New guidelines have been issued on pressure relief for patients sitting in chairs
Clark, M. (2009) Guidelines for seating in pressure ulcer prevention and management. Nursing Times; 105: 16, early online publication.
While guidance is available on most aspects of pressure ulcer prevention and management, there has been little discussion of how to address these issues in patients who are seated for long periods. To address this issue the Tissue Viability Society has published guidelines on pressure relief for patients who are sitting chairs. This article discusses the development and consultation process used by the guideline development panel and outlines the key recommendations.
Keywords: Pressure ulcer assessment, pressure-redistributing cushions, seating, guidelines
Mike Clark, PhD, is senior research fellow, School of Medicine, Cardiff University.
When pressure ulcer prevention and management are discussed, the specific issues most often addressed relate to the use of pressure-redistributing beds and mattresses, risk assessment, patient repositioning and local management of established pressure ulcers. Each of these topics has been exhaustively covered within three clinical practice guidelines issued by NICE between 2001 and 2005.
However, some important topics are often overlooked. For example, the role of nutrition in pressure area care is often mentioned but given cursory attention in existing pressure ulcer guidelines, which prompted the European Pressure Ulcer Advisory Panel (EPUAP) to develop a specific guideline in 2004 (Clark et al, 2004).
In a similar fashion, the role of seating in both pressure ulcer prevention and management has been neglected. For example, in the NICE (2005) guidelines on pressure ulcer treatment, the only comments on seating consisted of four sentences stressing the need for qualified assessment for seating needs, the importance of correct seating positions, the need to maintain posture and support the feet when using a wheelchair and the lack of comparative data on the effectiveness of seat cushions.
The lack of practical guidance on issues related to seating and pressure ulcers prompted the Tissue Viability Society (TVS, 2008) to develop new clinical practice guidelines dedicated to this important area of care.
There have been marked changes in the ways clinical practice guidelines have been developed since the 1990s, with consensus approaches giving way to guideline recommendations based on systematic reviews of the evidence (van Zelm et al, 2006).
This shift, in part flowing from the growth of evidence-based practice as the paradigm for exploring the impact of healthcare interventions, also helped to ensure that guideline development would not be ‘vulnerable to being driven by panel members with the greatest authority rather than the recommendations flowing from scientific evidence’ (van Zelm et al, 2006).
However evidence-based guidelines depend on the existence of evidence, which is lacking in the case of pressure ulcers and seating.
These clinical guidelines were proposed by the TVS, a UK-based registered charity that provides wound management education for health professionals. Their development was partially funded by the society itself and was further supported by an unrestricted educational grant provided by ArjoHuntleigh.
A literature search was undertaken in February 2008 and updated at six-monthly intervals until March 2009. This search was based on the following key words - pressure ulcer (and other terms for the same wounds - bedsore, decubitus and pressure sore), seat, cushion, and wheelchair. Using these key words searches of the electronic databases MEDLINE, CINAHL, AMED, EMBASE and the Cochrane Library were undertaken. Hand searching of relevant conference proceedings was also undertaken covering the EPUAP and European Wound Management Association (EWMA) annual meetings. These searches identified few rigorous clinical studies on which guideline recommendations could be based. The absence of evidence means that guidance may have to be pragmatic rather than fully informed by a wealth of available studies. The guidelines can therefore at best be considered to be informed by the limited primary data available on the effect of sitting on pressure ulcer prevention and healing and largely based on consensus opinion.
The first draft of the guidelines was developed by a panel of three members of the TVS all with previous published research in seating and pressure ulcers. The initial draft was circulated to the society’s trustees for comment before they were presented at the TVS annual conference in April 2008. Conference delegates and the wider health professional community were invited to comment on the draft guidelines presented on the TVS website and published in the Journal of Tissue Viability.
Two further rounds of consultation were undertaken following presentation of the draft guidelines at the EWMA conference (Lisbon, May 2008) and the EPUAP conference (Bruges, September 2008). The draft guidelines were also made available to the main guideline development group of the International Pressure Ulcer Guidelines project (www.pressureulcerguidelines.org). No specific consumer involvement occurred during the development of the guidelines; consultation was targeted at healthcare professionals.
All recommendations in the guidelines are considered to be offered at the expert opinion level. The cost implications of implementating the guidelines were not considered, although some of the recommendations may have an impact on healthcare resources. Quantification of these costs and the potential benefits in terms of reduced pressure ulcer incidence are outside the scope of the guidelines.
The guidelines will be disseminated to healthcare professionals through a number of routes: the TVS website (www.tvs.org.uk), its quarterly publication the Journal of Tissue Viability, distribution at conferences in the UK and Europe, and distribution channels offered by ArjoHuntleigh and other commercial supporters of the TVS. Implementation of the guidelines will be monitored after 12 months dissemination has occurred. This monitoring will follow the route described by Meijers et al (2007) for assessment of the uptake and use of single-issue clinical practice guidelines.
