Miss Lilli Cooper (pictured) and Professor Gerry Stansby discuss NICE Quality Standard 89 and the importance of prevention and repositioning in people at risk of pressure ulcers

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Read this article to learn more about:

  • the impact of pressure ulcers on health and quality of life for patients and carers
  • serious and life-threatening complications associated with pressure ulcers
  • how the statements in NICE QS89 relate to recommendations in NICE CG179.

Key points

Audit points

GP commissioning messages

Pressure ulcers (PUs) are common in all settings where healthcare is provided, and represent a significant clinical and financial burden with a prevalence of 3–14% in hospital, and 2–28% in nursing homes.1,2 A review of death and severe-harm incidents reported to the National Reporting and Learning System found that PUs were associated with the largest proportion of patient safety incidents in 2011/12, accounting for 19% of all reports.3 Some 80–95% of PUs are avoidable,4 and their prevalence is recorded in the NHS Safety Thermometer,5 a local improvement tool for measuring, monitoring, and analysing patient harms across a range of settings, including care homes, community nursing, and hospitals on a monthly basis. The morbidity, economic implications, and potential for prevention of PUs have made them an indicator of effective practice, recognised in the NHS Outcomes Framework 2015/16. 6

Pressure ulcers form when the blood supply to skin and soft tissue is reduced secondary to pressure, most commonly over bony prominences. They are graded with increasing severity from category 1–4, according to the European PU Advisory Panel classification system (2009). 3,7 Category 1 refers to non-blanchable erythema, a potentially preventable stage.7

Pressure ulcers represent a major burden of sickness and reduced quality of life for people and their carers. Left untreated, PUs can be serious and lead to life-threatening complications such as sepsis or gangrene. As PUs can occur for many reasons, interventions for prevention and treatment need to be applied across a wide range of settings, including the community, care homes, and hospitals. These interventions may require organisational and individual change and a commitment to ensure effective delivery. Staffing levels can also have an impact on the number of PUs.

Certain patients are at higher risk than others, due to neurological conditions, impaired nutrition, impaired mobility, poor posture, or deformity, with the most vulnerable patients being over the age of 75 years.3 Factors extrinsic to the patient that increase the risk of pressure damage include the prolonged use of equipment such as beds or chairs, or periods of sedation or anaesthesia, without adequate pressure relief being provided.

In recognition of the impact of PUs on mortality and morbidity, in 2014 NICE updated and replaced Clinical Guideline (CG) 7 and CG29 with CG179 on Pressure ulcers—prevention and management of pressure ulcers.8 The recommendations apply to any setting where NHS care is provided or funded, and aim to reduce the incidence and optimise the management of PUs in the interests of patient safety and clinical and economic outcomes. This article provides an overview of NICE Quality Standard (QS) 89 for PUs published in June 2015, and provides guidance for healthcare professionals on its implementation.

NICE Quality Standard 89 for pressure ulcers

Since the Health and Social Care Act 2012, 9 the Department of Health has declared its commitment to outcomes-based quality assessment in the NHS, most recently with the NHS Outcomes Framework 2015/166 and the Adult Social Care Outcomes Framework 2015/16. 10 In recognition of this, NICE has produced QS893 for the prevention, assessment, and management of PUs in all settings where care is funded by the NHS, including hospitals, care homes with and without nursing, and people's own homes. Quality Standard 89 currently comprises a prioritised set of eight specific, concise, and measurable statements (see Table 1, below), which draw on NICE CG179,8 and outline key areas for quality improvement within PU care, to help focus and monitor the delivery of best practice. It also includes a ninth 'placeholder statement' on the Prevention of medical device-related pressure ulcers. A placeholder statement is defined as: '… an area of care that has been prioritised by the Quality Standards Advisory Committee, but for which no source guidance is currently available.'

