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.
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. 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
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....