Pressure ulcers or ‘bed sores’ are typically thought of as a fairly innocuous injury that occurs in people who are bedbound. But all patients, of any age, are potentially at risk of developing a pressure ulcer, which can affect any area of the body and can sometimes lead to permanent damage or loss of muscle or bone underneath the affected area of skin.
In fact, just under half a million people in the UK will develop at least one pressure ulcer in any given year. This adds up to a huge treatment bill for the NHS which spends a staggering amount of money - over £1 billion - each year on treating pressure ulcers.
It’s a problem not just confined to the NHS but for health services around the world, as highlighted by today’s international Stop Pressure Ulcer Day.
So what can be done to address this problem?
Prevention is key
Preventing pressure ulcers is of national importance and is included in domain 5 of the Department of Health's NHS outcomes framework 2014/15.
Updated in April 2014, the NICE pressure ulcers guideline rationalises the approaches used for the prevention and management of pressure ulcers and applies to all people in NHS care and in care funded by the NHS. Its implementation will ensure practice is based on the best available evidence.
NICE recommends carrying out and documenting an assessment of pressure ulcer risk for adults admitted to secondary care or care homes, and for those receiving NHS care in primary care or community settings.
Adults who have been assessed as being at high risk of developing a pressure ulcer should be offered a skin assessment by a trained healthcare professional. The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for skin integrity in areas of pressure, colour changes or discoloration, and variations in heat, firmness and moisture.
Adults who have been assessed as being at risk of developing a pressure ulcer should be encouraged to change their position frequently, and at least every six hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required.
NICE recommends that a high specification foam mattress is used for adults who are admitted to secondary care and assessed as being at high risk of developing a pressure ulcer in primary and community care settings.
Pressure ulcers can develop at any age
The guideline also covers the care of neonates, infants, children and young people and recommends a risk assessment for those admitted to secondary or tertiary care, or those receiving NHS care in other settings. Those at high risk should be offered a skin assessment.
For neonates and infants who have been assessed as being at high risk, consider repositioning more frequently than every four hours. Document the frequency of repositioning needed.
The guideline states that children and young people, who have been assessed as being at high risk, should be encouraged to change their position more frequently than every four hours. If they are unable to reposition themselves, offer help to do so, using equipment if needed. Again, document the frequency of repositioning required.
Training and education
The guidance has important advice on training and education and makes the recommendation that training is offered to nurses and other healthcare professionals. This should include:
- Who is most likely to be at risk of developing a pressure ulcer
- How to identify pressure damage
- How to prevent new or further pressure damage
- Who to contact for further information and for further action
Further training should be offered for those who have contact with anyone who has been assessed as being at high risk of developing a pressure ulcer. Training should include:
- How to carry out a risk and skin assessment
- How to reposition
- Information on pressure redistributing devices
- How to discuss the prevention of pressure ulcers with patients and their carers
- Details of sources of advice and support.
The management section of the guideline addresses nutrition and hydration, dressings, the use of pressure redistributing devices, and debridement.
Systemic antibiotics should not be offered specifically to heal a pressure ulcer in adults but may be considered for neonates, infants, children, and young people with a pressure ulcer with clinical evidence of local or systemic infection.
Anyone of any age can develop a pressure ulcer so strategies for prevention and management need to apply across all care settings. This requires a systems approach, modifications at all organisational levels, individual change, and constant vigilance, because even a brief lapse can result in a pressure ulcer that could take weeks or months to heal.
A range of support tools are available to help put this guideline into practice, including audit tools, a costing statement, and risk assessment algorithms. The guidance is also presented in pathway format which provdes quick and easy access to everything NICE has produced on pressure ulcers.
Look out for a NICE quality standard on pressure ulcer prevention, expected in May 2015. The quality standard will outline the high-priority areas for quality improvement, derived either from NICE guidance or NICE accredited sources.
A great case study can be seen by Nurses in Birmingham who used the guidance to reduce the number of pressure ulcers among patients in nursing homes. Through effective communication, and a strategic approach to pressure ulcer prevalence, the team have demonstrated a year on year reduction in the numbers of pressure ulcers.