Table 1: NICE quality standard for pressure ulcers—list of quality statements 3
No.Quality statement
1 People admitted to hospital or a care home with nursing have a PU risk assessment within 6 hours of admission
2 People with a risk factor for developing PUs who are referred to community nursing services have a PU risk assessment at the first face-to-face visit
3 People have their risk of developing PUs reassessed after a surgical or interventional procedure, or after a change in their care environment following a transfer
4 People have a skin assessment if they are identified as high risk of developing PUs
5 People at risk of developing PUs receive advice on the benefits and frequency of repositioning
6 People at risk of developing PUs, who are unable to reposition themselves, are helped to change their position
7 People at high risk of developing PUs, and their carers, receive information on how to prevent them
8 People at high risk of developing PUs are provided with pressure redistribution devices
9 Prevention of medical device-related PUs

This placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee, but for which no source guidance is currently available. A placeholder statement indicates the need for evidence-based guidance to be developed in this area.

PU=pressure ulcer

NICE (2015) QS89. Pressure ulcers. Available at: www.nice.org.uk/guidance/qs89

Reproduced with permission

The quality standard contributes towards meeting national outcome domains 3, 4, and 5 of the NHS Outcomes Framework 2015/16, 6 and domains 2 and 4 of the Adult Social Care Outcomes Framework 2015/16, 10 and is expected to contribute to improvements in the following outcomes: 3

  • incidence of category 2, 3, and 4 PUs
  • health-related quality of life
  • length of hospital stay
  • discharge destination (such as a patient's home, or care home).

Table 2 (below) shows how recommendations from NICE CG179 relate to the quality statements from QS89.

Table 2: NICE QS89 and CG179 for pressure ulcer prevention, and management3,8
CG179 sectionRecommendations from NICE CG179Quality statement
Risk assessment
1.1.2

Carry out and document an assessment of PU risk for adults:

  • being admitted to secondary care or care homes in which NHS care is provided or
  • receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor.
1, 2, 4, 5, 6, 7, 8
1.2.1

Carry out and document an assessment of PU risk for neonates, infants, children and young people:

  • being admitted to secondary or tertiary care or
  • receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor.
1, 2, 4, 5, 6, 7, 8
1.1.3 Consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) when assessing PU risk. 1, 2, 3
1.2.2 Use a scale validated for this population (for example, the Braden Q scale for children), to support clinical judgement. 1, 2, 3, 4
1.1.4 Reassess PU risk if there is a change in clinical status (for example, after surgery, on worsening of an underlying condition or with a change in mobility). 3
Skin assessment
1.1.5 Offer adults who have been assessed as being at high risk of developing a PU a skin assessment by a trained healthcare professional. 4
1.2.3 Offer neonates, infants, children, and young people who are assessed as being at high risk of developing a PU a skin assessment by a trained healthcare professional. 4
Repositioning
1.1.8 Encourage adults who have been assessed as being at risk of developing a PU to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required. 5, 6
1.1.9 Encourage adults who have been assessed as being at high risk of developing a PU to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required. 5, 6
1.2.5 Ensure that neonates and infants who are at risk of developing a PU are repositioned at least every 4 hours. 5, 6
1.2.6 Encourage children and young people who are at risk of developing a PU to change their position at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. 5
1.2.8 Encourage children and young people who have been assessed as being at high risk of developing a PU to change their position more frequently than every 4 hours. If they are unable to reposition themselves, offer help to do so, using equipment if needed. Document the frequency of repositioning required. 5
1.2.11 Ensure that patients, parents, and carers understand the reasons for repositioning. If children and young people decline repositioning, document and discuss their reasons for declining. 5
Patient and carer information
1.3.2 Offer timely, tailored information to people who have been assessed as being at high risk of developing a PU, and their family or carers. The information should be delivered by a trained or experienced healthcare professional. 7
Pressure redistribution devices
1.1.13

Use a high-specification foam mattress for adults who are:

