VOL: 101, ISSUE: 46, PAGE NO: 40
Julie Stevens, MSc, RGN, DN, FETC, is consultant/lead nurse tissue viability, Hounslow Primary Care Trust and West Middlesex University Hospital, Isleworth;
Will Gray, BSc, MMedSci, RN, PGrad Dip Nursing, is a research and development fellow, Royal College of Nursing Institute, Oxford.Julie Stevens was a member of the Institute's guideline development group and Will Gray was lead on the development of the guidelineOn September 28 this year, the National Institute for Health and Clinical Excellence (NICE) in collaboration with the Royal College of Nursing (RCN) launched a new all-in-one clinical guideline on preventing and managing pressure ulcers (NICE, 2005). Its publication is the culmination of two years' work by a multidisciplinary group focusing on pressure ulcer management issues. The guideline development group was comprised of a range of experts, including specialists in tissue viability, occupational therapy, physiotherapy, gerontology and plastic surgery. There was also input from patients and carers who, respectively, made valuable contributions based on their own experiences of living with pressure ulcers and caring for relatives with pressure damage.
On September 28 this year, the National Institute for Health and Clinical Excellence (NICE) in collaboration with the Royal College of Nursing (RCN) launched a new all-in-one clinical guideline on preventing and managing pressure ulcers (NICE, 2005). Its publication is the culmination of two years' work by a multidisciplinary group focusing on pressure ulcer management issues. The guideline development group was comprised of a range of experts, including specialists in tissue viability, occupational therapy, physiotherapy, gerontology and plastic surgery. There was also input from patients and carers who, respectively, made valuable contributions based on their own experiences of living with pressure ulcers and caring for relatives with pressure damage.
The work was undertaken by research and development fellows from the Royal College of Nursing Institute's department for quality improvement, together with health economists from the Centre for Health Economics at the University of York who undertook systematic reviews of evidence to underpin the guideline recommendations. Approximately 30,000 citations were identified as part of the literature searches, and almost 200 research papers were included in the reviews. Many research papers were excluded because of the poor quality of the methodology.
This new guideline (NICE, 2005) combines the existing guideline on pressure ulcer prevention (NICE, 2003) (clinical guideline No.7) with the guideline on management of pressure ulcers in primary and secondary care (NICE, 2005) (clinical guideline No 29). This combined guidance provides nurses and clinicians with a single point of reference for health care professionals in any setting. It also provides evidence-based information for those at risk of developing pressure ulcers as well as for those who already have them.
The priorities were developed from a combination of research evidence and formal expert consensus. Ten key recommendations were identified (Box 1).
Clinicians in the guideline development group considered that risk assessment should be conducted as soon as possible, but because of the lack of evidence and methodological constraints, it was decided to uphold the six-hour limit published in previous NICE guidance (NICE, 2003).
In the community, initial risk assessment should be conducted during the first home visit and documented and reviewed weekly, or if the condition of the patient changes. In hospital, patients presenting to A&E should be screened on arrival to exclude any existing pressure damage which may have been caused by acute or chronic illness and that has resulted in prolonged bed rest, or which is as a result of collapse at home. Screening will identify patients who arrive with existing pressure ulcers who are in the care of independent health care providers or professional carers. These patients may become involved in litigation or be subjected to investigations related to adult protection, and any documentation taken on admission may be used in a subsequent investigation. Pressure-relieving equipment should be ordered at this point, as patients may spend prolonged periods in A&E waiting for a bed in a ward despite a government guideline of four hours being the maximum time that patients should wait in A&E.
Once patients have been transferred to a ward, the risk assessment should be repeated to ensure that they will be cared for on the correct mattress and that care planning reflects optimum treatment.
Patients in continuing care homes are often at increased risk because of their age and frailty, and risk assessment should be an ongoing part of daily holistic care. Initial and ongoing reassessment of the risk to skin integrity is part of a proactive strategy for preventing pressure damage.
Pressure-relieving and pressure-reducing equipment
All patients who are vulnerable to developing pressure ulcers (based on clinical judgement and risk assessment), should be placed on a high-specification foam mattress as a minimum intervention. These mattresses contain contoured foam with two-way stretch covers that combine to provide pressure-reducing qualities even for high-risk patients, provided they can turn themselves independently. All patients need a mattress that provides comfort, aids sleep, has pressure-reducing qualities and is resistant to infection. The guideline clearly recommends that standard provision should be a high-specification foam mattress.
