6Pressure ulcer prevention

Publication Details

6.1. Introduction

For an individual to suffer harm which could be prevented as a result of their care is clearly unacceptable and something to be avoided. Pressure ulcers are often an example of such avoidable harm occurring and their prevention is now a priority for the NHS.

It has been accepted for many years that pressure ulcers are often preventable. Unfortunately there is significant variation in the consistency of approach to pressure ulcer prevention, and to the treatment and care of established pressure ulcers across the NHS in both secondary and primary care. There is, therefore, a need for guidance to rationalise the approaches used for prevention, of pressure ulcers, and to ensure practice is based on the best available evidence. Every patient has the right to expect safe care as described by domain 5 of the NHS outcome Framework 2013/2014 and this includes prevention of avoidable pressure ulcers.

One of the potential problems is that all adults are potentially at risk of pressure ulcers - in certain circumstances anyone can develop one. However they are significantly more likely to occur in people who are seriously ill, neurologically compromised, have impaired mobility, impaired nutrition, poor posture or use equipment such as seating or beds that do not provide appropriate pressure redistribution. A significant number of pressure ulcers, therefore, arise during care for other disorders and people with limited mobility who live in residential or nursing care facilities are at increased risk of developing pressure ulcers. Because of this strategies for their prevention and treatment need to be applicable across a wide range of settings including both community and secondary care. This may require significant organisational and individual change and commitment to deliver preventative strategies effectively at a local level.

Another myth is that pressure ulceration is only a problem of older people. As mentioned above anyone can potentially develop a pressure ulcer at any time and neonates, children and young people can also be at risk. Neonates have particularly vulnerable skin and high rates of pressure ulceration can occur in neonatal intensive care for example. So in addition to developing recommendations for adults, we have carried out an expert Delphi process for prevention in neonates, infants, children and young people.

Regarding prevention we have looked at methods for risk assessment and who should be risk assessed for pressure ulceration. Several structured risk assessment scales have been developed for pressure ulcer risk and many are routinely used within the NHS. However, it is unclear if these scales are better than expert clinical assessment alone and whether their use can help prevent pressure ulceration. Prevention of ulceration caused by ischemia or neuropathy, moisture, friction and shear, venous leg ulcers, pressure ulcers caused by devices and Kennedy terminal ulcers have not been specifically included. However, in clinical practice these factors may also need to be considered.

It is hoped that this guideline will result in a reduction in the numbers of people developing pressure ulceration in the NHS. However, it will only be the start. Pressure ulcer prevention requires constant vigilance – even a brief lapse can result in a pressure ulcer which could take weeks or months to heal. Preventing pressure ulcers effectively will usually require a system approach that requires fundamental organisational change. That may be difficult, requiring multiple modifications to ways of working at all levels of an organisation. Some people may persist with the view that pressure ulcers are inevitable. However, that view is outdated and many organisations have already managed to very significantly reduce their pressure ulcer rates by some relatively simple interventions hinged around awareness and staff attitudes. It is hoped that this guideline will help others follow their lead successfully.

6.1.1. Adults ‘at risk’ and at ‘high risk’ of developing a pressure ulcer

For the purposes of this guideline, people receiving care from, or commissioned by, the NHS are considered to be either:

  • ‘at -risk’: people who are, after formal assessment using clinical judgement or a risk assessment tool, considered to be at risk of developing a pressure ulcer.
  • ‘at high risk’ of developing a pressure ulcer: people at high risk usually have multiple risk factors (for example, significantly limited mobility, risk of nutritional deficiency, an inability to reposition themselves, a neurological condition or significant cognitive impairmentb) identified during risk assessment with or without a validated scale. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.

The GDG noted that there were a number of methods of formally assessing an individual's level of risk (see Chapter 7). In addition to the use of clinical judgement, there were several risk assessment scales available but only limited evidence to suggest which method of risk assessment was a more accurate predictor of subsequent risk than clinical judgement. Additionally, the GDG noted that different tools have different thresholds for identifying those at risk and at high or very high risk, which healthcare professionals often amend for their own use.

As a result, the GDG did not consider that it was possible to develop recommendations based upon the categories outlined in a particular risk assessment scale and the group chose to develop the above two categories to help distinguish between those people at risk of developing a pressure ulcer and those with additional individual factors which may result in them having an high risk of developing a pressure ulcer.

Although it was outside the remit of the guideline to review the evidence and identify risk factors for pressure ulcer development, the GDG highlighted that there were likely to be a number of factors which might mean that an adult is considered to be at significant risk of developing a pressure ulcer. These may include, but are not limited to, a lack of activity and mobility (including people undergoing surgery and in the immediate post operative period), poor perfusion and skin status (for example, the presence of redness, blanching, erythema or dryness).34(Coleman et al 2013)

6.1.2. Neonates, infants, children and young people ‘at risk’ and ‘at highd risk’ of developing a pressure ulcer

For the purposes of this guideline, neonates, infants, children and young people receiving care from, or commissioned by, the NHS are considered to be either at:

  • ‘at-risk’: neonates, infants, children or young people who are, after formal assessment using clinical judgement or a risk assessment tool, considered to be risk of developing a pressure ulcer. Healthcare professionals should consider each neonate, infant, child or young person for their individual risk factors and formally assess whether they are at risk (see Chapter 7).
  • ‘at high risk’ of developing a pressure ulcer: neonates, infants, children and young people at high risk usually have multiple risk factors (for example, significantly limited mobility, risk of nutritional deficiency, an inability to reposition themselves, a neurological condition or significant cognitive impairmentb) identified during risk assessment with or without a validated scale. Those with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.

The GDG noted that neonates, infants, children and young people were likely to have different risk factors to adults and that these should be considered when assessing the risk of these populations.

6.1.3. Extrapolating adults recommendations to neonates, infants, children and young people

For ease of use, the guideline and its recommendations have been divided into two sections, part 1 (prevention) and part 2 (management). Part 1 and part 2 both contain recommendations for adults and neonates, infants, children and young people, using methods outlined in Chapter 3 and 4, respectively.

It is acknowledged that there are differences in the recommendations for adults and those for neonates, infants, children and young people. However, due to the significant differences in the means and sites by which younger populations may develop pressure ulcers, the GDG chose to use the results of the Delphi consensus to develop the recommendations, rather than extrapolating from evidence in adult populations.

However, the GDG acknowledge that some of those recommendations developed for adults may be applicable to neonates, infants, children and young people and that healthcare professionals may wish to consider the principles of these recommendations when treating these populations.

In each ‘Linking evidence to Recommendations’ section, recommendations for adults can be found in yellow boxes and recommendations for neonates, infants, children and young people in pink boxes. Recommendations which are applicable for all ages can be found in blue boxes.

6.1.4. Pressure ulcers caused by devices

The GDG wished to highlight that the prevention and management of pressure ulcers caused by devices is outside the scope of the current guideline (see Appendix A).

6.1.5. Accounting for individuals' comfort and preferences

Throughout the guideline, when developing recommendations for the prevention and management of pressure ulcers, the GDG have taken consideration of the individuals' concurrent needs for sleep, pain relief, meal times and rehabilitation. The GDG felt that it was important to highlight that a balance needs to be achieved between all of these factors for each individual who is at risk of or who has developed a pressure ulcer.

Footnotes

b

Please note that examples given are not exhaustive.