Centre for Reviews and Dissemination
Pressure ulcers affect around 5% of patients: but the majority of these may be avoidable.
Pressure ulcers can become painful, infected and malodorous, reduce health related quality of life and increase length of hospital stay.
Multicomponent interventions are recommended, incorporating: pressure-relieving surfaces, skin inspections, repositioning of patients, incontinence/ moisture management, and nutrition/hydration.
Key to implementation are: simplification and standardisation of pressure ulcer specific interventions, multidisciplinary teams and leadership, accountability and celebrating success, designated skin champions and ongoing education.
There is evidence of cost savings from pressure-ulcer prevention programmes.
Pressure ulcers are a serious concern, affecting around 5% of patients in England.1 Yet an estimated 80%-95% of these may be avoidable.2
Pressure ulcers are a type of injury that breaks down the skin and underlying tissue due to impaired blood supply caused by pressure and/or friction, often over bony prominences. All patients confined to bed or a chair are potentially at risk of developing a pressure ulcer, particularly those unable to reposition themselves (e.g. unconscious or sedated). This risk is increased in those who are seriously ill, have significant cognitive impairment, inadequate nutrition, a neurological condition, impaired sensation or mobility, incontinence, poor posture, or deformity. Pressure ulcers can become painful, infected and malodorous, reduce health related quality of life,3 and increase length of hospital stay.4
2004 estimates placed the cost of pressure ulcers to the NHS at £1.4 to 2.1 billion per year, equivalent to 4% of total NHS expenditure.5 More recently, the cost of treating individual pressure ulcers has been estimated to range from £1,200 to £14,000, depending upon the stage of the wound.
As an indicator of the size and importance of the problem, the proportion of patients with category 2, 3 and 4 pressure ulcers has been included as part of the NHS Outcomes Framework for 2014/15.6
This issue of Effectiveness Matters summarises the evidence relating to the implementation of interventions to prevent pressure ulcers in hospital and community care settings. The bulletin is based on existing sources of synthesised and quality-assessed evidence.
A number of standalone interventions to prevent pressure ulcers have been evaluated in high quality systematic reviews. These reviews have found convincing evidence of effectiveness for high-specification foam mattresses,7 but not for standalone nutritional interventions8 or for the application of topical agents over bony prominences.9 While both risk assessment and repositioning of patients are likely to be worthwhile practices, there is currently no clear evidence to favour one particular pressure ulcer risk assessment tool,10 or a particular frequency or position for repositioning.11
In practice, multicomponent interventions or ‘care bundles’ are generally recommended over standalone interventions for the prevention of pressure ulcers. Recently, an NHS ‘Stop the Pressure’ campaign was rolled out nationally to support a 50% reduction in pressure ulcer prevalence throughout winter 2013/14.2 As well as providing educational resources, the campaign promotes the “SSKIN” care bundle that emphasises the need for a bundle of practices, incorporating appropriate pressure-relieving surfaces, skin inspections, repositioning of patients, incontinence/moisture management, and where necessary nutrition/hydration support.
NICE has identified a number of priorities for the implementation of interventions for the prevention and management of pressure ulcers.12 These include:
Risk assessment for all patients being admitted to secondary care or care homes, and in other settings if they have a risk factor (such as limited mobility or nutritional deficiency).
Provision of a skin assessment for patients assessed as being at high risk of developing a pressure ulcer.
Individualised care plans for patients at high risk of developing a pressure ulcer, with a specific strategy to offload pressure in patients with heel ulcers.
Encouraging patients to reposition themselves frequently, offering help where necessary, and documenting the frequency of required repositioning.
Use of high-specification foam mattresses for all adults admitted to secondary care, and for those at high risk of developing a pressure ulcer in primary and community care settings.
Provision of training and education to healthcare professionals on predicting, identifying, preventing, and managing pressure damage.
The NICE guideline further states that additional research is needed on debridement techniques, negative wound pressure therapy, risk assessment in children, pressure redistribution devices, and the optimum position and frequency for repositioning patients.
The American Association for Healthcare Research and Quality (AHRQ) report Making Health Care Safer II13 assessed evidence on the implementation of multicomponent interventions for preventing in-facility pressure ulcers. This review included 23 moderate-quality studies.
Most multicomponent interventions evaluated in acute care settings were found to reduce pressure ulcer incidence and/or prevalence, though results were less consistent when such interventions were implemented in long-term care facilities. No harms were reported in either acute or long-term settings.