Box 1 presents some key recommendations from the latest version of the guidelines, which was published in the Journal of Tissue Viability in September 2008 (TVS, 2008). Given that they were derived through consensus, all can be considered to be rated at the expert opinion level. .
Box 1. Key recommendations on seating and pressure ulcers
- The guideline applies to all settings and separates people into two populations: the chronically at pressure ulcer risk, for example individuals with a long-term (often life-long) risk due to effects of trauma (for example spinal cord injury), disability, degenerative disease (for example multiple sclerosis) and frailty associated with extreme old age; and those acutely at risk,where vulnerability to pressure ulcers may be short term (usually no more than two weeks) and associated with events such as acute illness, recent trauma, surgery, being in ICU and sedation.
- The guideline takes as its foundation the concept that the correct seated posture for any individual is one that does not impede their mobility or their ability to carry out all activities and functions that they may wish to perform.
- Assessing the need for seating should be performed by staff who are trained and, where possible, in consultation with the person. This assessment may cover a wide range of issues, including but not limited to the individual’s level of independence, their posture, and ability and motivation to relieve pressure.
- A key part of consultation during the assessment with the individual is the requirement to inform them, their family and carers (where present) about why special seating or cushions may be provided and how to use and how to maintain them. A vital part of this education process is to explain factors that may suddenly increase their susceptibility to developing pressure ulcers. These ‘flash factors’ may include the following – vomiting, urinary infection, dehydration, influenza, increased alcohol consumption, depression, changes of routine (long journeys, holidays) and family or life changes.
- The provision of seat cushions should not be based solely upon the outcome of a pressure ulcer risk assessment tool.
- The selection of a cushion should not reduce or impede an individual’s inherent mobility.
- Seated stability and ease of transfer may be as important to consider as the degree of pressure redistribution offered by a cushion.
- There are many different types of pressure-redistributing cushions commercially available. There is little evidence that one cushion is better than another, and often there are strong individual opinions as to which is the best cushion. There are advantages and disadvantages to consider with all cushion materials.
- Where individuals present with established pressure ulcers, there needs to be consultation with the individual to establish their personal priorities – while restriction of chair use may be the apparent solution to promote healing of severe pressure ulcers (grades 3 and 4), this may restrict the individual’s lifestyle and ability to work. The risks of continued chair use should be explained and an informed decision reached and documented.
- In the management of severe pressure ulcers, dynamic seat cushions may be considered, although, as with all pressure-redistributing seating, there is little evidence of their effectiveness.
- At any change in an individual’s health condition, a reassessment of their seating needs and current equipment provision should be performed.
- The main outcome that should be documented for the long-term seated individual is whether the assessment and equipment provision for pressure relief has maintained their occupational performance, provides satisfaction and maintains their health-related quality of life.
- Assessment for the acutely ill individual’s vulnerability to pressure ulcer development should be based on consideration of risk factors such as immobility, poor sensory perception, incontinence and current medical problems.
- If an acutely ill individual is established to be at risk of pressure ulcer development, they should sit for no longer than two hours at a time then be returned to bed (ideally with a pressure-redistributing mattress), or encouraged to walk and not to return to sitting within an hour.
- It should be possible to adjust all hospital chairs used by acutely ill at-risk individuals to allow changes in seat height from the floor and seat depth and width by staff who are trained to undertake these modifications. There should be no need for supplementary use of seat cushions where variable height chairs are present if the integral cushion is in good condition and the seat is correctly adjusted.
Source: TVS (2008)
The TVS hopes that distribution of these guidelines will lead to a reduction in the incidence of pressure ulcers by increasing the attention paid to posture and correct seating. The need to base this guidance on achieving consensus between healthcare professionals highlights the requirement for further independent research into the effects of seating and cushion materials on pressure ulcer occurrence and healing. Without such investment, it will remain challenging to develop evidence-informed, let alone evidence-based, guidance on this neglected area of health care.
Clark, M. et al (2004) Pressure ulcers and nutrition: a new European guideline. Journal of Wound Care; 13:7, 267–272.
NICE (2005) Pressure Ulcer Management.
Tissue Viability Society (2008) Seating and pressure ulcers. Draft clinical practice guideline. Version 1.0. Journal of Tissue Viability; 17: 3, 68–75.
van Zelm, R.T. et al (2006) The development, dissemination and use of pressure ulcer guidelines. In: Romanelli, M. et al (ed). Science and Practice of Pressure Ulcer Management. London: Springer-Verlag.
The initial consensus development of the guidelines was funded by an unrestricted educational grant from ArjoHuntleigh.