Pressure ulcer prevention: making a difference across a health authority? Heidi Guy, Fiona Downie, Lyn McIntyre and Jeremy Peters
Pressure ulcers (PUs), their cause and prevention have been discussed in the literature for many decades. Their prevention and management has been the core of a tissue viability nurse’s daily clinical and strategic workload. The important point to acknowledge is that not all PUs can be prevented but it is believed most of them can and all preventative measures must be implemented and evaluated. Initial efforts focused on establishing a baseline of incidence and prevalence. More recently, the Department of Health has proposed that PUs could be eliminated in 95% of all NHS patients and incentivised the measurement of PUs and other harms by use of the NHS Safety Thermometer through the introduction of a new initiative. A research company was commissioned to explore which communications interventions would be effective in helping health professionals to prevent and treat PUs. A campaign was subsequently set in motion to educate and inform clinical staff on the cause and prevention of PUs. Key words: Campaign ■ Pressure ulcer ■ Prevention ■ Stop the Pressure ■ Strategic Health Authority ■ Unavoidable
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ressure ulcers (PUs), their cause and prevention have been discussed in the literature for many decades. They have captured the interest of nurses, doctors, biomedical engineers and health economists. Their prevention and management has been the core of a tissue viability nurse’s daily clinical and strategic workload. In 1988, Hibbs speculated that 95% of PUs were preventable. This estimate has neither been challenged nor confirmed since. To do so would require a full clinical and scientific understanding of the aetiology of PUs as well as an investigation into the care provided to prevent the occurrence. The latter requires evidence through documentation of all medical and nursing interventions.
Heidi Guy is Tissue Viability Clinical Nurse Specialist at East and North Herts NHS Trust and Honorary Lecturer, University of Hertfordshire; Fiona Downie is Nurse Consultant Tissue Viability at Papworth Hospital NHS Foundation Trust, Cambridge and a Senior Lecturer Tissue Viability at Anglia Ruskin University, Cambridge; Lyn McIntyre is Deputy Director – Patient Experience at NHS England (Midlands and East); and Jeremy Peters is Head of Corporate Communications at NHS Property Services Ltd Accepted for publication: April 2013
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The important point to acknowledge is that not all PUs can be prevented, but it is believed most of them can and all preventative measures must be implemented and evaluated. In 1991, the Department of Health (DH) advised there was a 6.7% prevalence rate (see Box 1) of people with PUs. A more thorough review (DH, 1993) reported prevalence rates ranging from 2.7% to 42.7%. While it is accepted that comparing prevalence studies is difficult, this range of difference has also been supported in more recent reviews (Vanderwee et al, 2007; van Gilder et al, 2008). Most frequently, published prevalence studies include hospital populations only. However, in 1977 Barbanel et al published a prevalence of 8.8% across both acute and primary care settings. In 1991, the DH initially proposed an annual reduction of 5–10% in incidence (see Box 1) and suggested that the first task towards achieving this was for health authorities to establish a baseline of incidence and prevalence. Some 21 years later, the DH (2011) has proposed that PUs could be eliminated in 95% of all NHS patients and incentivised the measurement of PUs and other harms by use of the NHS Safety Thermometer (The Health and Social Care Information Centre, 2012) through the introduction of a new Commissioning for Quality and Innovation (CQUIN) initiative goal (DH, 2012). The Safety Thermometer demonstrated a prevalence rate of patients with category 2–4 PU (see Box 2) of 5.39% in October 2012. This equates to 8833 people in 477 English organisations, both NHS and private, acute and community. Box 1. Differentiation between incidence and prevalence Prevalence ■■ This
is the number of people in a given population at a given time who have a pressure ulcer present (Defloor et al, 2005c) ■■ Period prevalence measures the number of people over a defined period of time ■■ Point prevalence measures the number of people on a set date, usually one particular day Incidence ■■ This
is the number of people who develop a new pressure ulcer in a given population over a defined time period. (Defloor et al, 2005c) ■■ When making comparisons between pressure ulcer rates it is important to ensure that the measuring rate is the same. Incidence might be seen as a means of measuring healthcare standards because it reflects the development of new pressure ulcers, whereas prevalence will take into account those patients who had existing pressure ulcers
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Abstract