The settings and interventions were diverse: even within acute care settings, multicomponent interventions were implemented in organisations ranging in size from 18 to 800 beds. Some programmes were focused specifically on reducing pressure ulcer rates, while others formed part of comprehensive initiatives aimed at patient safety more broadly.
Across evaluation studies, implementation tools included audit and feedback, education and training, identifying specific groups of patients at risk, monitoring progress and compliance, and streamlining of products and processes.
A number of barriers to implementation of pressure ulcer prevention programmes were noted, including: difficulties expanding the scale of an existing programme, staffing barriers (lack of motivation, turnover, and resistance to change), limited resources, inconsistent or missing documentation, difficulties in exporting data for clinical decision-making reports, miscommunication between electronic systems, and increased ulcer rates following less frequent monitoring of processes.
In spite of these barriers, substantial reductions in pressure ulcer rates were observed across most of the included studies. The majority of successful pressure ulcer prevention initiatives incorporated the following key components:
Simplification and standardisation of pressure ulcer specific interventions. One study reported a successful pressure ulcer prevention intervention that incorporated streamlining and standardisation of a skin product line, alongside rationalisation of seven existing policies and procedures into one.14 Two studies reported that success was more easily sustained through the implementation of simple components (such as institution-wide pressure relieving mattresses) than more complex components (particularly those dependent on staffing).15,16
Involvement of multidisciplinary teams and leadership. All studies specifically mentioned the influence of staff on implementation. Several studies attributed success to the engagement of multiple clinical disciplines14,15,17,18 and strong support across different levels of leadership.15,17,19
Ensuring leadership and staff accountability and celebrating success. Typically, this has been achieved through sustained audit and feedback. One study recommended that managers should anticipate a possible spike in reported skin breakdown immediately after the successful implementation of a programme, due to increased awareness, education and reporting among front-line staff.20
Designated skin champions. In response to barriers such as high staff turnover, several studies suggested that wound care coordinators or similar specialist roles can help sustain improvements.16,17,18, 21-28
Ongoing education. One study demonstrated the need for weekly reports indicating the completion of training to maintain initial improvements in ulcer rates.29
Implementing change one unit at a time. One study reported an attempt to expand an initiative from a single critical care unit to all nursing units on two sites, noting difficulties in coordinating a skin committee, coordinating schedules, and tracking the acquisition of new equipment.19
Key components of successful pressure ulcer prevention initiatives
The AHRQ report included five US-based studies providing information on the costs of pressure ulcer prevention programmes. With the exception of one study that reported an increase in costs attributable to new technology,28 all reported substantial cost-savings.24,27,30,31 One further US-based cost effectiveness analysis showed a programme for nursing care residents at risk of developing pressure ulcers to be effective and cost efficient.32
NHS Safety Thermometer: Patient harms and harm free care. England March 2013-March 2014, official statistics. Health and Social Care Information Centre, April 2014.
NHS Stop The Pressure Campaign. http://www.nhs.stopthepressure.co.uk/
Essex HN, Clark M, Sims J, Warriner A, Cullum N. Health-related quality of life in hospital inpatients with pressure ulceration: assessment using generic health-related quality of life measures. Wound Repair Regeneration 2009;17:797-805.
Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Advances in Wound Care 1999;12:22-30.
Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age and Ageing 2004; 33: 230–235.
The NHS Outcomes Framework for 2014/15. Department of Health, November 2013.
McInnes E, Jammali-Blasi A, Bell-Syer SEM, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD001735. DOI: 10.1002/14651858.CD001735. pub4.
Langer G, Fink A. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD003216. DOI: 10.1002/14651858.CD003216.pub2.
Moore ZEH, Webster J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD009362. DOI: 10.1002/14651858.CD009362.pub2.
Moore ZEH, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub3.
Moore ZEH, Cowman S. Repositioning for treating pressure ulcers. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD006898. DOI: 10.1002/14651858. CD006898.pub3.
NICE. Pressure ulcers: prevention and management of pressure ulcers. (CG179). London: NICE, 2014.
Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDonald KM, Dy SM, Shojania K, Reston J, Berger Z, Johnsen B, Larkin JW, Lucas S, Martinez K, Motala A, Newberry SJ, Noble M, Pfoh E, Ranji SR, Rennke S, Schmidt E, Shanman R, Sullivan N, Sun F, Tipton K, Treadwell JR, Tsou A, Vaiana ME, Weaver SJ, Wilson R, Winters BD. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. (Prepared by the Southern California-RAND Evidence-based Practice Center under Contract No. 290-2007- 10062-I.) AHRQ Publication No. 13-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2013. www.ahrq.gov/research/findings/evidence-based-reports/ ptsafetyuptp.html.
Young J, Ernsting M, Kehoe A, Holmes K. Results of a clinician-led evidence-based task force initiative relating to pressure ulcer risk assessment and prevention. J Wound Ostomy Continence Nurs 2010 Sep-Oct;37(5):495-503. PMID: 20736858
Walsh NS, Blanck AW, Barrett KL. Pressure ulcer management in the acute care setting: a response to regulatory mandates. J Wound Ostomy Continence Nurs 2009 Jul-Aug;36(4):385-8. PMID: 19609158.
Lyder CH, Grady J, Mathur D, Petrillo MK, Meehan TP. Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement. Jt Comm J Qual Saf 2004 Apr;30(4):205-14. PMID: 15085786.
Bales I, Padwojski A. Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 2009 Apr;18(4):137-144. PMID: 19349933
Horn SD, Sharkey SS, Hudak S, Gassaway J, James R, Spector W. Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports. Adv Skin Wound Care 2010 Mar;23(3):120-31. PMID: 20177165.
Dibsie LG. Implementing evidence-based practice to prevent skin breakdown. Crit Care Nurs Q 2008 Apr¬Jun;31(2):140-9. PMID: 18360144.
Gibbons W, Shanks HT, Kleinhelter P, Jones P. Eliminating facility-acquired pressure ulcers at Ascension Health. Jt Comm J Qual Patient Saf 2006 Sep;32(9):488-96. PMID: 17987872.
Ballard N, McCombs A, Deboor S, Strachan J, Johnson M, Smith MJ, et al. How our ICU decreased the rate of hospital-acquired pressure ulcers. J Nurs Care Qual 2008 Jan-Mar;23(1):92-6. PMID: 18281882.
Catania K, Huang C, James P, Madison M, Moran M, Ohr M. Wound wise: PUPPI: the Pressure Ulcer Prevention Protocol Interventions. Am J Nurs 2007 Apr;107(4):44-52; quiz 53. PMID: 17413732.
LeMaster KM. Reducing incidence and prevalence of hospital-acquired pressure ulcers at Genesis Medical Center. Jt Comm J Qual Patient Saf 2007 Oct;33(10):611-6, 585. PMID: 18030863.
Courtney BA, Ruppman JB, Cooper HM. Save our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage 2006 Apr;37(4):36, 38, 40 passim. PMID: 16603946.
Hiser B, Rochette J, Philbin S, Lowerhouse N, Terburgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manage 2006 Feb;52(2):48- 59. PMID: 16464994.
Milne CT, Trigilia D, Houle TL, Delong S, Rosenblum D. Reducing pressure ulcer prevalence rates in the long¬term acute care setting. Ostomy Wound Manage 2009 Apr;55(4):50-9. PMID: 19387096.
Tippet AW. Reducing the incidence of pressure ulcers in nursing home residents: a prospective 6-year evaluation. Ostomy Wound Manage 2009 Nov 1;55(11):52-8. PMID: 19934464.
Ryden MB, Snyder M, Gross CR, Savik K, Pearson V, Krichbaum K, et al. Value-added outcomes: the use of advanced practice nurses in long-term care facilities. Gerontologist 2000 Dec;40(6):654-62. PMID: 11131082.
Rosen J, Mittal V, Degenholtz H, Castle N, Mulsant BH, Hulland S, et al. Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home. J Am Med Dir Assoc 2006 Mar;7(3):141-6. PMID: 16503306.
McInerney JA. Reducing hospital-acquired pressure ulcer prevalence through a focused prevention program. Adv Skin Wound Care 2008 Feb;21(2):75-8. PMID: 18349734.
Xakellis GC, Frantz R. The cost of healing pressure ulcers across multiple health care settings. Adv Wound Care 1996 Nov-Dec;9(6):18-22. PMID: 9069752.
Shannon RJ, Brown L, Chakravarthy D. Pressure ulcer prevention program study: a randomized, controlled prospective comparative value evaluation of 2 pressure ulcer prevention strategies in nursing and rehabilitation centers. Advances in Skin and Wound Care 2012; 25(10): 450-464