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Practice comment

'Pressure ulcers will still be seen until basic care is right'


During the last 10 years, several evidence-based guidelines have been published that describe a range of preventative strategies to help health professionals reduce the burden of pressure ulcers.

Disappointingly, there is limited evidence to demonstrate they are embedded in clinical practice.

Since 2005, pressure ulcers stage 2 and above have to be reported as clinical incidents and are subject to root cause analysis. The risk of vulnerable patients acquiring pressure damage has become so urgent that in 2009, pressure ulcers became the focus of one of the High Impact Actions. As they move up the patient safety agenda, coroners see the presence of pressure ulcers as an indicator of unsafe and poor care. 

So why do we continue to see recurrent and increasing problems with pressure ulcers?

We are seeing an upsurge in the prevalence of patients at risk of pressure ulcers, with an increase in the elderly and underlying risk factors such as diabetes and obesity. Demand for prevention is now out-stripping our ability to provide the expertise required. While most pressure ulcers are largely preventable, an increasing number of patients will develop an unavoidable pressure ulcer as defined by the Department of Health. 

The health service often fails to get pressure ulcer prevention right. This is not surprising as it would seem many elements of fundamental care are absent or poorly delivered.

The recent damning Health Service Ombudsman report about the care of older people contains evidence of disturbing practice. Ageism may be another issue - we know the wellbeing and dignity of older people is not always considered by the NHS.  Pressure ulcers may be seen as an inevitable outcome of old age and illness. 

Technical advances have increased, perhaps at the expense of pressure ulcer prevention.  For example, we have a vast range of sophisticated, pressure-relieving mattresses available in the market place.  Some of these are being relied upon too heavily and the critical act of examining and caring for skin is being overlooked. We must start to work differently and get the essentials right before we immerse ourselves in technology.

A recent study has suggested a link between the value a nurse places on pressure ulcer prevention and the patient care that they deliver (Samuriwo, 2010).  This provokes useful discussion around how we can engage with, and empower our workforce to deliver quality care for our patients.

Nurses across the UK have been making considerable progress in reducing the burden of pressure ulcers.  Examples of quality improvement tools include the use of the SKIN bundle, which is a collection of interventions that are implemented for at-risk patients and hourly rounding. These involve nurses proactively visiting patients on an hourly basis, on top of their usual duties.

Examples of good practice can be found on the NHS Institute for Innovation and Improvement website at

These achievements must be celebrated and nurses should be shamelessly stealing any successful ideas and innovations that can help improve pressure ulcer care, without reinventing the wheel.

Judy Harker is wound healing and tissue repair nurse, consultant tissue viability, Pennine Acute Hospitals NHS Trust 


Readers' comments (3)

  • I am not at all surprised that the incidence of pressure ulcers is on the rise. The emphasis placed on skin care in recent years has been poor (despite all of the research and introduction of new 'tools'). What we need to do is get back to (and yes I was trained long ago) nurses having designated time to care for skin. Obviously I am not suggesting a return to the old 'back rounds' of long ago, however at least they highlighted the importance of skin management every four hours by trained and untrained staff. Research I read recently highlighted that the incidence of pressure sores at home was much lower in comparison to care homes and hospitals with hospitals performing least well. Of course this could be due to the general well being of the patient so must be treated with some caution. However, a recent visit to a local care home (elderly) by a colleague who was asked to give a talk on skin care revealed that the care workers did not understand the basic terminology and were clueless with regard to the dangers of poor pressure care practice. This is despite all of the staff members having a minimum level 2 vocational qualification.

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  • Having recently completed a tissue viability course. My research in nursing homes highlighted that trained nurses did not know what EPUAP meant, how to grade pressure ulcers or assess wound bed %. Documentation did not correspond to wound status. Action plans were documented but not carried out or monitored.

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  • “Knowing is not enough; we must apply. Willing is not enough; we must do.”
    Johann Wolfgang von Goethe

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