Guidelines for the prevention of pressure ulcers

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• Summary
• Background
• Management of the at risk patient
• Discharging and transferring patients
• Education and Training
• Additional Guidance for At Risk Clinical Areas
• Appendix 1: Pressure ulcer categorisation, Taken from EPUAP quick reference guide
• Appendix 2: Flowchart for reporting and investigating Pressure Ulcers within LTHT
• Appendix 3: A guide to selecting a pressur ulcer equipment
• Appendix 4: Nutritional Flow Chart
• Appendix 5: Equipment Selection Guide for discharge to LCH
• Appendix 6 – Flow Chart for Pressure Area Care in the Perioperative Department

Summary of Guideline

These guidelines include how to complete a formal risk assessment, skin assessment and management of the “at risk” patient, including care planning using the ‘SSKIN’ acronym, the selection of appropriate equipment, reporting and investigating acquired ulcers and discharge planning. These guidelines also include the management of an at risk patient.

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Background

A pressure ulcer (also known as decubitus ulcer, pressure injury, bed sore) is defined as localised damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. Pressure ulcers usually occur over a bony prominence but may also be related to a medical device or other object. [1]. They are categorised according to the depth of the tissue damage, from Category 1 for non-blanching erythema of intact skin, to Category 4 for full thickness tissue loss extending to underlying structures such as bone, muscle or tendon (Appendix 1).

Pressure ulcers are a worldwide problem affecting hospital and community patient populations [2, 3]. In practice, the emphasis is on identifying patients at risk and implementing appropriate interventions to prevent pressure ulcer occurrence [1,4-6].

The costs of treating a pressure ulcer have been conservatively estimated as ranging from £1214 to heal a Category 1 to £14108 to heal a Category 4 pressure ulcer [7]. However, the major impact is on the patient’s quality of life [8]. Distressing symptoms include pain, odour, exudate, prolonged immobility and delayed rehabilitation; these have a far reaching physical, psychological and social impact on the patient and their family or carers.

A pressure ulcer can occur due to the forces of a patient’s bodyweight, or as a result of externally exerted forces such as those applied by a medical device or other object, or by a combination of these. A pressure ulcer can present as unbroken skin or an open wound which could be shallow or deep, and may be painful. A pressure ulcer is damage to the tissues that occurs as a result of intense and/or prolonged exposure to pressure, friction, shear or a combination of these loading modes [9].

Pressure ulcer prevention involves identifying those who could be at risk of developing a pressure ulcer and implementation of an appropriate plan of care

Step 1: Screening

Screening is a process of identifying patients who already have or who are at risk of developing pressure ulcers and who therefore require a further comprehensive assessment.

All patients in our hospitals are potentially at risk of developing a pressure ulcer; therefore all patients require screening, within 6 hours of initial contact, to identify if they may be at risk of developing pressure ulcers [4].

The risk assessment tool of choice in LTHT is the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T) for adults and Paediatric PURPOSE T for paediatrics and Braden Q for neonates.

Step 1 of the PURPOSE T risk assessment tool is a screening tool which should be used in all clinical areas (there are different versions for adults and paediatrics). PURPOSE T is completed on PPM+. The over-riding risk factors are reduced mobility or immobility and skin status e.g. current or previous history of pressure damage or vulnerable skin (table 1). The list is not exhaustive and the updated PURPOSE T [11] recognises this; a patient can now be screened as at risk if professional and clinical judgement dictates. This should include patients whose condition is anticipated will rapidly deteriorate including patients who are to undergo major surgery, or whose condition could change on a daily basis.

Table 1: Risk factors identified at screening which will prompt a full risk assessment

Evidence Level B

Step 2: Risk Assessment

All patients who are screened as ‘at risk’ should have a documented formal risk assessment using the PURPOSE T completed within 6 hours of admission or transfer. Risk assessments should be used to assist, but not replace, professional clinical judgement.

