Pressure Ulcers

Feature Strategies to improve the prevention of pressure ulcers Judy Elliott describes a project that sought to improve tissue viability during the patient journey from admission to discharge Summary This article outlines the actions taken by one acute trust to implement evidence-based, best practice recommendations for pressure ulcer prevention. Initially, an exploratory study identified specific areas for practice development, particularly improving early risk assessment, intervention and focus on heel ulcers.

Further actions included recruiting tissue viability support workers to promote a pressure ulcer campaign. Prevalence audit results demonstrated improved prevention and reduced prevalence of hospital-acquired pressure ulcers by 6 per cent and heel ulcers by 4. 9 per cent. Further work is required to ensure prevention strategies are consistent and documented. Keywords Best practice, evidence base, pressure ulcer prevention ( Institute for Innovation and Improvement 2009), therefore it is important to seek further initiatives to eliminate avoidable pressure ulcers from NHS care.

Tissue damage A pressure ulcer is defined as (European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) 2009): '... localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. ' Healthy individuals are continuously moving and readjusting their body posture to prevent excess pressure and shear forces. Reduced mobility or sensation interrupts this natural response, rendering an individual vulnerable to tissue damage.

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Eurther susceptibility is influenced by an individual's intrinsic risk factors reflected by their tissue tolerance (Bonomini 2003). Individual risk factors include immobility, malnourishment, cognitive impairment, acute and chronic ulness (National Institute for Health and CUnicad Excellence (NICE) 2005). Pressure ulcer prevention involves the modification of an individual's risk factors by the whole multidiscipUnciry team (Gould et al 2000). Risk assessment Identification of vulnerable individuals can be challenging.

Designated risk assessment tools have been found to lack reliability and validity with a tendency to overestimate risk (Pancorbo-Hidalgo et al 2006). The NICE (2005) guideline emphasises the importance of early assessment, within sbc hours, using clinical judgement. Vanderwee et al (2007a) found skin inspection more reliable compared with an assessment tool, with 50 per cent fewer patients identified as requiring intervention cuid no significant difference in patient outcomes. The skin should be assessed for early signs of tissue damage, which November 2010 | Volume 22 | Number 9

PRESSURE ULCERS have potentially devastating consequences for patients, hospitals and the overaU hecdth economy. An estimated 5 to 10 per cent of patients admitted to hospital develop pressure ulcers, resulting in increased suffering, morbidity and mortaUty (Clark 2002, Redelings et al 2005) and depleting NHS budgets by 4 per cent, or more than ? 2 billion ? mnually (Bennett et al 2004). Prevention is a complex, multifactorial process and although it is accepted that some pressure ulcers are unavoidable, most are considered preventable.

Acknowledging the difficulty in establishing national comparative prevalence data because of variances in methodology and settings (Calianno 2007), a prevalence of 21. 9 per cent of patients affected was reported in a pilot study of UK acute hospitals in 2001 (Clark et al 2004). Pressure ulcer prevention is a nursing quality indicator and high impact action for nursing and midwifery (NHS NURSING OLDER PEOPLE Feature Figure 1 I Illustrations showing a correctly fitting chair to ensure sufficient I pressure redistribution and poor sitting posture 1.

The patient should be seated with hips and knees at right angles, feet flat on the floor and arms/shoulders supported. The patient's weight is evenly displaced through the feet, thighs and sacrum. 2. The chair is too low; the patient's upper legs are not supported, and weight is increased onto the buttocks leading to greater risk of pressure damage. include observable discolouration and palpable tissue changes such as localised bogginess, heat or cold (NICE 2005). International guidelines (EPUAP/NPUAP 2009) advise a structured approach to risk assessment using a combination of all three techniques.

Ecirly intervention Once risk is identified immediate action is imperative to minimise risk of pressure ulcer development. As evidence is weak for specific interventions a number of areas should be addressed, involving ecirly initiation of preventive action, improving tissue tolerance and protecting from the adverse effects of pressure, friction and shear (Calianno 2007). Nutrition and tissue loading are two areas of nursing influence. Strategies to ensure optimal nutrition should be used and the provision of oral nutritioneil supplements has been associated with reduced tissue breakdown (Bourdel-Marchasson et al 2000).