  • admitted to secondary care
  • assessed as being at high risk of developing a PU in primary and community care settings.
8
1.1.14 Consider a high-specification foam theatre mattress or an equivalent pressure redistributing surface for all adults who are undergoing surgery. 8
1.1.17 Consider a high-specification foam or equivalent pressure redistributing cushion for adults who use a wheelchair or who sit for prolonged periods. 8
1.2.17 Use a high-specification foam cot mattress or overlay for all neonates and infants who have been assessed as being at high risk of developing a PU as part of their individualised care plan. 8
1.2.18 Use a high-specification foam mattress or overlay for all children and young people who have been assessed as being at high risk of developing a PU as part of their individualised care plan. 8
1.2.20 Offer infants, children, and young people who are long-term wheelchair users, regular wheelchair assessments and provide pressure relief or redistribution. 8
1.2.21 Offer neonates, infants, children, and young people at risk of developing an occipital PU an appropriate pressure redistributing surface (for example, a suitable pillow or pressure redistributing pad). 8
1.4.9 Use high-specification foam mattresses for adults with a PU. If this is not sufficient to redistribute pressure, consider the use of a dynamic support surface. 8
1.4.12 Consider a high-specification foam or equivalent pressure redistributing cushion for adults who use a wheelchair or sit for prolonged periods and who have a PU. 8
1.5.10 Consider using specialist support surfaces (including dynamic support surfaces where appropriate) for neonates, infants, children, and young people with a PU, taking into account their current PU risk and mobility. 8
1.5.11 Use a high-specification cot or bed mattress or overlay for all neonates, infants, children, and young people with a PU. 8
1.5.12 If pressure on the affected area cannot be adequately relieved by other means (such as repositioning), consider a dynamic support surface, appropriate to the size and weight of the child or young person with a PU, if this can be tolerated. 8

Pressure ulcer risk assessment—statements 1 and 2

An assessment of pressure-ulcer risk should be based on clinical judgement and/or the use of a validated scale such as the Braden scale, the Waterlow scale, or the Norton risk-assessment scale for adults, and the Braden Q scale for children.

Risk factors for pressure ulcers include:3,8

  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • malnutrition
  • the inability of a person to reposition themselves
  • significant cognitive impairment
  • a previous or current pressure ulcer (high risk).

People who have multiple risk factors identified during risk assessment with or without a validated risk assessment tool are deemed at 'high risk' of developing a pressure ulcer.

Reassessment following surgical intervention or a change in care environment—statement 3

Pressure ulcer risk status is not constant; it is likely to change during the course of care. A PU risk assessment should be repeated if there is a change in a person's clinical status; however, changes in clinical status can be difficult to define. Specific instances where a reassessment should be carried out to ensure patient and service user safety include after surgery or an interventional procedure, with worsening of an underlying condition, or a change in mobility, or after a change in the patient's care environment following a transfer.

Box 1: Sources of further information

Complementary NICE quality standards

Policy context

Other national guidance and current policy documents have been referenced during the development of NICE QS89. It is important that the quality standard is considered alongside the documents listed below:

  • Wounds UK (2014) Best practice statement: eliminating PUs19
  • Department of Health (2010) Essence of care20
  • National Patient Safety Agency (2009) Pressure ulcers under plaster casts: signal21
  • Department of Health (2004) National service framework for children, young people and maternity services: core standards.22

Skin assessment—statement 4

Adults, neonates, infants, children, and young people who have been assessed as being at high risk of developing a PU should be offered a skin assessment by a trained healthcare professional.

In adults, the skin assessment should take into account:3

  • any pain or discomfort reported by the patient
  • skin integrity in areas of pressure
  • colour changes or discoloration
  • variations in heat, firmness, and moisture (for example, because of incontinence, oedema, dry or inflamed skin).

When performing the skin assessment, consideration should be given to people with cognitive and behavioural difficulties who may have problems reporting pain.

In neonates, infants, children, and young people the skin assessment should take into account:3

  • skin changes in the occipital area (back of the head)
  • skin temperature
  • the presence of blanching erythema (redness on the skin that goes away when pressed with the fingers) or discoloured areas of skin.

