Prevention and management of pressure ulcers in primary and secondary care: summary of NICE guidance
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2592 (Published 23 April 2014) Cite this as: BMJ 2014;348:g2592
- Gerry Stansby, professor of vascular surgery and honorary consultant vascular surgeon1,
- Liz Avital, associate director2,
- Katie Jones, project manager2,
- Grace Marsden, senior health economist2
- On behalf of the Guideline Development Group
- 1Department of Vascular Surgery, Freeman Hospital, Newcastle upon Tyne, UK
- 2National Clinical Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
- Correspondence to: L Avital liz.avital{at}rcplondon.ac.uk
Pressure ulcers are serious and distressing, and they can affect people of any age. Not only do they increase mortality, result in extended hospital stays, and consume substantial healthcare resources, they are often an example of avoidable harm. Reported prevalence rates range from 4.7% to 32.1% in hospital populations and as much as 22% in nursing home populations.1 Prevention of this devastating condition must be a priority for the NHS. Stage 1 pressure ulcers (see box for definition of stages) can be reversible if identified promptly, and most stage 2 and 3 ulcers can be healed with appropriate care, but all require a multidisciplinary approach for effective management. It is hoped that this guideline will help reduce pressure ulcers nationally and improve care when pressure ulcers do occur.
Pressure ulcer categories/stages2
Category/stage 1: Non-blanchable redness of intact skin
Intact skin with non-blanchable erythema of a localised area, usually over a bony prominence. Discoloration of the skin, warmth, oedema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching.
The area may be painful, firm, soft, and warmer or cooler than adjacent tissue. This category may be difficult to detect in people with dark skin tones. It may indicate that the person is “at risk.”
Category/stage 2: Partial thickness skin loss or blister
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open (or ruptured) blister filled with serum or sero-sanguinous fluid.
Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration, or excoriation.
Category/stage 3: Full thickness skin loss (fat visible)
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Some slough may be present, as may undermining, where the ulcer extends under the surface.
The depth of category 3 ulcers varies according to anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue so the category 3 ulcer can be shallow. In contrast, areas with a high degree of adiposity can develop extremely deep category 3 ulcers. Bone and tendon are not visible or directly palpable.
Category/stage 4: Full thickness tissue loss (muscle or bone visible)
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Undermining and tunnelling are often present.
The depth of category 4 ulcers varies according to anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue so ulcers can be shallow. Category 4 ulcers can extend into muscle or supporting structures (for example, fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur. Exposed bone or muscle (or both) is visible or directly palpable.
This article summarises the most recent guidance for people of all ages from the National Institute for Health and Care Excellence (NICE),3 and it replaces previous guidance on risk assessment and prevention in 2003 and management in 2005.4 5
Recommendations
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. The full guidance includes five detailed algorithms on identifying who is at risk; prevention of pressure ulcers in adults at risk and high risk; prevention of pressure ulcers in neonates, infants, children, and young people; management of pressure ulcers in adults; and management of pressure ulcers in neonates, infants, children, and young people.
Definitions of terms
At risk: Those who, after assessment using either clinical judgment or a validated risk assessment tool (or both), are considered to be at risk of developing a pressure ulcer.
At high risk: Those with multiple risk factors (such as seriously limited mobility, nutritional deficiency, inability to reposition themselves, severe cognitive impairment), a history of pressure ulcers or a current pressure ulcer, evaluated using either clinical judgment or a risk assessment tool.
General
Be aware that all patients are potentially at risk of developing a pressure ulcer. [Based on the experience and opinion of the Guideline Development Group (GDG)]
Prevention in adults
Risk assessment
Carry out and document an assessment of the risk of developing a pressure ulcer for adults who are:
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 settings, and emergency departments, if they have a risk factor, for example:
- Significant limited mobility (for example, people with a spinal cord injury)
- Inability to reposition themselves
- Significant loss of sensation
- Previous or current pressure ulcer
- Nutritional deficiency
- Significant cognitive impairment.
[Based on very low quality evidence and the experience and opinion of the GDG]
Consider using a validated scale to support clinical judgment (such as the Braden scale, the Waterlow score, or the Norton risk assessment scale6 7 8) when assessing risk. [Based on very low quality prognostic studies, low to very low quality evidence from randomised controlled trials (RCTs) and the experience and opinion of the GDG]
Skin assessment
Offer adults who have been assessed as being at high risk a skin assessment by a trained healthcare professional. This should take into account any pain or discomfort reported by the patient and the skin should be checked for:
- Skin integrity in areas of pressure
- Colour changes or discoloration (healthcare professionals should be aware that non-blanchable erythema may present as colour changes or discoloration, particularly in darker skin tones or types)
- Variations in heat, firmness, and moisture (for example, because of incontinence, oedema, or dry or inflamed skin).
