1:
Risk assessment form
Method and findings
Design of the questionnaire
It became clear that there was a need to design a questionnaire that could provide guidance to clinicians when they discuss the issue of smoking and fire with patients, their families and general practitioners. To create this questionnaire, a task and finish group was formed comprising members from community nursing teams, TVTs, South Yorkshire Fire and Rescue, as well as a fire officer from the Trust. This questionnaire could help create scenarios to reduce fire risk, such as by having a family member present when the patient is smoking. Although this does not provide a solution to the problem, it does support the decision-making process (Table 2).
Table 2: Decision support tool for fire risk in patients nursed in their own homes
| Home environment. |
|---|
| Does the patient live alone? Are family carers friends able to supervise the smoking? Is the patient nursed in bed? Are family or friends providing the cigarettes? What sort of accommodation does this patient live it? House flat, which floor, shared occupancy? Are there any hording issues? Are the fire alarms in the property? |
| Emollients and the risks. |
| Is the patient using any paraffin based emollients? Is the bedding clean with signs of regular washing (to remove any oil based build up) Are there signs of emollient build up on furniture or carpets? Are there any identified signs of risk from fire, for example burn marks in clothing, furniture carpets? Are there overflowing ash trays? Equipment provision Are there any sign of cigarette damage to the mattress or cushion? What pressure area equipment is in place already? Is an upgrade required? If so what to? |
| Cognitive / capacity issues. |
| Does the patient have capacity issues? Does the patient have any cognitive issues? Does the patient have any alcohol or substance misuse issues? Risk of pressure damage. Does the patient have existing pressure damage? Has the patient had previous pressure damage? What is the current Waterlow? And is this score increasing over time? Is the patient independently mobile? Does the patient have any visual or sensory impairment? Does the patient have reduced ability to escape a fire? |
The questionnaire was added to the electronic patient record used by the Trust as a web link. This acted as a prompt to be completed when any new patient in the nurse's caseload were smokers and also required a pressure ulcer care plan with an air-alternating mattress.
Introduction of the questionnaire
The questionnaire was then promoted to all the teams who visited patients at home for use with individuals who met the criteria. Further work is now planned to audit the implementation of the questionnaire and survey team members, to ascertain how its use can help the decision-making process when discussing risks with patients who are at risk.
Conclusion
The NHS is required to continually work towards improving patient safety, with its three main strategic aims being insight, involvement, and improvement (NHS England and NHS Improvement, 2019). The design and implementation of this questionnaire and risk assessment combines all three by recognising: the risk (insight); working with both clinicians, the fire service, patients and their families to discuss the risks (involvement);and reducing the risk of fires associated with smoking and air alternating mattresses (improvement). Along with the NHS' requirement for an organisational framework of risks, it is also important to ensure individual clinicians understand how to recognise them and what actions they must take. A study to explore the conceptual frameworks used by clinicians from health and social care to identify and manage risks noted six paradigms to guide practice (Taylor, 2006), two of which were protecting the individual and others, and balancing benefits and harms. An example of the former is when clinicians recognised situations where individuals could harm themselves or others (including setting fire to a building). As part of balancing benefits and harms, clinicians took an approach that respected the right of patients to make choices regarding potential hazardous behaviours, but discussed these risks as part of their professional responsibility.
There is currently a review by local commissioners which may lead to a complete ban on any patient who smokes receiving air alternating equipment, but this is still in the discussion phase.