The formal risk assessment must be undertaken by a qualified practitioner (e.g. RN, ODP,TNA etc.) with the knowledge and expertise required i.e. pressure ulcer prevention level 1 and 2 priority training completed and recorded on the Electronic Staff Record. The assessment of risk should be carried out, where possible, in consultation with the patient and/or carer.

Where it is expected that the patient’s clinical condition will rapidly deteriorate, for example, in patients who are to undergo major surgery or where they will be immobile post operatively, or patients in critical care, the pressure ulcer prevention needs of the patient should be anticipated using clinical/professional judgement.

The formal pressure ulcer risk assessment may indicate specific factors that require further assessment, e.g. nutritional status, continence status.

The outcome of the risk assessment will either identify the patient as being ‘not currently at risk’, or ‘at risk of developing a pressure ulcer’, or ‘at risk of developing a pressure ulcer with pre-existing pressure damage’. All patients identified at risk must have a documented, individualised plan of care that reflects the identified domains of the risk assessment (see documentation section). Those patients with pre-existing pressure damage should also have a Datix is completed and those with Category 2 or above pressure ulcer should also have a wound care plan.

The plan of care must be developed by a registered practitioner and should be made, wherever possible, in partnership with the patient and/or carer and the multidisciplinary team. All individuals involved should be aware of the level of risk.

The pressure repositioning schedule, skin evaluation schedule and redistributing device should be clearly documented and re-evaluated as the patient’s condition changes

Evidence Level C

Step 3: Reassessment of risk

All patients identified as at risk should have a documented reassessment when their condition changes, either improving or deteriorating, when transferred between clinical areas, including between wards and theatres, and/or at weekly intervals. The frequency of this will be determined by the individualised patient assessment and documented in the nursing record. A change in skin status should prompt a re-assessment of risk. Patient’s condition may change on a daily basis which could indicate a daily re-assessment of risk.

The reassessment should result in a review of the plan of care including frequency of repositioning and equipment selection. Any revision to the plan of care should be implemented and documented.

All patients who are identified as not ‘at risk’ during their initial screening should be re-assessed if their condition changes.

Evidence Level C

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Management of the at risk patient

All patients assessed as being at risk of developing a pressure ulcer should have an individualised care plan (LTH0485) and SSKIN Bundle (LTH0486) which takes into account the result of the risk assessment using the SSKIN acronym:

Skin assessment - the results should be clearly documented, along with frequency of planned re-inspection
Surface - the need for additional pressure relief, taking into account specific at risk sites, including heel and medical devices
Keep moving - the mobility of the individual and their ability to reposition themselves
Incontinence/skin moisture - keeping the skin clean, dry, and protected against moisture associated skin damage
Nutrition – check that the patient’s nutritional requirements are being met and if necessary refer to a Dietitian

All patients who are found to have developed a hospital acquired category 1 or above pressure ulcer require a Datix completing and the root cause for the pressure ulcer must be investigated as per Trust Policy (see Appendix 2).

Patient and carer information

Any patient who has been assessed as being at risk of developing a pressure ulcer, along with their family and/or carers, should be offered information about the causes, early signs, and ways to prevent pressure ulcers. All relevant information is available in the patient information leaflet (print unit order code LN003690 for adults and LN004386 for Paediatrics) and supported with verbal advice. They should be given the opportunity to discuss their personal pressure area prevention plan and future pressure ulcer prevention risks and needs. Where possible the plan of care should be agreed with the patient and include their actions to help prevent pressure ulcers.
Evidence Level C

Skin Assessment

All patients assessed as being at risk of developing a pressure ulcer should be offered a skin assessment by a healthcare professional who has been trained (i.e. pressure ulcer theory priority training). This should be recorded on the PURPOSE T as part of the risk assessment and then subsequently on the SSKIN bundle chart. The skin inspection should be documented using the European Pressure Ulcer Advisory Panel classification [1] (Appendix 1).

