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Guidance sets out change in pressure ulcer recording at end of life


Nurses must stop attempting to distinguish between “avoidable” and “unavoidable” pressure ulcers to help ensure all are properly investigated, says new official reporting guidance.

Pressure ulcers that occur at the end of life should also no longer be recorded separately, according to the recommendations published by NHS Improvement, which will start to be rolled out this year.

“We anticipate that full implementation will improve understanding of the level of pressure damage harm”

Ruth May

The guidance on the definition and measurement of pressures ulcers, which were published last month, are designed to ensure a more consistent approach across all trusts in England.

Devised as part of the national Stop the Pressure programme, led by NHS Improvement, they set out an agreed definition of a pressure ulcer for the first time.

The guidance follows concerns that current systems used locally, regionally and nationally to monitor harm from pressure ulcers lack standardisation, with high levels of under-reporting.

Despite this inconsistency, they have been used to compare trusts and in some cases have lead to financial penalties, the document explained.

In an introduction to the guidance, Ruth May, executive director of nursing at NHS Improvement, said improving recording of ulcers would help organisations learn from incidents and ultimately improve the quality of care.


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Ruth May

“We anticipate that full implementation of the recommendations from April 2019 will improve understanding of the level of pressure damage harm in England,” she wrote.

“This will in turn support an organisation’s ability to learn from reported incidents, and inform the quality improvement programmes that are required to help reduce reported pressure damage and improve the quality of care,” she added.

Under the guidance, the words “avoidable” and “unavoidable” will no longer be used in reference to ulcers in order to “help focus on learning and any lapses in care”.

“Ceasing use of these terms will lead to all incidents being investigated to support organisational/system learning and appropriate actions,” said the document.

The guidelines also state that ulcers that develop near the end of life due to skin failure – known as Kennedy ulcers – should no longer be given a separate category.

Instead, they should be classified in the way same away as all other ulcers with the term “Kennedy ulcer” ceasing to be used.

“This is an artificial split irrelevant in clinical practice due to the complexity of patient pathways”

NHS Improvement

Meanwhile, the so-called “72-hour rule” – where an ulcer is only identified as “new” if it developed more than 72 hours after someone is admitted to a setting – should also be abandoned.

“This is an artificial split irrelevant in clinical practice due to the complexity of patient pathways,” said the guidance.

Instead, pressure ulcers can be said to be new if they are “first observed in the current episode of care”.

In addition, the definition of a pressure ulcer on admission has also changed. “The definition of a pressure ulcer on admission (POA) should be that it is observed during the skin assessment undertaken on admission to that service,” said the document.

Other recommendations are designed to ensure all trusts are consistently reporting unstageable and deep tissue ulcers, as well as moisture-associated skin damage.

The guidance was published alongside a new curriculum designed to inform the training of nurses and others on the prevention and treatment of pressure sores.

This comes after recent research uncovered “inconsistency in the frequency and length of time organisations spend on pressure ulcer prevention education”.

Based on an extended version of the well-established SSKIN care bundle, additional elements including a focus on “giving information” to ensure nurses are communicating effectively with patients, carers and other team members.

The curriculum also contains specific modules on the anatomy and physiology of the skin and medical device-related pressure ulcers.

The Stop the Pressure programme has also designed a pressure ulcer audit tool to give trusts greater insight into their pressure ulcer practice – to be used alongside the revised definition and measurement framework. This should be available in autumn 2018.


Readers' comments (2)

  • Before you put the stick into to the ant's nest - how about updating CG179? Certain recommendations are based on the 28 years old, low-quality trials.

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  • Actually, that entire "new and (already?) updated guideline" is worth only the paper its written on. WHERE IS __ANY__ EVIDENCE behind those orders???

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