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Implementing best practice in pressure ulcer prevention

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VOL: 97, ISSUE: 24, PAGE NO: 69

Suzanne Reed, MPhil, MSc, BEd, DipN, CERT Ed, RNT, RCNT, RGN, is practice development research manager, Nuffield Hospitals Centre for Education and Clinical Effectiveness, Birmingham

Kevin Hambridge, BSc, DipN, RGN, is charge nurse, Nuffield Hospital, Plymouth;Lucy Land, RGN, DipSN, BSc, PGCE, is senior lecturer, health and community care, University of Central England

The emotional cost of living with a pressure ulcer cannot be quantified. Patients can experience pain and dependency together with a fear of possible odour from the wound and a feeling of being unclean (EKAC, 1992). The Department of Health (1993) estimated that the financial cost to the NHS is around £60million, based on a prevalence rate of 6.7% in hospitalised patients, and Perdue (1995) surmised that £300m of the total health care budget is used in this respect.

A national increase in the number of pressure ulcers is indicated, which makes the requirement for effective patient care imperative. This, together with clinical governance initiatives, provides the impetus not only for investigating best practice but also to implement it.

This article describes a project that evolved from the need to standardise pressure ulcer risk assessment among nurses working for a service provider in the independent sector. Fagan and Closs (1996) drew attention to the fact that the prevention and treatment of pressure ulcers is not well documented in this sector, even though pressure ulcers are a major factor contributing to the need for extended care.

Some regimes employed for pressure ulcer prevention and management are more efficient and cost-effective than others. It was therefore decided that clinical guidelines were necessary to support practitioners in their decision-making. To ensure that these were based on the best available evidence it was necessary to undertake a systematic review of the literature. This focused on the evaluation of risk assessment tools and pressure ulcer prevention strategies.


The wide-ranging nomenclature and definitions relating to the assessment of individuals at risk of pressure ulcers made it necessary to establish operational definitions of the key factors at the start.

Pressure ulcer

‘A pressure ulcer is an area of localised damage to the skin and tissue and usually occurs over bony prominences such as the base of the spine, hips and heels. They are caused by a range of internal and external factors, but the primary factor is unrelieved pressure that occludes microcirculation.’

This definition is based on components of the four main, theoretical definitions of a pressure ulcer (Birchall, 1993; Department of Health, 1993; Reid and Morrison, 1994; Nuffield Institute for Health, 1995).

Risk assessment tools

‘A measurement tool that numerically predicts the degree of risk of an individual developing a pressure ulcer.’

Risk assessment tools are used to make decisions about the prevention of pressure ulcers. The knowledge and skills required to design and implement prevention strategies relies on the competence of the individual nurse, combined with the degree of sensitivity and specificity of the risk assessment tool used. This definition is based on theoretical definitions from Edwards (1994) and Department of Health (1993).

Reviewing the literature

A multidisciplinary research team was established which included a researcher, a physiotherapist, an educationalist and two nurse practitioners. The aim of the group was to develop clinical guidelines that would assist in the identification of individuals at risk of pressure ulcers and promote early interventions to prevent their development.


The extent of literature available in the area of pressure ulcer prevention made it necessary to limit the review to published articles produced from 1993 onwards. It is generally acknowledged that systematic reviews should also include other sources of material, but the wealth of published literature, limited time and personnel resources made a more wide-ranging search unfeasible. Medline, Cinahl and Healthstar databases were searched, using key words relating to pressure ulcer risk assessment and prevention.

The review

Eight hundred abstracts were reviewed and papers that were duplicated or considered non-specific were discarded. Each paper was analysed, tabulated and the level of evidence identified according to criteria based on the National Health Service Executive and RCN recommendations for determining levels of evidence. Only 16 studies addressing risk assessment tools (Table 1) and 14 assessing prevention strategies (Table 2) met the criteria for evaluation.

The researcher graded the papers, and once this had been verified by a second person the overall results were ratified by an advancing practice group comprising 22 individuals. An open forum was convened where recommendations for change were presented and discussed by a wider audience, including representatives from the local university and a specialist from Sweden. The whole process was subjected to external academic and professional review by the local university research unit.


For a risk assessment score to have any clinical utility it must demonstrate validity and reliability and have a high degree of predictive validity, sensitivity and specificity. Sensitivity is the ability of the score to successfully predict all those who will develop a pressure ulcer and specificity its ability to correctly predict those who will not (Deeks, 1996; Larson, 1996).

Of the 16 studies available, 12 tested sensitivity and specificity of the Braden scale (Braden and Bergstrom, 1987; Bergstrom et al, 1987). The other papers examined the use of the Waterlow score for children (Waterlow, 1997), a neonatal risk assessment tool, and the Norton score (Norton et al, 1962).