Tissue loading may be addressed by manual and mechcinical repositioning, mobuisation and exercise. Strategies to minimise shear forces include addressing posture, moving and handling techniques and use of electric profiling beds (Keogh and Dealey 2001). Positioning and repositioning Research has not established an optimeil frequency of patient repositioning (Defloor et al 2005). Repositioning should be undertaken on an individual basis in Une with ongoing skin evaluation, avoiding bony prominences (NICE 2005).

The skin shoiUd be closely monitored to ensure effectiveness of the regimen and further actions taken if ciny signs of tissue damage occur. November 2010 Volume 22 Number 9 A flatter position distributes body weight more evenly. Semi-Fowler (semi-recumbent) and prone positions yield the lowest interface pressures with sitting cind 90-degree side-lying the highest (Sewchuk et al 2006). Repositioning using the 30-degree tuted side-lying position (alternately right side, back, left side) or prone position is advised (EPUAP/NPUAP 2009).

The repositioning regimen should be agreed with the patient and will require adaptation to ensure concordance with comfort, symptoms and medical condition. Prolonged chair sitting is impUcated with greater risk of pressure ulcer development (Gebhardt and BUss 1994). Chair sitting should be Umited to less than two hours at ciny one time for the acutely ul at-risk individual (Clark 2009). A correctly fitting chair is important to ensure sufflcient pressure redistribution (Figure 1).

Poor sitting posture may cause posterior pelvic tilt (sacral sitting) or pelvic obUquity (side tUting onto one buttock), with the ideal chair allowing feet to sit flat on the floor, with hips and knees at 90 degrees and arm/shoulders supported (Beldon 2007). Support surfaces High specification foam mattresses have demonstrated improved performance in pressure ulcer prevention (Defloor et al 2005), leading assessme Low risk • Use static foam mattress. • Reassess if patient's condition changes. Medium risk • Use static foam mattress. • Implement repositioning regimen. Check skin at least daily. • If any signs of pressure damage request dynamic (air) mattress. • Reassess if patient's condition changes. High risk (contraindicated if patient weighs more than 39 stone (refer to guidelines), has a spinal injury (refer to trauma and orthopaedics) or unstable fracture). • Use dynamic (air) mattress. • Implement repositioning regimen. • Check skin at least daily. • If any further signs of pressure damage increase repositioning programme. • Reassess and step down onto static mattress as patient's condition improves.

Remember to apply heel protector boots for patients at risk or with heel pressure ulcers. NURSING OLDER PEOPLE Feature to replacement of standard mattresses by most hospital trusts. There has also been considerable investment in mechanical (dynamic) support surfaces, where air is pumped through the mattress via alternating pressure or low air loss. However, the benefits of these devices remain unclear in terms of clinlccd and cost effectiveness (Reddy et al 2006). Pressure ulcer incidence rates of 5 to 11 per cent have been reported in studies, with longer use associated with greater risk (Theaker et al 2005).

These devices should be considered m conjunction with other support surfaces as delayed or inconsistent use may negate the benefits. Multiple strategies A number of studies have attained favourable outcomes using multiple interventions. Examples include introducing a multidisciplinary working party, improving management of pressure-relieving equipment, educational programmes and developing new guidelines (Gould et al 2000, Catania et al 2007, Dobbs et al 2007). Variations in approach suggest the commitment of practitioners is vital to success. For example, a support surface . howed improved outcomes only when used In conjunction with an educational programme for registered nurses (RNs) (Sewchuk et al 2006). Factors identified as impeding pressure ulcer prevention include lack of time, staffing levels and staff knowledge (Moore and Price 2004, Pancorbo-Hidalgo et al 2006, Robinson and Mercer 2007). Skill mix may also influence outcomes. Horn et al (2005) investigated staffing levels in a nursing home and found fewer pressure ulcers were associated with more direct RN care for each resident. heels' protocolj Apply heel protector boots to patients at high risk of heel ulcers when on bed rest.