Benefits and frequency of repositioning—statements 5 and 6

Repositioning aims to reduce or eliminate pressure on the area at risk, through a change in a person's position on their chair or bed. To improve patient experience, healthcare and social care professionals should advise people at risk of developing PUs (or their carers, as appropriate) about the importance of frequent repositioning, and that it may help to prevent PUs. The frequency of repositioning advised should be appropriate for the individual person and their wishes or needs. For safety reasons, repositioning is recommended at least every 6 hours for adults at risk, and every 4 hours for adults at high risk.

For children and young people at risk, repositioning is recommended at least every 4 hours and more frequently for those at high risk. Document the frequency of repositioning required. Ensure that patients, parents, and carers understand the reasons for repositioning. If children and young people decline repositioning, document and discuss their reasons for declining. Ensure that people at risk of developing PUs, who are unable to reposition themselves, are helped to change their position, using appropriate equipment if needed.

Prevention and pressure redistribution devices—statements 7 and 8

Information should be provided to people at high risk of developing pressure ulcers (and their carers) about preventative care that may stop pressure ulcers from developing. 3 Information should include:3

  • the causes of PUs
  • the early signs of PUs
  • ways to prevent PUs
  • the effect of having a PUs (for example, for general health)
  • treatment options, and the risk of developing PUs in the future
  • a demonstration of techniques and equipment used to prevent a PU.

People at high risk of developing PUs should be provided with appropriate pressure redistribution devices. The type of device required will depend on the individual's circumstances. Pressure redistribution devices include different types of high-specification mattresses and overlays, pressure redistribution cushions and seating, and equipment that offloads heel pressure.3

Prevention of medical device-related pressure ulcers (placeholder)—statement 9

People with conditions that are managed with medical devices, such as those cared for in intensive care units, may be at risk of developing PUs. Guidance is needed on PU risk assessment and preventative measures for people at risk of medical device related PUs.

This placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee, but for which no source guidance is currently available. A placeholder statement indicates the need for evidencebased guidance to be developed in this area. 3

Conclusion

The NICE CG1798 and QS893 provide a set of clinical objectives that, if achieved, will improve the quality of patient care. They are relevant to all healthcare professionals committed to achieving best practice, from commissioners to practising doctors in all specialties.

Number of people:

  • with a risk factor for developing PUs and who are referred to community nursing services who have a pressure ulcer risk assessment at the first face-to-face visit
  • with a change in care environment following a transfer who have a PU risk reassessment carried out afterwards
  • who have a PU risk assessment when shows that they are at high risk of developing PUs, in whom a follow-up skin assessment is carried out
  • at risk of developing PUs who are given advice on the benefits and frequency of repositioning
  • who are helped with repositioning at the appropriate frequency, if required
  • at high risk of developing PUs who are given tailored information to help to prevent PUs developing
  • at high risk of developing PUs who are provided with a pressure redistribution device.
PU=pressure ulcer

Key points

  • PUs represent a major burden of sickness and reduced quality of life for people and their carers
  • PUs can lead to life-threatening complications such as sepsis or gangrene
  • Interventions for prevention and treatment need to be applied across a wide range of settings, including the community, care homes, and hospitals
    • interventions may require organisational and individual change and a commitment to ensure effective delivery
  • Quality standards recognise the important role families and carers have in supporting people with PUs. If appropriate, healthcare professionals and social care practitioners should ensure that family members and carers are involved in the decision-making process about investigations, treatment, and care.

PU=pressure ulcer

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Audit points

Number of people:

  • with a risk factor for developing PUs and who are referred to community nursing services who have a pressure ulcer risk assessment at the first face-to-face visit
  • with a change in care environment following a transfer who have a PU risk reassessment carried out afterwards
  • who have a PU risk assessment when shows that they are at high risk of developing PUs, in whom a follow-up skin assessment is carried out
  • at risk of developing PUs who are given advice on the benefits and frequency of repositioning
  • who are helped with repositioning at the appropriate frequency, if required
  • at high risk of developing PUs who are given tailored information to help to prevent PUs developing
  • at high risk of developing PUs who are provided with a pressure redistribution device.