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Category 1: non-blanchable erythema Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category 1 may be difficult to detect in individuals with dark skin tones. May indicate ‘at-risk’ persons Category 2: partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanguinous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates deep tissue injury). This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration or excoriation Category 3: full thickness skin loss Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.The depth of a category/stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and category/stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable Category 4: full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a category/stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable Unstageable/unclassified: full thickness skin or tissue loss—depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a category/stage 3 or 4. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed Suspected deep tissue injury—depth unknown Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment
Of these people, 2007 (22%) were reported as having a new incidence of a PU. So, is 5.39% a true decline since the 6.7% reported in 1991 and is it good enough? After several decades of increasing awareness and two decades of international, national and governmental guidance (DH, 2001; NICE, 2003; NICE, 2005; European Pressure Ulcer Advisory Panel/ National Pressure Ulcer Advisory Panel (EPUAP/NPUAP), 2009; DH 2010) the question must be asked—why were they not all prevented? The Strategic Health Authority (SHA) cluster of NHS Midlands and East (2012a), which provides health care for
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15 million people, established a formal ambition to eliminate avoidable category 2–4 PUs (McIntyre et al, 2012). It is a reasonable assumption that if a PU is avoidable and can be prevented, then it should be prevented. To support the strategy to eliminate avoidable PUs, a definition of ‘unavoidable’ (NHS Midlands and East, 2012b) has been adopted (see Box 3). This definition recognises that there are certain circumstances and clinical conditions that may result in the unavoidable development of PU. It also recognises that there are certain accepted preventative strategies that need to be in place to prevent a PU occurring and only if these are all used and re-evaluated for effectiveness can it be clearly shown that any PU that subsequently developed, despite these interventions, is unavoidable. This requires documented evidence of care interventions to include: ■■ Risk assessment ■■ Skin inspection ■■ Pressure reducing/relieving equipment ■■ Repositioning ■■ Management of incontinence and moist skin ■■ Nutritional support. These care interventions are not new. All of the above have been extensively researched or discussed in the literature over the past few decades.
Risk assessment Norton et al (1962) is the first published risk assessment tool to guide nurses to identify those patients who may be at particular risk of PU development. Since then, many other risk assessment tools have been devised for generalist and specialist areas (Guy, 2012), most notably the Waterlow (2005) and Braden (Bergstrom et al, 1987) scores. Risk assessment is not a new concept and while a numerical tool is not always entirely reliable (Papanikolaou et al, 2007) and whether it is better than clinical judgement has been challenged (Webster et al, 2011), it formalises assessment and is an auditable action. It has long been an accepted precursor to PU prevention.
Preventative interventions Skin inspection of all bony areas will highlight to nursing staff the early signs of pressure damage. Webster et al (2011) suggest it is more useful than a risk assessment tool. Looking for reddened areas is key. If noted, then care interventions need to be re-evaluated. Skin inspections need to be undertaken as often as possible in relation to the risk of the patient and the outcomes documented. Patients with a darker skin colour may well be at increased risk of PU development (Scanlon and Stubbs, 2004; van Gilder et al, 2008) because their skin will not present with a reddened area. Other changes in skin tone or temperature may need to be considered (EPUAP/NPUAP, 2009). The support surface has long been recognised as playing a part in the prevention of PUs (Norton et al, 1962). Studies over the years that have compared pressure-reducing foam mattresses with standard foam mattresses have consistently demonstrated that fewer patients develop PUs on the former (NICE, 2004). Despite some evidence that patients nursed
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Box 2. International NPUAP/EPUAP pressure ulcer classification system 2009
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The definition of an unavoidable pressure ulcer has been defined in full elsewhere (NHS Midlands and East, 2012b), but to summarise: If all risk assessments, preventative interventions and continuous re-evaluations of implemented care have been instigated and a pressure ulcer develops, then it may be deemed unavoidable. There may be some other conditions and circumstances that lead to the development of an unavoidable pressure ulcer
