Jo Rycroft-Malone describes the development of the RCN's evidence-linked interdisciplinary guideline on risk assessment and prevention of pressure ulcers

Pressure ulcers, also known as pressure sores, decubitus ulcers or bedsores, can dramatically affect a person's life. Not only do they impose a major burden of sickness and reduced quality of life on patients and carers,1 but also the financial costs to the NHS are substantial.2

Collier,3 applying a similar formula to that used by Hibbs,4 calculated the cost of treating a patient with a grade IV pressure ulcer to be £40 000. Epidemiological studies conducted in a range of healthcare settings have reported a wide range of pressure ulcer prevalence rates – from 5-23% in an acute hospital5 to 17% in the community.6

Research has demonstrated that implementation of evidence-based clinical guidelines in conjunction with educational input can reduce the prevalence of pressure ulcers. 7

Against a background of the human and financial costs of pressure ulcers, the known variation in practice and a growing body of knowledge about clinically effective care in this area, there was clearly a need for recommendations for practice.

In response, the NHS Executive commissioned the Royal College of Nursing (RCN) to produce an evidence-linked clinical guideline on risk assessment and prevention of pressure ulcers. This commission subsequently became one of the first inherited guidelines on the National Institute for Clinical Excellence's (NICE) programme of work.

The guideline has recently been published through NICE and also through the RCN (see Addendum, bottom). It complements and builds on the work that others have undertaken, e.g. European Pressure Ulcer Prevention Guidelines.8

The guideline provides health professionals with recommendations that:

  • Help early identification of individuals at risk of developing pressure ulcers
  • Suggest preventive interventions
  • Identify potentially harmful or ineffective practice.

The overall aim of the guideline is to help reduce the occurrence of pressure ulcers.

A key defining attribute of clinical guidelines is that their recommendations are based on evidence. Care must not only be the best, as identified from research, but must also be tailored to the identified needs of a particular individual.

The evidence base underpinning the RCN's guideline on pressure ulcer risk assessment and prevention came from a wide range of sources:

  • The Agency for Health Care Policy and Research9 evidence-linked guideline Pressure Ulcers in Adults: Prediction and Prevention
  • An update of sections of their literature base via systematic review10
  • The Effective Health Care Bulletin The Prevention and Treatment of Pressure Sores11
  • Systematic review of the effectiveness of pressure-redistributing devices12
  • Systematic review of the effectiveness of risk assessment tools.13

The development of the pressure ulcer risk assessment and prevention guideline presented a number of challenges, mainly because of the variable quality and quantity of research available for critical appraisal.

The challenge lay in developing a robust method of guideline development that incorporated a number of different sources of evidence. In the light of this, a formal consensus process was used to integrate the different evidence sources, and, where necessary, agree recommendations based on current best practice.

More specifically, the formal consensus development process was based on a modified nominal group technique.14,15 This involved convening an 'expert group' of 10 people who reflected the full range of those to whom the guideline will apply. The group included individuals with expertise from medical, biomechanical, physiotherapy, and nursing domains of practice plus patient representation and researcher input.

Statements were devised from the various evidence sources. A pre-meeting rating round was conducted by post to determine the level of agreement with the statements. Following this, a meeting was held at which participants were able to discuss the statements face to face and then privately re-rate them. This was facilitated by an expert in nominal group technique.

In order to establish consensus, the median and interquartile ranges were used as measures of central tendency and dispersion, and were calculated for each statement from the ratings of the second round.

The recommendations were drafted, based on the panel's level of agreement about issues. If a statement's median was 7–9 this was considered to be agreement or consensus, and it was developed into a practice recommendation (or became part of one). Likewise, if it did not reach this criterion it was rejected. Consequently, a number of the recommendations in the guideline are based solely or partially on consensus expert opinion.

The recommendations were graded on their evidence base (adapted from Waddell et al16) as follows:

I Generally consistent finding in a majority of multiple acceptable studies

II Based on either a single acceptable study or a weak or inconsistent finding in multiple acceptable studies

III Limited scientific evidence that does not meet all the criteria of acceptable studies or absence of directly applicable studies of good quality. This includes expert opinion.