[Based on very low quality prognostic studies, low quality RCT evidence, and the experience and opinion of the GDG]
Repositioning
Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently, and at least every six hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required. [Based on low to very low quality RCT evidence, a cost-effectiveness model, and the experience and opinion of the GDG]
Devices for prevention of pressure ulcers
Use a high specification foam mattress for adults who are admitted to secondary care and assessed as being at high risk of developing a pressure ulcer in primary and community care settings. [Based on low to very low quality RCT evidence and the experience and opinion of the GDG]
Prevention in neonates, infants, children, and young people
Risk assessment
Carry out and document an assessment of the risk of developing a pressure ulcer for neonates, infants, children, and young people who are:
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, such as:
- Significant limited mobility
- Inability to reposition themselves
- Significant loss of sensation
- Previous or current pressure ulcer
- Nutritional deficiency
- Significant cognitive impairment.
[Based on the experience and opinion of the Delphi consensus panel]
Use a scale validated for this population (such as the Braden Q scale for children9) to support clinical judgment. [Based on very low quality evidence from one cohort study and the experience and opinion of the Delphi consensus panel]
Skin assessment
Offer those who are assessed as being at high risk a skin assessment by a trained healthcare professional. Take into account:
• Skin changes in the occipital area
• Skin temperature
• The presence of blanching erythema or discoloured areas of skin.
[Based on the experience and opinion of the Delphi consensus panel]
Repositioning
For neonates and infants who have been assessed as being at high risk, consider repositioning more frequently than every four hours. Document the frequency of repositioning needed. [Based on the experience and opinion of a Delphi consensus panel]
Encourage children and young people who have been assessed as being at high risk to change their position more frequently than every four hours. If they are unable to reposition themselves, offer help to do so, using equipment if needed. Document the frequency of repositioning required. [Based on the experience and opinion of a Delphi consensus panel]
Care planning for all ages
Develop and document an individualised care plan for all people who have been assessed as being at high risk of developing a pressure ulcer, taking into account:
- The outcome of risk and skin assessment
- The need for additional pressure relief at specific at risk sites
- Patients’ mobility and ability to reposition themselves
- Other comorbidities
- Patient preference.
[Based on the experience and opinion of the GDG]
Training and education of healthcare professionals
Provide training to healthcare professionals on preventing a pressure ulcer, including:
- Who is most likely to be at risk of developing a pressure ulcer
- How to identify pressure damage
- How to prevent new or further pressure damage
- Who to contact for further information and for further action.
[Based on evidence from high quality qualitative evidence and the experience and opinion of the GDG]
Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure ulcer. Training should include:
- How to carry out a risk and skin assessment
- How to reposition
- Information on pressure redistributing devices
- How to discuss the prevention of pressure ulcers with patients and their carers
- Details of sources of advice and support.
[Based on evidence from high quality qualitative evidence and the experience and opinion of the GDG]
Management for all ages
Document the surface area of all pressure ulcers using a validated measurement technique if possible (for example, transparency tracing or a photograph). [Based on very low quality evidence, the experience and opinion the GDG and of a Delphi consensus panel]
Document an estimate of the depth of all pressure ulcers and the presence of undermining (a cavity under the skin that cannot be directly observed), but do not routinely measure the volume of a pressure ulcer. [Based on very low quality evidence, the experience and opinion of the GDG and of a Delphi consensus panel]
Categorise each pressure ulcer for all patients at onset using a validated classification tool (such as the international NPUAP-EPUAP 2009 pressure ulcer classification system2) to guide ongoing preventive and management options. Repeat and document each time the ulcer is assessed. [Based on high quality and low quality evidence, a cost-effectiveness model, and the experience and opinion of the GDG]
Do not routinely use negative pressure wound therapy to treat a pressure ulcer. [Based on low quality evidence, considered alongside a cost analysis and the experience and opinion of the GDG and of a Delphi consensus panel]
Do not routinely use topical antiseptics or antimicrobials to treat a pressure ulcer. [Based on low quality evidence, the experience and opinion of the GDG and of a Delphi consensus panel]
Dressings
Consider using a dressing that promotes a warm, moist healing environment to treat grade 2, 3, and 4 pressure ulcers. [Based on low quality evidence, the experience and opinion of the GDG and of a Delphi consensus panel]
Do not offer gauze dressings to treat a pressure ulcer. [Based on low to very low quality evidence, the experience and opinion of the GDG and of a Delphi consensus panel]
Hyperbaric oxygen therapy and electrotherapy
Do not use hyperbaric oxygen therapy or electrotherapy to treat a pressure ulcer. [Based on low to very low quality evidence, the experience and opinion of the GDG and of a Delphi consensus panel]
Management in adults
Nutrition and hydration
Offer nutritional supplements to adults with a pressure ulcer who have a nutritional deficiency. [Based on low quality evidence and the experience and opinion of the GDG]
Do not offer nutritional supplements to treat a pressure ulcer in adults whose nutritional intake is adequate. [Based on low quality evidence and experience and opinion of the GDG]
Do not offer subcutaneous or intravenous fluids to treat a pressure ulcer in adults whose hydration status is adequate. [Based on the experience and opinion of the GDG]
Pressure redistributing devices
Use a high specification foam mattress for adults with a pressure ulcer. If this is not sufficient to redistribute pressure, consider the use of a dynamic support surface. [Based on low to very low quality evidence and the experience and opinion of the GDG]
Do not use standard specification foam mattresses for adults with a pressure ulcer. [Based on the experience and opinion of the GDG]
Debridement
Assess the need to debride a pressure ulcer, taking into consideration:
- The amount of necrotic tissue
- The grade, size, and extent of the pressure ulcer
- Patient tolerance
- Any comorbidities.