The skin assessment should include finger palpation of the skin to determine whether any skin discolouration or erythema (redness) is blanchable. It should also take into account:

• any pain or discomfort reported by the patient
• colour changes or discolouration
• variations in firmness or heat compared to the surrounding skin
• signs of moisture

N.B. This is particularly important in individuals with darker skin, where normal erythematous changes are not always seen.

The skin inspection should also be on-going and influence the care provided. The frequency of skin inspection should be determined by a registered healthcare professional according to the individualised patient assessment and skin response along with the repositioning need – i.e. if the patient requires 2 hourly repositioning, then they should have their skin inspected every 2 hours alongside the repositioning. Where there is evidence of skin redness or tissue damage that is not relieved by the care planned, a review of the care plan must be undertaken and any action taken should be documented. Staff should consider increasing the frequency of skin assessments to 2 hourly until the redness has resolved [4]and this should be documented on the SSKIN bundle.

The areas of skin inspected should be based on the individual patient assessment of the most vulnerable areas of risk. These should include areas subject to pressure, shearing forces or friction i.e. “BEST-SHOT”

Buttocks
Elbows/Ears
Sacrum (lower back, at the top of the buttocks)
Trochanters (hips)
Spine/Shoulders
Heels
Occipital area (back of the head)
Toes

Other at risk areas include those that could be affected by medical devices such as anti-embolic stockings, splints, casts, catheters, face masks, NG tubes and ET tubes etc. along with areas affected by pressure from the patients position where two skin sites are in close contact e.g. knees or ankles pressing against each other.

Surface (and devices)

The use of medical devices to aid pressure relief or pressure reduction should be considered for patients at risk. Equipment selection should be based on the overall assessment of the patient and take into account the level of risk, patient comfort, the patient’s ability to move themselves and their general health and rehabilitation.

When choosing pressure relieving devices the following needs to be considered:

• Support surface (bed/mattress) for patients who spend the majority of their time in bed
• Seating (chair/cushion) for patients who are either high risk or spend prolonged periods sitting out
• For patients at high risk of developing a heel pressure ulcer should have the heel elevated from the bed

All beds within LTHT have a high risk foam mattress as standard, which is suitable up to and including patients with Category 2 pressure damage. For high risk patients, those who are immobile with a pressure ulcer more severe than a Category 2 or where clinical judgement deems appropriate, a powered mattress should be considered. A flow chart has been provided to aid in equipment selection (Appendix 3).

See Arjo equipment PDF

The use of incontinence pads or additional padding on top of a pressure relieving mattress or cushion will reduce the pressure relief provided. Incontinence pads should be used if necessary but not kept in place as a precaution and only a singular pad should be used. Absorbent sheets/incontinence sheets should not be used for the management of incontinence.

Water-filled gloves, synthetic sheepskins or doughnut-type devices should not be used as pressure-relieving or redistributing aids. Pillows and wedges can be used as a repositioning aid with a 30º tilt and to offload heels, but only in patients who can maintain their position and care should be taken not to hyper-extend the knee as this can compress the popliteal vein and increase the risk of deep vein thrombosis.

Further details of the devices approved by LTHT Tissue Viability team for pressure ulcer prevention can be found on the intranet: http://lthweb.leedsth.nhs.uk/sites/tissue-viability/tissue-viability/pressure-area-care-equipment-selection-guide-and-information-1
Evidence level C

Seating should be chosen to meet the individual patient’s needs and take into account seat height, depth, need for padded armrests, use of chair with integral pressure relief. The effect of increased seat height when a pressure cushion is used should be considered. Use of an inappropriate chair may increase risk (even with a pressure cushion in situ) as well as increasing the risk of falls.

Seating assessments for aids and equipment should be carried out by trained professionals that have developed specific knowledge and skills in this area (e.g. qualified nurses, physiotherapists or occupational therapists).

Positioning of individuals who spend substantial periods of time in a chair or wheelchair must take into account, distribution of weight, postural alignment, and support of the lower limb / feet.

