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Pressure ulcers: an assessment of the latest guidance

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VOL: 97, ISSUE: 28, PAGE NO: 68

Amanda Tong, BN, RGN, FAETC, is lecturer, tissue viability, Buckinghamshire Chilterns University College

Based on anecdotal reports, the incidence of pressure ulcers in all health care settings remains unacceptably high. The available figures range from 5.1-32.1% in hospital patients alone (Hanson, 1997), but depend on the nature of the clinical area studied, the lack of a standardised approach to data collection and difficulties in recognising when pressure damage has occurred.

Based on anecdotal reports, the incidence of pressure ulcers in all health care settings remains unacceptably high. The available figures range from 5.1-32.1% in hospital patients alone (Hanson, 1997), but depend on the nature of the clinical area studied, the lack of a standardised approach to data collection and difficulties in recognising when pressure damage has occurred.

For this reason, it is difficult to find accurate data that identifies the true extent of the problem nationally. What is clear is that most pressure damage could be prevented (European Pressure Ulcer Advisory Panel, 1998), so there is a clear need for the systematic implementation of preventive measures.

The Department of Health commissioned the RCN to develop pressure ulcer guidelines at the same time as the college's guidance on the management of patients with venous leg ulcers (RCN Institute, 1998). Since then, the National Institute for Clinical Excellence (NICE) has been established and given a remit to take the lead on using systematic reviews of clinical and cost effectiveness in health care to produce evidence-based guidelines for practice (DoH, 1997).

Although a draft version of the RCN guidelines has been available on the internet for some time, they were formally published alongside the NICE guidance only in April this year (RCN, 2001; NICE, 2001a).

The RCN guidelines
Technical reports providing details of the methods used to develop the RCN guidelines (2001) are available on request but they appear to come in one format only, without the pocket-sized summary of the recommendations that is available with the leg ulcer guidelines (RCN Institute, 1998). Nurses might have found this more useful but the flow chart on page seven, which provides a quick reference guide to pressure ulcer prevention, and the summary of recommendations on the subsequent pages may be a valuable alternative.

Evidence and evaluation

Disappointingly, the RCN guidelines are less comprehensive than the college's guidance on venous leg ulcers (RCN Institute, 1998). Full references of studies informing the recommendations and the results of systematic reviews are included (Cullum et al, 2000), but there is no commentary on these studies, apart from those included in the update of the Agency for Health Care Policy and Research review (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992). The relevant Effective Health Care Bulletin is also referenced but not included. Both of these were informative features of the leg ulcer guidelines (RCN Institute, 1998).

The introduction usefully highlights the background to the development of the guidelines, in terms of variations in practice and the cost of preventing pressure ulcers, and summarises their aims.

A key issue is the fact that pressure ulcers are seen as indicators of quality of care, and although the DoH (1993) aimed to reduce their incidence by 5-10% by 2000, no comment is made on whether this has been achieved. This is significant because these guidelines are the third set on pressure ulcer prevention to have been implemented since this target was set (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; European Pressure Ulcer Advisory Panel, 1998). It is crucial to know whether the target has been achieved and therefore whether previous guidance has been effective.

There is also no mention of a national approach to the evaluation of the guidelines, although the evidence base will be reviewed by the RCN in 2002 and by NICE in 2005. The RCN guidelines identify difficulties in determining the extent of the problem, and therefore imply that an evaluation of the effectiveness of previous guidelines will be difficult also. Suggestions for an approach to quality improvement based on figures obtained by practitioners in their own areas are provided, emphasising the importance of this as part of formal clinical governance arrangements.

Research base

The DoH says the recommendations contained in clinical guidelines should be based on sound evidence provided by quality randomised controlled trials rather than the subjective opinion of individual practitioners (NHS Executive, 1996; RCN, 1997; Feder et al, 1999).

An overview of the methods used to develop the RCN guidelines states that a review of the literature revealed little good research evidence. This is illustrated by the fact that, using the hierarchy of evidence given on page five, most of the recommendations are supported by the weakest form of evidence. This is described as 'limited scientific evidence which does not meet all the criteria of acceptable studies or absence of directly applicable studies of good quality'.

In recognition of this, a formal consensus process was carried out among a range of academics and practitioners in the field. The results are provided, with recommendations based on the weakest evidence. The figures are explained but this is confusing and may mean little to most nurses. Generally, the group agreed on most of the recommendations.

Given the lack of new research, there must be doubts about the value of producing further guidelines rather than concentrating on improving the quality of the available evidence. However, these recommendations are more comprehensive, and on the whole more useful, than the European Pressure Ulcer Advisory Panel guidelines (1998), which they claim to complement.