[Based on low quality evidence and the experience and opinion of the GDG]
Do not routinely offer adults with a pressure ulcer:
- Larval (maggot) therapy
- Enzymatic debridement.
Consider larval therapy if sharp debridement is contraindicated or if there is associated vascular insufficiency.
[Both points above based on low quality to very low quality cohort and RCT evidence and the experience and opinion of the GDG]
Systemic antibiotics
Do not offer systemic antibiotics specifically to heal a pressure ulcer in adults. [Based on the experience and opinion of the GDG]
Do not offer systemic antibiotics to adults on the basis of positive wound cultures only without clinical evidence of infection. [Based on the experience and opinion of the GDG]
Management in neonates, infants, children, and young people
Dressings
Do not use iodine dressings to treat a pressure ulcer in neonates. [Based on the experience and opinion of a Delphi consensus panel]
Consider using topical antimicrobial dressings to treat pressure ulcers where clinically indicated in neonates, infants, children, and young people—for example, in the context of spreading cellulitis. [Based on the experience and opinion of a Delphi consensus panel]
Debridement
Consider autolytic debridement with appropriate dressings for dead tissue. Consider sharp and surgical debridement by trained staff if autolytic debridement is unsuccessful. [Based on the experience and opinion of a Delphi consensus panel]
Systemic antibiotics
Consider systemic antibiotics for neonates, infants, children, and young people with a pressure ulcer with clinical evidence of local or systemic infection. [Based on the experience and opinion of a Delphi consensus panel]
Nutrition
Offer advice on a diet that provides adequate nutrition for growth and healing in neonates, infants, children, and young people with a pressure ulcer. [Based on the experience and opinion of the GDG and a Delphi consensus panel]
Pressure redistributing devices
Use a high specification cot or bed mattress or overlay for all neonates, infants, children, and young people with a pressure ulcer. [Based on the experience and opinion of a Delphi consensus panel]
Overcoming barriers
In certain circumstances anyone of any age can develop a pressure ulcer. Thus, strategies for prevention and management need to apply across all care settings. This requires a systems approach, modifications at all organisational levels, individual change, and constant vigilance, because even a brief lapse can result in a pressure ulcer that could take weeks or months to heal.
Every patient has the right to expect safe care, which includes the prevention of avoidable pressure ulcers. Many organisations have greatly reduced pressure ulcer rates with relatively simple interventions that hinge on increased awareness and changing staff attitudes.10 Implementing this guideline will require clinicians in all healthcare settings to understand that preventing pressure ulcers is feasible and to be committed to this priority.
Further information on the guidance
Although much clinical expertise and existing good practice is focused on preventing and treating pressure ulcers, care is not universally provided to an optimal standard.11 It is hoped that this evidence based guidance will contribute to a national reduction in pressure ulcers and the improvement of care when pressure ulcers do occur. The guideline is in two parts: prevention and management. Recommendations are divided into those for adults and those for neonates, infants, children, and young people. Areas of management included are pressure ulcer measurement, categorisation, pressure redistributing devices, nutrition and hydration, adjunctive therapies, debridement, systemic antibiotic, topical antimicrobials, and antiseptics and dressings.
