Pressure ulcers: applying All Our Health

Updated 10 June 2022


The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities (OHID) on 1 October 2021.

A pressure ulcer is defined as localised damage to the skin and or underlying tissues as a result of pressure or pressure in combination with shear. Pressure ulcers occur over bony prominences but may also be related to a medical device or other object.

There are 6 categories of pressure ulcer:

  • Stage I: non-blanchable
  • Stage II: partial thickness
  • Stage III: full thickness skin loss
  • Stage IV: full thickness tissue loss
  • Suspected deep tissue injury
  • Unstageable: full thickness skin or tissue loss

See more information on categories of pressure ulcer (PDF, 1.22MB).

Facts about pressure ulcers

Older people are the most likely group to have pressure ulcers. This is especially true for those older than 70, up to a third of whom will have had surgery for a hip fracture. Age alone is not a risk factor. Instead, it is the problems common in older people that are associated with pressure ulceration. For example hip fractures, faecal and urinary incontinence, smoking, dry skin, chronic systemic conditions, and terminal illness.

Those with spinal injuries form another distinct group. In this group the prevalence is 20% to 30%, 1 to 5 years after injury.

Pressure ulcers in older patients are associated with a fivefold increase in mortality. In addition, in-hospital mortality in this group is 25% to 33% (Grey, 2006).

Pressure ulcers can result in longer lengths of stay in hospitals. One study found that adult patients who develop pressure ulcers had an extended stay of over 4 days (Graves, 2005). Another study found patients over 75 years of age, who develop a pressure ulcer in hospital, had a 10 day longer stay (Theisen, 2012).

Treating pressure ulcers costs the NHS more than £1.4 million every day (Guest et al. 2017).

Core principles for healthcare professionals

Healthcare professionals should:

  • know the needs of individuals, communities and population and the services available
  • think about the resources available in health and wellbeing systems
  • understand specific activities which can prevent, protect, and promote

Population level

Healthcare professionals should be aware of the interventions at population level, which include:

  • adhering to commissioning standards, linking to NICE quality standards, and specifying that services should be commissioned from and coordinated across all relevant agencies encompassing the whole pressure ulcer care pathway
  • reporting all patient safety incidents to the NHS National Patient Safety Agency national reporting and learning system
  • thoroughly investigating any pressure that meets or potentially meets the threshold of a serious incident following the principles of the Patient Safety Incident response framework
  • utilising a recognised systems-based method for conducting investigations, commonly known as Root Cause Analysis (NHS England)
  • providers using pressure ulcer safety crosses or numbers of days free approach to measure incidents of pressure damage to raise awareness and change attitudes to pressure damage
  • sharing appropriate data between health, social care and community safety organisations to target prevention activity and coordinate care

Community level

Community health professionals and providers of specialist services can have an impact by:

  • developing targeted social marketing and public health campaigns to raise the awareness that pressure ulcers can affect anyone in their lifetime
  • ensuring local ‘Making Every Contact Count’ initiatives include an assessment of the risks which contribute to pressure ulcer development. For example immobility, incontinence and poor diet
  • communicating that pressure ulcers are preventable
  • ensuring all healthcare staff can recognise the various risk factors that lead to pressure ulcers, and have the knowledge and expertise to promote prevention and treatment strategies
  • targeting ‘at risk’ groups whilst acknowledging pressure ulcers can affect anyone
  • ensuring people with an existing pressure ulcer or identified at risk of developing one, in any setting, have access to pressure redistribution devices
  • getting to know the community and care home initiatives developed to improve prevention
  • referring to the NICE quality standards when choosing, commissioning or providing high-quality pressure ulcer services

Family and individual level

Healthcare professionals can have an impact on an individual level by:

  • recognising the important role individuals, families and carers have in preventing and managing pressure ulcers
  • engaging individuals, carers and families in what to look for and how pressure ulcers can be prevented
  • using appropriate literature with visual images to explain how quickly pressure ulcers can develop
  • educating the individuals and caregivers about the causes, assessment and management of pressure ulcers
  • using appropriate terminology; recognising and informing patients that pressure ulcers are another term for ‘bed sores’
  • encouraging individuals to move independently whenever possible
  • directing individuals to appropriate healthcare professionals if they suspect a pressure ulcer is forming or is present
  • looking out for skin discolouration or soreness, particularly in areas where bones are close to the skin
  • repositioning or turning patients frequently; at least every 2 hours for those patients who need help
  • using moving and handling aids to help reposition individuals who require assistance moving
  • performing regular skin inspections to check areas at risk and document pressure areas at least once a day
  • checking that patients with pressure ulcer risk factors are registered with a GP and receive primary health care support to minimise the risks
  • providing holistic health assessments for people at risk of developing pressure ulcers

Measuring outcomes

A replacement to the NHS Safety Thermometer is currently being developed and will be available to view in the Model Health System.

Examples of good practice

SSKIN offers 5 essential steps to prevent pressure ulcers.

Learn more about current work to prevent pressure ulcers.

The Eatwell Guide shows the proportions in which different types of foods are needed to have a well-balanced and healthy diet.

PROSPER: Promoting safer provision of care for elderly residents includes a focus on pressure ulcers.


There are 9 quality standards which describe pressure ulcers as a high-priority area for quality improvement. Each standard consists of a prioritised set of specific, concise and measurable statements. The standards draw on existing guidance, which provides an underpinning, comprehensive set of recommendations. They are designed to support the measurement of improvement.

Pressure ulcers (QS89) covers the prevention, assessment and management of pressure ulcers in all settings. This includes hospitals, care homes with and without nursing, and people’s own homes.

Pressure ulcers: prevention and management (CG179) covers evidence-based advice on the prevention and management of pressure ulcers.

New guidelines from the European Pressure Ulcer Advisory Panel covers evidence based advice on the prevention of pressure ulcers.

Nutrition support for Adults: oral nutrition support, enteral tube feeding and parenteral nutrition (CG32) covers the care of patients with malnutrition. Patients who are malnourished are potentially at risk of developing a pressure ulcer.