Guidance

Pressure ulcers: applying All Our Health

Published 1 April 2015

Introduction

A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence. The 4 main factors implicated are interface pressure, shear, friction, and moisture. Pressure ulcers can range in severity from patches of discoloured skin to open wounds that expose the underlying bone or muscle.

There are a number of stages of pressure ulcers defined by the National Pressure Ulcer Advisory Panel.

  • 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.

Facts about pressure ulcers

NHS Safety Thermometer (PDF, 709KB, 19 pages) reported that from April 2014 to the end of March 2015, just under 25,000 patients were reported to have developed a new pressure ulcer, and on average 2,000 pressure ulcers are newly acquired each month within the NHS in England.

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; rather, it is the problems common in older people that are associated with pressure ulceration (hip fractures, faecal and urinary incontinence, smoking, dry skin, chronic systemic conditions, and terminal illness).

Those with spinal injuries form another distinct group, in whom 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, and 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).

The cost of treating a pressure ulcer varies from £1,214 to £14,108; costs increase with severity because the time to heal is longer and the likelihood of complications are higher in severe cases (Dealey, Posnett, Walker 2012).

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 ulcer that meets, or potentially meets, the threshold of a Serious Incident (PDF, 1.6MB, 90 pages)
  • utilising a recognised systems-based method for conducting investigations, commonly known as Root Cause Analysis (NHS England)
  • providers collecting NHS Safety Thermometer data on pressure ulcer prevalence, until a new measure of pressure ulcer prevalence is available
  • providers using pressure ulcer safety crosses 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 co-ordinate 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 such as immobility, incontinence and poor diet
  • communicating that pressure ulcers are preventable and ensuring all healthcare staff can recognise the various risk factors that lead to them 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 is 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

NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and ‘harm free’ care.

Examples of good practice

SSkin offers 5 simple steps to prevent and treat pressure ulcers.

Stop the Pressure provides details of many pressure reduction and pressure prevention initiatives across England.

PUinfo App by Buckinghamshire New University provides information to prevent pressure ulcers for people at risk and their carers.

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.

React to Red has been developed by the University Hospitals Coventry and Warwickshire NHS Trust, encouraging patients, carers and families to react to red skin over bony areas and ask for help and advice from a healthcare professional.

Guidance

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. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.

Pressure ulcers (QS89) covers the prevention, assessment and management of pressure ulcers in all settings, including 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.

Prevention and treatment of pressure ulcers: clinical practice guideline provides evidence-based recommendations for the prevention and treatment of pressure ulcers that can be used by healthcare professionals throughout the world.

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.