Methods
The Guideline Development Group (GDG) followed standard NICE methods in the development of this guideline (www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp). The GDG comprised a vascular surgeon, two tissue viability nurse consultants, a senior nurse, a consultant dermatologist, a senior occupational therapist, a specialist dietitian, a consultant in spinal injuries, a consultant physician (acute medicine and medicine for the elderly), a paediatric rheumatology nurse specialist, and two patient members. The GDG also co-opted a physiotherapist.
The group developed clinical questions, collected and appraised clinical evidence, and evaluated the cost effectiveness of proposed interventions through a systematic literature review and original economic modelling. Quality ratings of the evidence were based on GRADE methodology (www.gradeworkinggroup.org). These relate to the quality of the available evidence for assessed outcomes rather than the quality of the clinical study. Where standard methods could not be applied owing to the scarcity of available evidence for neonates, infants, children, and young people, and limited paediatric clinical expertise on the GDG, a modified Delphi consensus was carried out to develop corresponding recommendations for this population (see chapter 4 of the full guideline3).
The draft guideline went through a rigorous reviewing process, during which stakeholder organisations were invited to comment. The GDG took all comments into consideration when producing the final version of the guideline. Further updates of the guideline will be produced as part of NICE’s guideline development programme.
NICE has produced three different versions of the guideline: a full version; a summary version, known as the “NICE guideline”; and a version for patients, their families and carers, and the public. All these versions, as well as a pathway and a suite of tools to help implement the guideline, are available from the NICE website (http://guidance.nice.org.uk/CG179). Updates of the guideline will be produced as part of NICE’s guideline development programme.
The guideline was developed as part of a collaboration with the Belgian Healthcare Knowledge Centre (KCE), which was developing a guideline on the prevention and management of pressure ulcers at the same time as the National Clinical Guideline Centre. Evidence reviews were developed by both parties using the same methodology (as outlined above) and were shared to inform development of the recommendations. Each organisation discussed the evidence and developed recommendations independently.
Cost effectiveness analysis
An economic model was developed from an NHS and personal social services perspective to compare the cost effectiveness of repositioning every four hours versus every two and four hours alternately for the prevention of pressure ulcers. Repositioning every four hours was found to be the most cost effective treatment at a willingness to pay threshold of £20 000 (€24 180; $33 230) per quality adjusted life year. A cost comparison was also carried out from an NHS personal social services perspective, which analysed the costs of negative pressure wound therapy compared with a standard care dressing regimen for the management of pressure ulcers. The analysis did not consider clinical evidence because the GDG thought that there was insufficient evidence on which to base an economic model. Negative pressure wound therapy was found to be more costly than the standard care dressing regimen, and in the absence of evidence to show clinical benefit, it was not considered to be cost effective for the management of pressure ulcers.
Future research
The GDG identified the following high priority areas that needed further research:
Which pressure ulcer tools are most effective for predicting pressure ulcer risk in neonates, infants, children, and young people?
Do pressure redistributing devices reduce the development of pressure ulcers for those who are at risk of developing a pressure ulcer?
When repositioning a person who is at risk of developing a pressure ulcer, what are the most effective position and the optimum frequency of repositioning to prevent a pressure ulcer developing?
In any person who has adequate nutritional status and a pressure ulcer, does the provision of further nutritional supplements improve healing of the pressure ulcer?
In adults, what are the relative effects of enzymatic debridement of non-viable tissue versus sharp debridement on the rate of healing of pressure ulcers?
In adults, does negative pressure wound therapy (with appropriate dressing) improve the healing of pressure ulcers compared with the use of dressing alone?
Notes
Cite this as: BMJ 2014;348:g2592
Footnotes
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the Guideline Development Group were Gerard Stansby (chair), John Borthwick, Nigel Broad, Richard Bull, Mark Collier, Elizabeth McGinnis, Raquel Siganporia, Laura Stuart, Carolyn Taylor, Pradeep Thumbikat, Chandi Vellodi, Jane Willock, and Davina Richardson (co-opted member). The technical team at the National Clinical Guideline Centre (NCGC) worked in collaboration with the Belgium Health Care Knowledge Centre (KCE). The technical team at the NCGC comprised Liz Avital, Katie Jones, Grace Marsden, Paul Miller, Zahra Naqvi, Julie Neilson, and Maggie Westby. The technical team at KCE comprised Dimitri Beeckman, Catharina Matei, Raf Mertens, Christian Leonard, Sabine Stordeur, Koen van den Heede, Sabine van Houdt, and Aurélie van Lancker. The members of the Delphi consensus panel are outlined in the full guideline.
Contributors: GS drafted the summary and all authors were involved in writing further drafts and reviewed and approved the final version for publication. GS is the guarantor.
Funding: The National Clinical Guideline Centre was commissioned and funded by the National Institute for Health and Care Excellence to write this summary.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.