Evidence Level C

Keep Moving (Repositioning)

All patients assessed as ‘at risk’ of developing a pressure ulcer must change their position at least every 4 hours [4, 6]. Where possible the patient should re-position themselves. Any repositioning schedule must be agreed with the patient (if possible) and detailed within the SSKIN documentation. Repositioning should be appropriate to any particular body site at risk e.g. offloading the heels of immobile patients in bed, or if the patient has vulnerable skin on the buttocks or ischial tuberosities then more frequent repositioning should occur when they are sat in a chair (rather than in bed). If the skin assessment shows deterioration in the condition of the patient’s skin, then the frequency of repositioning must be increased accordingly.

The support surface the patient is positioned on e.g. specialist mattress should not influence the repositioning schedule.

Positioning of patients should ensure that; prolonged pressure on bony prominences is minimized, bony prominences are kept from being in direct contact with one another, friction and shear damage are minimised. Any repositioning of the patient must take into account: the vulnerable areas of skin presented by the patient, the comfort of the patient, their clinical symptoms e.g. shortness of breath, their routines e.g. meal times, investigations or treatments e.g. diagnostics, dialysis.

Patients who might not be able to feel or respond to pressure appropriately e.g. neurological conditions such as stroke, cognitive impairment, multiple sclerosis, spinal cord injury, analgesics or anaesthetics, are at risk of pressure ulcers. They may be capable of moving themselves but require regular prompting.

The use of the 30° tilt or profiling the patient’s position should be considered to minimise friction and shear. Where complex moving and handling issues are identified or positioning of a patient is difficult, expert advice should be sought e.g. moving and handling advisors, specialist physiotherapists. Slide sheets must be used to move patients in bed to minimise friction and shear and should be placed underneath the buttocks and the heels. Patient handling equipment used to assist in the transfer or repositioning of a patient should be removed from under that individual after use unless this would pose further risk to the patient or staff. (LTHT Guidelines for Safer Patient Handling http://lthweb/sites/manual-handling/care-planning-tools).

All of the bedframes in LTHT are electric profiling beds, which can be used to assist in the repositioning of patients. Instructions for the different bedframes used at LTHT can be found here
Evidence Level C

Incontinence

Skin moisture, is a key factor in the development of pressure ulcers [10]. Assessment of risk should take into account causes of moisture e.g. urinary or faecal incontinence, perspiration in the pyrexial patient, leakage from wounds. Effective promotion of continence or management of incontinence is needed to keep the skin dry. Separate guidance can be found for the management of patients at risk of developing moisture associated dermatitis http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1153

Emollients (moisturisers) should be used on dry or oedematous skin to reduce vulnerability and barrier creams should be used in patients at high risk of developing moisture lesions (e.g. patients with incontinence or excessive sweating).

Vigorous skin rubbing or massage, particularly over bony prominences, is likely to have a detrimental effect and should be avoided.
Evidence Level C

Nutrition

Poor nutritional status and dietary intake is associated with the risk of developing pressure ulcers [10]. The relationship between nutritional status and pressure ulcers is complex and poor nutritional status may be a contributory factor, rather than a major causal factor in the development of pressure ulcers.

Dehydration can also cause skin to become dry and fragile. Fluid intake should be encouraged with the aim of 6-8 cups daily (approximately 1.5 litres per day). This can include water, hot drinks and nourishing fluids such as milky drinks and fruit juice.

Risk factors include low body mass index (BMI), malnutrition, nutritional deficiencies, unintentional weight loss, an impaired ability to eat independently and obesity. Obesity is an independent risk factor for developing a pressure ulcer, and the risk is further increased if the individual is obese and has malnutrition [12].