PU=pressure ulcer

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GP commissioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • PUs are a major cause of avoidable morbidity and CCGs should monitor their incidence in contracts with all hospital and residential care providers
  • CCGs should:
    • report regularly against SIRIs for category 3 and 4 PUs in their quality reports
    • require through contracts for community nursing providers and residential care providers for complex NHS funded care that PU risk assessments are conducted for all new patients and regularly during care packages
    • consider education programmes for residential care staff to increase their awareness of PUs and risk factors for them developing.

PU=pressure ulcer; CCGs=clinical commissioning groups; SIRIs=serious incidents requiring investigation

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References

  1. Grey J, Harding K, Enoch S. Pressure Ulcers.BMJ 2006; 332 (7539): 472–475.
  2. Levine S, Sinno S, Levine J, Saadeh P. An evidence-based approach to the surgical management of pressure ulcers. Ann Plast Surg 2012; 69 (4): 482–484.
  3. NICE. Pressure ulcers. Quality Standard 89. NICE, 2015. Available at: www.nice.org.uk/ guidance/QS89
  4. Stop the Pressure. NHS. www.nhs.stopthepressure.co.uk (accessed 16 June 2015)
  5. NHS safety thermometer. Health and Social Care Information Centre. www.hscic.gov.uk/thermometer (accessed 16 June 2015) .
  6. The NHS Outcomes Framework 2015/16, Department of Health 2015. www.gov.uk/government/publications/nhs-outcomesframework-2015-to-2016 (accessed 16 June 2015)
  7. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel, 2009. Available at: www.epuap.org/guidelines/ Final_Quick_Treatment.
  8. NICE. Pressure ulcers: prevention and management of pressure ulcers. Clinical Guideline 179. NICE, 2014. Available at: www.nice.org.uk/guidance/CG179
  9. The Health and Social Care Act, 2012. UK Government. www.legislation.gov.uk/ukpga/2012/7/contents/enacted/data.html (assessed 16 June 2015)
  10. The Adult Social Care Outcomes Framework 2015 to 2016. Department of Health. www.gov.uk/government/publications/adult-socialcare-outcomes-framework-ascof-2015-to-2016 (assessed 16 June 2015)
  11. NICE. Urinary incontinence in women. Quality Standard 77. NICE, 2015. Available at: www.nice.org.uk/guidance/qs77
  12. NICE. Infection prevention and control. Quality Standard 61. NICE, 2014. Available at: www.nice.org.uk/guidance/qs61
  13. NICE. Faecal incontinence. Quality Standard 54. NICE, 2014. Available at: www.nice.org.uk/guidance/qs54
  14. NICE. Peripheral arterial disease. Quality Standard 52. NICE, 2014. Available at: www.nice.org.uk/guidance/qs52
  15. NICE. Nutrition support in adults. Quality Standard 24. NICE, 2012 . Available at: www.nice.org.uk/guidance/qs24
  16. NICE . Patient experience in adult NHS services. Quality Standard 15. NICE, 2012. Available at: www.nice.org.uk/guidance/qs15
  17. NICE. End of life care for adults. Quality Standard 13. NICE, 2011. Available at: www.nice.org.uk/guidance/qs13
  18. NICE. Diabetes in adults. Quality standard 6. NICE, 2011. Available at: www.nice.org.uk/guidance/qs6
  19. Best practice statement: eliminating pressure ulcers. Wounds UK, 2014. Available at:wounds-uk.com/pdf/content_10815.pdf
  20. Essence of care. Department of Health, 2010. www.gov.uk/government/publications/ essence-of-care-2010 (Accessed 16 June 2015)
  21. Pressure ulcers under plaster casts: signal. National patient safety agency, 2009. www.nrls.npsa.nhs.uk/resources/?EntryId45=65330 (accessed 16 June 2015).
  22. National Service Framework for Children, Young People and Maternity Services: core standards. Department of Health, 2004. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/199952/National_Service_Framework_for_Children_Young_People_and_Maternity_Services_-_Core_Standards.pdf