All patients with grade 1 and 2 pressure damage should be cared for on high-specification foam mattresses. Close observation of these patients for signs of deterioration, together with an holistic assessment of their condition, will alert the nurse to whether or not an alternating overlay pressure-relieving mattress is needed.
Patients with grade 3 and 4 pressure damage should be cared for on an alternating overlay or replacement mattress. There is no evidence that a replacement mattress is more effective in the healing of pressure ulcers than an overlay. The patient's weight, and safety risks, should therefore be considered before a replacement mattress is selected. Some patients, particularly those requiring palliative care, find the constant movement of these mattresses induces a feeling of nausea, and in these circumstances they should be cared for on a continuous low-pressure system (for example, low air loss, air flotation).
Grading of existing pressure damage
The new guideline recommends using the European Pressure Ulcer Advisory Panel Classification System to assess the grade of existing pressure damage. This four-stage grading tool was chosen because of its rigorous development by leading experts in the field of pressure ulcer management across Europe, and it provides a concise, easily-understood guide that addresses, also, the requirements of patients who have darker skin colour.
Another key recommendation is that all patients with pressure damage graded as 2 or above (partial thickness skin loss involving epidermis or dermis - superficial ulcer, blister or abrasion, for example), should have this notified as a local clinical incident through trust procedures.
Pressure damage can occur as a result of sub-optimal care and therefore merits local reporting to initiate investigation by tissue viability specialists/senior nurses. Root-cause analysis may identify that the patient is refusing efforts to turn him- or herself regularly, or has refused to be placed on a pressure-relieving mattress (a not uncommon occurrence in the community). Clinical incident reporting should be used constructively to promote awareness and can lead to improved patient outcomes in a blame-free culture.
Wound assessment and management
A further key recommendation is accurate assessment of all pressure damage in terms of grading, size and type of tissue visible in the wound bed. The type of tissue in the wound bed will determine the treatment objective and the choice of dressing, product or technique to achieve that objective. For example, a wound with 70 per cent yellow sloughy tissue will require debridement, for which the most appropriate product to achieve this objective may be a hydrogel.
The condition of the surrounding skin is also important, and the presence of odour and pain, which may indicate infection, needs to be documented and addressed. Tracings and/or photographs are recommended as a means of recording information. While health professionals need to be conscious of additional costs to the NHS, digital imagery will provide an accurate baseline measure by which care interventions can be evaluated. Standardised documentation, such as wound assessment charts, was identified as being important by the guideline development group in its full report.
In their promotion of a moist wound-healing environment, the guidelines encourage the use of modern wound dressings. These are designed to meet the needs of patients in terms of maintaining the activities of daily living, allowing pain-free removal, reducing odour and leakage, and promoting healing, so that they can return to a normal life.
Clinicians need a dressing to do what it says on the packet: it must be able to achieve the objectives identified in the care plan. Basic gauze is not a modern primary dressing; it adheres to wounds and causes pain when it is being removed. It is, therefore, not an appropriate dressing.
The new guidelines from NICE (2005) are patient-centred. Responsibility for preventing and managing pressure damage has to be taken by the whole health care team in close collaboration with the patient, family and carers. Recognising the potential consequences of pressure damage, particularly in patients with sensory impairment, will promote prevention strategies and prevent further complications such as septicaemia, osteomyelitis and even death.
Prevention of pressure ulcers is essential, and this national clinical guideline will support individuals at a local level. Planning for, and purchasing, appropriate equipment, providing competency-based training and ensuring specialist nurse support is available are essential if the guideline is to realise its full potential. Every nurse has a role to play in implementing it; this is crucial if standards of care are to be improved.
Further information on the full guideline is available from the website of the National Institute for Health and Clinical Excellence: www.nice.org.uk
European Pressure Ulcer Advisory Panel: www.epuap.org/
POINTS FOR REFLECTION
- In your clinical area can you identify how soon patients receive a pressure ulcer risk assessment following admission?
- Is your pressure ulcer risk assessment holistic?
- Which patients in your clinical area should be nursed at a minimum on a high specification foam mattress?
- How can clinical incidence reporting improve the prevention of pressure ulcers?