Assessment criteria include limited mobility and: • • • • I Is patient immobile, heavily sedated or unconscious? Can patient lift his or her leg up in bed? Is there any evidence of heel tissue breakdown, blistering or ulceration? Does the patient have diabetes, vascular or renal disease? experiences highlighted the challenges in delivering timely, optimal preventive care. Opportunities to improve preventive care during the patient journey from admission to discharge were identified. These processes were influenced by the level of communication and collaborative care.

Practice development recommendations included: • Improve early risk assessment and intervention. • Direct resources to the start of the patient journey. • Prevent heel ulcers. Further actions were taken during 2009/10 to develop practice in line with these recommendations. Method Tissue viabUity support workers were recruited for each hospital site to focus on pressure ulcer prevention, in particular managing pressure-relieving equipment. They reclaimed dynamic mattresses and recurected them to admitting areas to enable immediate access 'at the front door'.

They were entrusted with keeping a 'float' of mattresses in a clean library store and helping with maintenance, decontamination eind training. In September 2009 a trust-wide pressure ulcer campaign was launched. This focused on three Interventions: support surface, positioning and repositioning and heel offloading: 1. Risk assessment within six hours and appropriate support surface (Box 1). A simple flow chart was disseminated highlighting a structured patient pathway, based on NICF (2005) best practice recommendations.

Initial risk assessment was encouraged using clinical judgement to help early assessment in the emergency admitting areas. A more detailed assessment was requested during the following 24 hours using the Waterlow assessment tool (Waterlow 1988) to provide risk status confirmation and identify individual risk factors. Patients were assessed as low risk (fuUy mobile and minimal risk factors/Waterlow score 20). All trust static mattresses consist of high specification foam offering protection to all admitted patients. The trust has purchased November 2010 Volume 22 Background

An exploratory study of pressure ulcer prevention was undertaken in the project hospital trust during 2007/08. The trust includes three acute sites covering a large geographical area consisting of more than 1,200 beds and serving a predominantly ageing population. A case study meth(3dology was used to consider the topic from a range of perspectives using quantitative zind qualitative data (Yin 2003). A reduction in overall and hospital-acquired pressure ulcer prevcdence since 2001 was found. Steady reduction in sacral ulcers was observed with the heel emerging as the most common site for hospital-acquired pressure ulcers by 2008.

Increased prevalence observed in 2009 reflected revised data collection methods and improved reuabuity with thorough skin inspection. Data were also generated from focus group interviews with multidisciplinary clinicians. Their NURSING OLDER PEOPLE Feature more than 350 dyncimic mattresses and local recommendations prioritise patients at high risk, unless contraindicated. 2. Implementation of revised positioning cind repositioning documentation. Revised documentation included a visual care plan/ regimen, repositioning chart and skin evaluation for all vulnerable patients. 3. F*revention of heel ulcers.

The 'hecilthy heels' project ran concurrent to the Ccimpaign cind was undertaken from October 2009 to March 2010. Funding was procured for regular provision of heel protector boots that 'float the heel' and offload pressure to augment the repositioning and positioning programme. A protocol was disseminated aiming to protect patients with high risk factors such as diabetes or early signs of tissue damage located at the heel (Box 2). The annual prevalence audit methodology was revised to improve reliabUity of data collection cind undertciken in Februcuy 2009 and repeated in February 2010.