Issues in the RCN guidelines
- Section 1.2 of the RCN guidelines (2001) states that 'risk assessment should be carried out by personnel who have undergone appropriate and adequate training to recognise the risk factors'. In its basic form, this recommendation is misleading. There is some attempt to qualify this with the fact that personnel other than nurses are not exempt from responsibilities for risk assessment, but what constitutes 'specific knowledge and expertise' may be a stumbling block. The word 'specific' could provide a get-out clause for practitioners who have not completed ENB validated courses in pressure ulcer management or relevant study days. Specific knowledge should be integral to all basic health care practitioner courses as this will increase awareness that the whole multidisciplinary team is responsible for pressure ulcer prevention, not just nurses.

- Section 2.2 provides food for thought about the origins of risk assessment scores. Many of the most popular scoring systems are implemented in clinical areas with little thought on the environments in which they were developed or their validity and reliability in other areas. This section should stress that risk assessment is an integral part of holistic nursing assessment. The suggestion is that this is not always so (Hanson, 1997).

- Section 4.5 appears to have some typographical errors since the statement that 'health care professionals should be vigilant to the following signs' precedes a list of vulnerable areas rather than clinical signs. The reason for repeating some of the clinical signs later in this section is not clear.

- Section 5.1 emphasises the value placed on clinical judgement throughout the guidelines, but specifically recognises the potential to make inappropriate decisions on pressure redistributing surfaces as a result of relying too heavily on risk assessment scores.

- Section 5.2 highlights 'standard' NHS mattresses as being inappropriate for patients who are at risk of developing pressure ulcers, but although it mentions the fact that the definition of 'standard' varies this recommendation should be interpreted with caution. Many trusts have replaced traditional orange King's Fund mattresses, which are generally considered to be the NHS standard, with various specialised foam mattresses. Anecdotal evidence suggests that some of these do not meet the claims made by their manufacturers in terms of pressure redistribution and a reduction in humidity next to the skin, and should therefore not be relied upon to prevent pressure damage.

- Section 6.1 is a welcome attempt to lay the ghosts of sheepskins and water-filled gloves to rest. An alarming number of nurses in a variety of settings are still not aware of their potential to cause damage.

- Section 7.0 also looks at the tendency to rely on some support surfaces to reduce the need to reposition frequently. However, it should be emphasised that repositioning is required for reasons other than pressure relief.

- Nutritional status, continence management and hygiene are discussed in a separate section titled 'essentials of care' because of a lack of clarity on their influence on pressure ulcer development.

The NICE guidelines
The NICE guidelines (2001a) are identified as 'inherited' from the RCN and derived from their pressure ulcer prevention guidelines. However, there is a disclaimer that although the guidelines were developed in accordance with the process set out at the time of commissioning, there was not enough time to subject them to the full process now in use at NICE. This is a disappointing revelation for the first and most eagerly awaited guidelines to be issued by the institute and undermines their significance.

The guidelines are essentially designed to put NICE's seal of approval on the RCN guidelines. However, there are some differences. Recommendation 2.2 of the RCN guidelines suggests that individual clinical areas should choose the most appropriate risk assessment tool for their patients because there is no evidence of the superiority of any particular scoring system. Why that recommendation has been left out of the NICE guidelines is not clear.

There is also some discrepancy in terminology, as when the RCN uses the term 'pressure redistributing' and NICE uses 'pressure relieving', when other sources have suggested that these terms are not interchangeable (Kenny and Rithalia, 1999).

Both sets of guidelines acknowledge the limitations on fully assessing the cost effectiveness of pressure redistributing devices, and therefore no recommendations for their use are made. Treatment strategies for existing pressure ulcers are also not provided.

What is refreshing is that these guidelines highlight the fact that the recommendations aim to prevent pressure ulcers in children as well as adults, although it is not clear how many of the studies used to inform them were carried out on paediatric populations.

The NICE guidelines provide a summary of recommendations that may benefit busy practitioners. A clear and concise guide for patients and their carers is also available from NICE (2001b).

Implementation of the recommendations
Advice on implementation, which is perhaps the most important aspect of any guidelines (Baeyens, 2000; Duff et al, 1996), is included in both the RCN and NICE documents. But before guidelines can be implemented, practitioners need to be aware of their existence. The RCN guidelines have been available on the internet for a year for consultation purposes, but a straw poll of practitioners in my own clinical areas revealed that only one in 25 knew about them and had accessed them on the website.

NICE states that the guidelines will be distributed to members of the Tissue Viability Society. As a member, I note that this has not yet transpired, although it is still early days.

It should have been gratifying to see that the first set of guidelines to be published by NICE is none other than Pressure Ulcer Risk Assessment and Prevention (2001). It should also have been pleasing to see a united approach with the RCN. However, the publication of what are supposed to be the same guidelines, but with each organisation putting their mark on them, will only compound the conflict and confusion that already surrounds the use of guidelines (Thomas et al, 1998).

The need for quality improvement in health care is not in dispute and initiatives that aim to improve patient care are welcome. But a great deal remains to be done to ensure that clinical guidelines achieve the health gains and cost reductions they claim to be able to make.

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