Patients identified as at risk of malnutrition with a Category 2 or above pressure ulcer should be referred to the Dietitian for a comprehensive assessment of nutritional status noting their risk of pressure ulcers. Alongside the referral they should be started on an oral nutritional care plan, nutritional supplements (Appendix 4), and offered a copy of the patient information leaflet “Eating well for wound healing and preventing skin break down” (print unit code LN004189)

Patients with adequate nutritional intake should not be offered additional supplements, and patients with adequate hydration should not be offered subcutaneous or intravenous fluids just for the specific purpose of pressure ulcer prevention [1].
The Guideline for the Oral Nutritional Care of Adult Inpatients can be found here http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1391

The Nutritional Care Guidelines for Children can be found here:
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1805

Evidence level C

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Discharging and transferring patients

All at risk patients should have skin status checked (the presence or absence of pressure ulcers) prior to discharge or transfer. All at risk patients who are being transferred between clinical areas e.g. ward to ward, theatres to PACU, A&E to ward, should have their risk and skin status communicated verbally and in writing to the receiving area.

Hospital patients’ who remain identified as at risk of developing pressure ulcers or who have a pressure ulcer(s), should have a reassessment of their risk as part of the discharge planning process.

Where the patient is identified as ‘at risk’ or as having a pressure ulcer and is to be discharged from hospital to their home or a residential home, verbal contact with the neighbourhood nursing team should be made as soon as possible. Prior to discharge, information should be given to the neighbourhood nursing team that provides details of the patient, their level of risk, skin status, any treatment, the patient’s cognitive state, their ability and willingness to comply and carer availability and knowledge.

The neighbourhood nursing team must be informed of any planned home visits. Where a home visit has been made and the neighbourhood nursing team has been unable to attend, there should be liaison between the Occupational Therapist and the neighbourhood team regarding the assessment of the environment and the need for equipment. The Occupational Therapist and neighbourhood team both have a responsibility to communicate with each other.

The neighbourhood nursing team will authorise the provision of pressure relieving equipment for use in the community. This requires a minimum of 72 hours’ notice to be given prior to the discharge date to allow the equipment to be ordered and delivered (appendix 5).

Where the patient is to be discharged from hospital to a nursing home, communication regarding the pressure ulcer prevention needs of the patient should be discussed with the assessment team from the nursing home. It is the responsibility of the nursing home to assess the need for and provide appropriate pressure reducing equipment.
Evidence Level C

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Education and Training

All patient facing clinical staff should have an awareness of the causes of pressure ulcers and ways to prevent pressure ulcers. There are 2 levels of pressure ulcer priority training available through the training interface:

Level 1 pressure ulcer prevention training (theory) is compulsory for all clinical staff, which can be undertaken either through face to face training (e.g. pressure ulcer prevention study days, Introduction to Professional Practice) or directly through the training interface by watching a training video.

Level 2 pressure ulcer prevention training is an e-learning package. This is required of all patient facing nursing staff, (including CSWs, Nursing Associates, ODPs and Midwives) who care for patients who could be at risk of developing a pressure ulcer. Level 2 training can also be achieved through attending a pressure ulcer prevention study day or link practitioner day (with a pressure ulcer focus) run by the Tissue Viability department.

Evidence Level C

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Additional Guidance for At Risk Clinical Areas

Paediatrics

All paediatric areas should adhere to these guidelines, although in addition:

• Paediatrics PURPOSE T or Braden Q for neonates should be completed as per the guidelines, but at the time of writing are still in paper format.
• Specific sites such as the occiput should be monitored closely amongst this population and pressure should be relieved to the scalp and head when repositioning.
• Ensure that the patients, parents and carers are involved in the repositioning plan, if repositioning is declined by the patient document and discuss their reasoning for declining. Consider involving a play expert to encourage repositioning in patients who have difficulty or decline repositioning [4].

Outpatients/Day Case/Short Stay areas

According to the NICE guidelines [4] all patients in secondary care should have a risk assessment. In LTHT for short stay and outpatients this could start with screening via the PURPOSE T.
Risk factors are:

• Mobility problems and spending longer than 2 hours in a chair or bed in the same position (e.g. waiting for a procedure or post op)
• Current or previous history of pressure damage

Repositioning must be offered for these patients as per guidelines. All day case and short stay wards should adhere to this guidance.