Additionally, the gradings of the recommendations derived from the consensus process have figures next to them, e.g. m9, iqr1.25 (see Figure 1, below), showing the results of that process. The figures refer to the median (m) and interquartile range (iqr) calculated from the consensus ratings. An iqr of 1.25 indicates that there was a distribution of scores around the median. In the previous example, if everyone had rated 9, the iqr would be 0. The larger the iqr, the lower the level of agreement within the group.

Figure 1: Extract from the guideline recommendations showing the grading system derived from the consensus development process

4.5 Health care professionals should be vigilant to the following signs which may indicate incipient pressure ulcer development:

Heels (m 9, iqr 0)
Sacrum (m 9, iqr 0)
Ischial tuberosities (m 9, iqr 0)
Parts of the body that are affected by the wearing of anti-embolic stockings (m 9, iqr 0)
Trochanter (m 9, iqr 0)
Parts of the body where pressure, friction or shear is exerted in the course of an individual's daily living activities, e.g. on the hands of wheelchair users (m 9, iqr 1)
Part of the body where there are external forces exerted by equipment and clothing e.g. endotracheal tubes, intravenous lines, sites of pulse oximetry, catheters, shoes, elastic clothing (m 9, iqr 1)
Elbows (m 7, iqr 1)
Temporal region of the skull (m 7, iqr 1.25)
Shoulders (m 7, iqr 2.25)
Back of head (m 7, iqr 1.75)
Toes (m 7, iqr 2.5)

It was felt important to include these scores to give guideline users a clear idea of the extent of agreement within the panel.

To provide a coordinated approach, health professionals need to see risk assessment and prevention of pressure ulcers as an interdisciplinary issue.

While this aim may be difficult to achieve in practice, the guideline has been written for use by all healthcare staff, including managers, professionals allied to medicine, nurses, doctors, tissue viability specialists, healthcare assistants, porters, equipment suppliers and academics.

Additionally, NICE commissioned work to translate the guideline into a resource that can be used by patients and carers. This resource is located at the back of the NICE publication.

The recommendations included in the guideline are for patients (adults and children) with no pressure ulcers who are seen in hospital, nursing homes, supported accommodation or at home. The guideline does not include recommendations for the treatment of existing ulcers.

Various aspects of pressure ulcer risk assessment and prevention are covered by the guideline's recommendations. Accordingly, the guideline is divided into six sections:

  • Quick reference guide (see Figure 2, below) and a summary of the recommendations
  • A philosophy of care which describes the ideal environment within which the recommendations should be implemented
  • Evidence-linked recommendations for:
    • identifying individuals at risk
    • use of risk assessment scales
    • recognising risk factors
    • skin inspection
    • pressure-redistributing devices
    • use of aids
    • positioning
    • seating
    • education and training.

The guideline also contains a section on the 'Essentials of care', which covers nutritional status, continence management and hygiene, a section on quality improvement activities such as monitoring, discharge planning and audit criteria, and a final section comprising a glossary of terms.

Figure 2: Algorithm from Pressure Ulcer Risk Assessment and Prevention: Quick Reference Guide.*
* Reproduced from the RCN Clinical Practice Guideline Pressure Ulcer Risk Assessment and Prevention: Quick Reference Guide, April 2001, by kind permission of the Royal College of Nursing

The necessary broad remit of this guideline means that, as with all national guidelines, recommendations will have to be adapted to suit the particular local circumstances in which the guideline is to be implemented.

In the earliest phases of pressure ulcer development there may be no outward visible signs of damage, therefore it is important that individuals identified as being at risk are given an immediate prevention plan.

The guideline specifies the risk factors that need to be considered when assessing an individual's risk of developing a pressure ulcer.

It also highlights the role that risk assessment tools should play in this process. There is insufficient evidence to recommend the use of any particular tool in the assessment process. The guideline therefore suggests that, as part of an overall strategy, a tool could be used to aid the process but should not rule it.

It is also important that once those at risk have been identified, preventive action in terms of repositioning and pressure-redistributing devices is taken. The guideline offers recommendations for such practice.

All too often, pressure ulcers are seen as an issue related to acute care; however, the recommendations apply equally to patients seen in the surgery, in their homes or in community care settings.