Data was collected by tissue viabibty nurses at the bedside including skin inspection eind related preventive interventions. Previously, ward nurses supplied the date using vcirious collection methods. Data analysis was undertaken by the trust's clinical audit team. ulcers as some patients hav e more than one pressure ulcer. Audit results from Februciry 2010 showed a reduction in hospital-acquired pressure ulcer prevcilence by 6 per cent and a reduction in total pressure ulcer prevalence by 4. 7 per cent (Table 1). Prevalence of patients with pressure ulcers had reduced from the previous audit by 2. per cent to 13. 4 per cent (Table 1). More than half of the total inpatient population was assessed as vulnerable to pressure dcimage. This information enables comparison with similar populations and indicates a 2 per cent increase in the population at risk from the previous year. There was also a reduction in all grades/ categories of hospiteil-acquired pressure ulcers (Table 2). The grade (category) of ulcer is used to assess depth of tissue damage, with grades 1 to 2 affecting the top skin layers and grades 3 to 4 including the deeper underlying tissues (EPUAP/ NPUAP 2009).

The origin of some pressure ulcers was not fully established, mainly because of lack of documentation and appearance of the ulcer (Table 2). There were observable improving standards in best practice and patient comfort and care on the wards. Repositioning care plcinning documentation had improved by 7 per cent but ongoing documented repositioning had reduced by 1 per cent (Table 3). Further improvements are required to meet best practice standards in both cases. Although the heel remained the most common site for pressure dcimage, there was a reduction in hospital-acquired heel ulcers by 4. per cent. Results Benefits beccime apparent during the campaign with observable improvements in patient access to equipment cind eeirly intervention. The results were analysed in terms of patient prevalence (percentage of patients with one or more pressure ulcer) and pressure ulcer prevcilence (percentage of pressure ulcers). The prevalence of pressure ulcers is usually greater than the prevalence of patients with pressure Prevalence of pressure ulcers Discussion The tissue viability support workers were instrumental in raising awareness of prevention 009 Number Number of patients Population at risk Prevalence of patients with pressure ulcers Prevalence of pressure ulcers Pressure ulcers acquired in hospital Pressure ulcers present on admission Origin not known (unsure/not completed) Percentage Number 2010 Percentage Change Percentage 976 497 151 242 132 930 51 15. 5 24. 7 13. 5 492 125 186 53 13. 4 20. 0 7. 5 6. 8 5. 7 T2. 0 i 2. 1 J. 4. 7 J. 6. 0 i 0. 8 I2. 2 70 63 53 75 35 7. 6 3. 5 1 November 2010 Volume 22 Number 9 NURSING OLDER PEOPLE Feature in the admitting areas and improving early access to dynamic mattresses.

Previously, dynamic systems were often a late intervention, once pressure damage was appeirent, cind competing demands from the wards impeded availability. A structured approach supported fairer allocation, prioritisation by patient need and improved availability. The support workers also improved processes by fostering good teamwork with support staff, hospital management teams and nursing departments. Their presence in the ward areas improved preventive care, related protocols and provided a link with the tissue viability nurses.

Our experiences suggest that further education and communication are essential to reach a staff. The 'healthy heels' campaign demonstrated the effectiveness of heel protectors in a prevention strategy. These devices were used for prevention and treatment to 'float the heel', with resolution of superflcial tissue damage often achieved through continued use. This included the treatinent of superficial necrosis (black heels), which in many cases were kept dry cind allowed to slough off retaining viable deeper tissues, as recommended by EPUAP/NPUAP (2009).

The audit results mirror previous reports of less than 10 per cent of hospiteil patients having documented adequate preventive care (Vanderwee ef al 2007b). Some nurses expressed concems over time constrEiints and extra paperwork, which may have contributed to a reluctance to adopt revised positioning and repositioning documentation. Communication and education Achievement of best practice standar Best practice standard quired pressujmJceyar^ajeiKe by grad Grade of pressure ulcer Grade 1 Grade 2 Grade 3 Grade 4 Total 2009 Number 59 54 7 12 2010 Number 35 24 6 5 70 Percentage Change Percentage Percentage 6,0 5. 3,7 2,5 0,6 0,5 i 2. 3 4-3. 0 0. 7 1. 2 i 0,1 1 0,7 132 Origin not known (unsure/not completed) Grade 1 Grade 2 Grade 3 Grade 4 16 15 2 2 1. 6 1. 5 0,2 0. 2 23 23 7 0 2,4 2. 4 0. 7 T0. 8 i 0,9 IO. 5 _ Total 35 " 1 issues were other possible factors. The trust operates a link nurse system for tissue viability education that may limit dissemination to all nursing staff. In an audit of 44 UK hospitals Phillips and Buttery (2009) also found a lack of documentary evidence of risk assessment on admission and C2ire planning, together with the need to improve immediate allocation of appropriate resources.