Patients with peripheral arterial disease/poor perfusion

Risk factors are:

• Patient group has by definition poor perfusion so all at some degree of risk. Any degree of immobility will have immediate impact and increase risk
• Peripheral neuropathy is associated with diabetes and arterial disease. If present the patient will not feel discomfort/ sensation in feet which prompts movement and position changes
• Patient group frequently have challenging health beliefs and values e.g. continue smoking or recreational drugs despite knowing the adverse effects
• Patients may also have more generalised vascular disease e.g. cerebral which could lead to compromised cognitive ability or cardiac which could lead to generalised poor perfusion, renal disease can also compromise perfusion
• Poor perfusion means patients are prone to infection, this increases metabolic demands and increases risk
• Abnormal foot shape due to either deformity or oedema will affect the parts of the foot subjected to pressure and/or the intensity of the pressure

These patients should have their heels offloaded wherever possible.

Patients who have had a stroke

Risk factor are:

• Likely to have poor perfusion (cerebral ischaemia is often accompanied by peripheral ischaemia) so many at some degree of risk. Any degree of immobility will have immediate impact, increasing risk
• Peripheral neuropathy is associated with stroke, diabetes and arterial disease. If present the patient will not feel discomfort/ sensation particularly in feet which prompts movement and position changes
• Patients may use ‘good’ heel for propulsion to reposition self in chair or mainly in bed, This will cause extra pressure, sheer and friction
• Patients may develop contractures which result in increased pressure on the affected heel when in supine position, or to knees and ankles if in contact when side lying.
• Patients may have compromised cognitive ability due to their stroke which will affect their ability to understand need for repositioning and pressure relief
• They may have other forms of vascular disease e.g. cardiac which could lead to generalised poor perfusion, renal disease can also compromise perfusion.
• Poor perfusion means patients are prone to infection, this increases metabolic demands and increases risk

Patients undergoing surgery

• All assessments for risk of developing pressure ulcers and assessment should be documents pre-operatively, intra-operatively and post-operatively using the Operating Theatres Record of Care
• Staff assessing pressure ulcer risk for patients undergoing surgery will need to anticipate the change in risk that will occur during the peri-operative period along with anticipating risk factors during theatre (Appendix 6)
• Additional consideration needs to be given to specific situations which will affect risk e.g. the presence of a tourniquet, hypotensive episodes, and major blood loss.
• The preferred option for all patients is that they should be transferred straight onto the theatre table with a high risk (memory foam) mattress. If it is not safe for the patient or staff to remove the transfer sheet then additional aids e.g. gel pads can be used
• Ensure the surgeons and anaesthetists are aware of the patients risk and skin condition. For all patients at high risk it is important to ask the surgeon and anaesthetist whether any change of position can be performed during surgery

Peri-operative patient positioning in the operating theatres at Leeds Teaching Hospitals NHS Trust guidance can be found here: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?id=6930

Declarations of Interest

None to declare

Evidence Search Strategy

The most updated search was performed on 15/04/2021 by LTHT Library service. Healthcare databases, Medline and CINAHL were searched for any new research on pressure ulcer prevention.

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Appendix 1: Pressure ulcer categorisation, Taken from EPUAP quick reference guide(1)

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Appendix 2: Flowchart for reporting and investigating Pressure Ulcers within LTHT

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Appendix 3: A Guide to selecting a pressure relieving equipment

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Appendix 4 - Nutritional Flow Chart

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Appendix 5: Equipment Selection Guide for discharge to LCH

Clinical judgement is needed in addition to active skin monitoring to inform mattress/bed and cushion choice. Skin inspection should help inform appropriateness of equipment.

*For all patients on dynamic alternating air mattresses refer to the Medical Device Alert (MDA) 2013/073 for advice on use if a patient smokes in bed

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Appendix 6 – Flow Chart for Pressure Area Care in the Perioperative Department