The results of this review suggested that the Braden scale is the most sensitive and specific risk assessment tool currently available. This is supported by four further studies (Barnes and Payton, 1993; Gruen et al, 1997; Tortual et al, 1997; Schue and Langman, 1998). The cumulative evidence indicates that the Braden scale is the only tool currently available which demonstrates an overall sensitivity of 79% and a specificity of 75%.

For prevention strategies to be effective they need to be individualised and appropriate for a particular patient. However, from the literature it is possible to identify several main categories relating to pressure ulcer prevention. These include positioning of the patient, selection of appropriate pressure-relieving/reducing equipment, nutritional balance and effective skin care through moisture prevention and the reduction of shear.

The use of mattresses and cushions as a method of preventing the development of pressure ulcers was a predominant theme in the literature. Eleven studies were found which evaluated the effectiveness of different mattresses in patients considered to be at risk of developing a pressure ulcer. In these studies, the alternating air mattress replacement systems were suggested as the most effective pressure-relieving surface.

The evidence in the literature for further prevention strategies tended to be limited or inconclusive, but there appeared to be a consensus on the following factors:

- Positioning - frequency of repositioning needs to be based on individual requirements and turning times must be recorded. The use of the 30° tilt should be implemented so that pressure redistribution can be achieved without lifting the patient (Colin et al, 1996);

- Sensory deficit - sensory perception should be assessed. Anaesthetised or unconscious patients should be carefully monitored; patients who have loss of sensation are particularly vulnerable to localised pressure damage (Braden, 1987);

- Reduction of shear and friction - careful repositioning, transferring and turning techniques with the use of hoists, aids and sliding boards need to be used to prevent damage to the skin and underlying structures;

- Skin care - excessive moisture needs to be controlled. If the patient is incontinent the skin should be cleaned at the time of soiling, using mild cleansing agents that minimise irritation and dryness. The use of barrier creams is appropriate, but it is more important to manage incontinence effectively. Leakage from wound drainage should also be controlled;

- Nutrition - emaciation and malnutrition have been linked to the development of pressure ulcers (Lewis, 1998). Lewis (1996) has also identified zinc and ascorbic acid as being linked with tissue viability, but this is not supported by other authors.

Other themes that emerged from the literature related to the need for patient and staff education, careful discharge planning and the importance of continuity of care.


Assessment of the risk of pressure ulcers and the planning of interventions to prevent them are a recurrent theme in the literature, but this review suggests that many of the factors discussed need to be subject to more rigorous research. However, in order to standardise care it was necessary to use the literature currently available.

As a result of the findings of the review and following comprehensive discussions with the advancing practice team within the organisation, it was decided to introduce the Braden scale (Bergstrom et al, 1987) into practice and to monitor its use.

Changing practice

Workshops were carried out on site in each of the hospitals by members of the advanced nursing practice group under the supervision of and supplemented by practice development nurses. Work books were developed to help with the introduction of the Braden scale and a teaching pack was produced in order to ensure consistency of presentation. Posters were designed and distributed strategically around each hospital to raise staff awareness.

Guidelines were developed to support the use of the Braden scale. These cover the key factors for effective skin care (Fig 1). An important component of the guidelines is the education of patients, nurses and physiotherapists; discharge planning, continuity of patient care, other areas highlighted by the project are also included. An algorithm accompanies the guideline. This acts as a decision-making tree and indicates actions that should be taken to prevent pressure ulcers as predicted by the Braden scale (Fig 2).

Documentation is an integral part of care and the Braden scale forms part of the patient assessment and multidisciplinary care pathway.


S taff were familiar with the Waterlow risk assessment tool and needed to be convinced of the rationale for the change in practice. Familiarisation with the tool and ensuring compliance of all staff involved a comprehensive teaching programme which required a great deal of time and resources. Ongoing monitoring of the change required a resource commitment on each site.

Quality measures

In order to ensure compliance and the effective ongoing use of the Braden scale and guidelines, focus groups comprised of the members of the multidisciplinary team were formed. These acted as a discussion forum where problems with implementation were explored. In addition, staff received ongoing support from clinical effectiveness facilitators who visited the hospitals on a regular basis. Quality monitoring through continuous internal and annual external auditing was deemed to be important to evaluate and sustain the change process.


A review of the literature led to the introduction of an alternative pressure ulcer risk assessment tool across the organisation, accompanied by guidelines to ensure its effective implementation. The Braden scale is now used effectively in 43 of our hospitals and the indications are that the incidence of pressure ulcers is greatly reduced. However, owing to the limited time in which the system has been in place this is yet to be formally evaluated.

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