Early risk assessment and immediate intervention may also be hcimpered by the focus on emergency care in admitting areas. Robinson and Mercer (2007) identified contextual barriers to pressure ulcer prevention in emergency departments as use of a stretcher and a lack of basic care provision for older Patients having a documented pressure ulcer risk assessment within six hours of admission. Patients with documented risk assessment at time of audit. Patients nursed on appropriate mattress.

Patients with a high or medium risk of developing a pressure ulcer with documented evidence of a positioning and repositioning regimen. Patients with a high or medium risk of developing a pressure ulcer with documented evidence of repositioning. Use of heel protectors and offloading techniques (of total number heel ulcers). Ulcers with resolving/treated infection. Prevalence of patients with hospital-acquired heel ulcers. 75 79 88 13 T9 11 33 2 7,9 10 4. 1 36 0. 2 3,0 I3 Improved by 1. 8 i 4. 9 NURSING OLDER PEOPLE November 2010 Volume 22 adults.

The improvement of resources and processes in admitting cireas is crucial to prevention. Technological advances may cdso have created a culture focused on dynamic systems as the primary intervention. Eurther difficulties may cuise in maintaining individual repositioning schedules in busy hospital Wcirds where competing demands often require a more immediate response. Hobbs (2004) demonstrated improved outcomes when regular repositioning schedules were re-established. Eurther work is required to place the emphasis on patient mobilisation and prevention and away from equipment and treatment.

Education and leadership are peiramount to generate this culture shift and rebalance these nursing priorities. Conclusion A comprehensive review of previous and current prevention activity was invaluable in identifying appropriate areas for improved intervention. The recruitment of tissue viability support staff assisted with early risk assessment and intervention, particularly in terms of pressure-relieving equipment. A pressure ulcer campaign was useful in raising awareness of three interventions: early risk assessment and intervention, positioning cind repositioning regimens eind 'healthy heels' project.

Audit results from Eebruary 2010 showed a reduction in hospital-acquired pressure ulcer prevalence by 6 per cent and a reduction in total pressure ulcer prevalence by 4. 7 per cent. Heel offloading using heel protector boots was an effective strategy for prevention and treatment of heel pressure ulcers. Although the heel remained the most common site for hospital-acquired pressure ulcers, there was a reduction in prevcilence by 4. 9 per cent. Improvements are indicated in the provision of documentary evidence to support prevention, particularly in terms of risk assessment, positioning and repositioning programmes.

This project has demonstrated that responding to organisational specific factors can produce encouraging results in pressure ulcer prevention and identify' areas for continued effort. Dedicated leadership, education, teamwork and commitment are fundamental to continue to improve standards and ensure best possible patient outcomes. Online archive For related information, visit our online archive of more than 6,000 articles and search using the keywords Find out more Copies of the positioning and repositioning regimen can be obtained by emailing the author at: Judy. ELuOTT@ekht. nhs. uk

This article has been subject to double-blind review and checked using antiplaglarism software. For author guidelines visit the Nursing Older People home page at www. nursingolderpeople. co. uk Judy Elliott is lead tissue viability nurse. East Kent Hospitals NHS University Foundation Trust, Canterbury References Bcldon P (2007) Silting safely to prevent pressure damage. Wound Essentials. 2, 102-104. Bennett G, Dealey C, Posnetl J (2004) The cost oi pressure ulcers in the UK. A^e and Ageing. 33, 3, 230-235. Bonomini J (2003) Effective interventions for pressure ulcer prevention. Nursing Standard. 17. 32. 4300.

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