It is generally thought that most pressure ulcers can be avoided. It is hoped that the publication of these guidelines will provide practitioners with a systematic framework for improving patient care, and that they will become integral to a healthcare provider's comprehensive strategy for promoting optimum standards in pressure ulcer prevention.

A pilot audit project has been set up to facilitate implementation and monitoring of the RCN guideline in practice (from which the NICE guideline was derived – see Addendum, below). This is being coordinated by the Quality Improvement Programme of the RCN.

The project includes the development of education and audit resources to accompany the guideline, working with a number of sites to test the resources and measure the impact on practice and pressure ulcer prevalence. Findings from this work will be published in approximately 12 months' time.

  • The guideline Pressure Ulcer Risk Assessment and Prevention is available in three formats: Quick Reference Guide, Recommendations, and Technical Report. Copies of the Quick Reference Guide and the Recommendations are available from: RCN Publishing Ltd, Distribution Depot, PO Box 1, Portishead, Bristol BS20 9EG (Tel 01275 847180). The Quick Reference Guide is free (plus £1.50 p&p), the Recommendations are £5.50 to RCN members and £7.50 to non-members (plus £1.50 p&p). The Technical Report can be downloaded from the RCN website:

  1. Franks PJ, Winterburg H, Moffatt C. Quality of life in patients suffering from pressure ulceration: a case controlled study (Abstract). Ostomy Wound Management 1999; 45: 56.
  2. Cullum N, Deeks JJ, Fletcher AW et al. Preventing and treating pressure sores. Quality in Health Care 1995; 4: 289-97.
  3. Collier ME. Pressure ulcer development and principles for prevention. In: Miller M, Glover D. Wound Management Theory and Practice. London: NT Books Emap, 1999.
  4. Hibbs P. Pressure Area Care Policy. London: City of Hackney Health Authority, 1988.
  5. Sacharok C, Drew J. Use of a total quality management model to reduce pressure ulcer prevalence in an acute setting. JWOCN 1998; 25: 88-92.
  6. Bours GJJW, Halfens RJG, Lubbers M, Haalboom JRE. The development of a national registration form to measure the prevalence of pressure ulcers in the Netherlands. Ostomy Wound Management 1999; 45(11): 28-40.
  7. Prentice J, Stacey M. An evaluation of clinical practice guidelines for pressure ulcers. Wound Care Conference presentation. Dublin, 2001.
  8. European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention Guidelines. Oxford: EPUAP, 1999.
  9. Agency for Health Care Policy and Prevention (AHCPR). Pressure Ulcers in Adults: prediction and prevention. Clinical Practice Guideline Number 3. Maryland: US Department of Health and Human Sciences. (AHCPR is now known as Agency of Health Care Research and Quality AHRQ) 1992.
  10. Rycroft-Malone J, McInnes E. Risk Assessment and Prevention of Pressure Ulcers. Technical Report. London: RCN Publishing, 2000. Available at
  11. NHS Centre for Reviews and Dissemination. The prevention and treatment of pressure sores. Effective Health Care Bulletin 1995; 2(1).
  12. Cullum N, Deeks J, Sheldon TA et al. Beds, mattresses and cushions for preventing and treating pressure sores (Cochrane Review). In: The Cochrane Library, Issue 1, 2000. Oxford: Update Software.
  13. McGough AJ. A systematic review of the effectiveness of risk assessment scales used in the prevention and management of pressure sores. MSc Thesis. University of York, 1999.
  14. Rycroft-Malone J. The challenge of a weak evidence base: formal consensus and guideline development. J Clin Excellence 2000; 2(1): 35-41.
  15. 0ycroft-Malone J. Formal consensus: the development of a national clinical guideline. Quality in Health Care 2001. In press.
  16. Waddell G, Feder G, McIntosh A et al. Low Back Pain Evidence Review. London: Royal College of General Practitioners, 1996.

This guideline has recently been endorsed and published by NICE. It should be noted that the NICE guideline does not include a full set of recommendations for the use of pressure-redistributing devices. This is because a cost-effectiveness analysis ofgthe use of such devices was not commissioned and thus conducted as part of the development process. The full guideline has been published|under the auspices of the RCN, and includes guidance on the use of pressure-redistributing equipment for at-risk patients.

Guidelines in Practice, November 2001, Volume 4(11)
© 2001 MGP Ltd
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