on alternating pressure-relieving mattresses are less likely to develop a PU than those nursed on standard foam, there is also evidence that patients may still develop PU on alternating mattresses (Nixon et al, 2006). Thus, the mattress (or chair cushion) only forms part of the prevention plan and must sit alongside regular repositioning. Immobility is thought to be one of the major risk factors for PU development. Barbanel et al (1977) found that PUs were most likely to be found in the more immobile patients. This has been supported by many researchers since (Sharp and McClaws, 2006). If a person can move independently at frequent enough intervals, they are unlikely to develop a PU. Repositioning is probably the oldest form of PU prevention and remains to this day the most important (Norton et al, 1962; DeFloor et al, 2005a; Krapfl and Gray, 2008). More recently, the confusion between moisture and pressure damage has been recognised (DeFloor et al, 2005b; Downie and Guy, 2012). Perhaps it could be conjectured that the prevalence figures of today cannot be compared to those of decades ago because many category 2 ulcers may have been moisture lesions. Today, these two distinctly separate aetiological lesions are diagnosed differently and moisture lesions are possibly less frequently identified as PUs. However, this risk factor was included in the Norton (1962) risk assessment and others since, as moisturedamaged skin is at increased risk of pressure damage. Hence, interventions must be put in place to protect the skin from body fluids. Poor nutritional status has long been associated with a higher risk of PU development (Berlowitz and Wilking, 1989; Langer et al, 2003) and Waterlow (2005) was first to include this risk in her assessment tool. The relationship between low serum albumin and PU risk has been debated for many years. Anthony et al (2000) demonstrated that serum albumin may be a useful predictor for PU development but suggested further studies were needed. In 2000, Russell reviewed several papers dating back to the 1980s that demonstrated correlation between low serum albumin, malnutrition and low body mass index (BMI) with PU development. More recently, Kottner et al (2011) found that PUs occurred significantly more often in people with a low BMI. Box 4: The SSKIN care bundle Surface Skin inspection Keep your patients moving Incontinence/moisture Nutrition
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Over the decades, all of the above have been explored and promoted as key preventative interventions. These elements have been the standard of PU prevention the world over. In recent years they have become the core of PU prevention care bundles (Healthcare Improvement Scotland, 2011). Yet PUs are still occurring. Perhaps these are the 5% that were not preventable, or perhaps elements of the care pathway are not being delivered. What is it that makes the difference in PU prevention? In 2009, Bales and Padwojski successfully eradicated hospital-acquired PUs for 1 month in a 300-bed community hospital after a management priority programme was introduced. A follow-up report demonstrated sustainability for both the programme and near consistent eradication of PUs (Bales and Duvendack, 2011). All of the aforementioned care interventions are included in the programme as well as other educational and motivational drivers and senior management involvement and engagement. So is it these additional factors that matter? The education about what is needed to be undertaken to prevent PUs has been delivered widely and increasingly now for over five decades. It is well recognised that education can be a poor driver for change (van Gaal, 2010). Clearly, more is needed to ensure the delivery and effectiveness of preventative interventions. Bales and Padwojski (2009) and Bales and Duvendack (2011) have demonstrated that it can be achieved in one hospital organisation but there is little evidence in the literature of a wider attempt to introduce a preventative programme. This is what is happening in NHS Midlands and East. The care delivery elements of the programme are not new, they constitute all that has been mentioned so far and certainly many if not all organisations were already using these interventions for preventative patient care. What is making the difference now is involvement and engagement from the very highest staff levels within the health authority organisation and multifactorial modes of guideline and educational delivery.
NHS Midlands and East’s ambition to eliminate all avoidable pressure ulcers Communications The work to deliver this ambition has been supported by an integrated communications campaign aimed at frontline staff, based on the findings of unique market research. Enventure Research, a market research company working with the public sector, were commissioned in January 2012 to explore which communications interventions would be effective in helping health professionals to prevent and treat PUs. Using quantitative (paper and online questionnaires) and qualitative techniques (focus groups), they investigated current knowledge, attitudes and perceptions of frontline staff (Thurman and Robinson, 2012). The response to the quantitative element of this research was good, with nearly 1600/287 000 (+/- 2.5% of the 95% confidence interval) staff sharing their detailed views (Thurman and Robinson, 2012). There was a real passion among staff to prevent PUs, but there was a need to bridge the knowledge and experience gap. Of the respondents, 92% believed a well-researched and planned campaign could be successful if hard hitting, direct, simple and using atypical approaches.
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Box 3: Definition of unavoidable pressure ulcer
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These findings continue to form the basis of all phases of the Stop the Pressure campaign. A multidisciplinary communications project group was formed and, after looking closely at the findings, decided the following would be instrumental in driving the campaign: ■■ Key messaging ■■ A ‘conversion moment’ approach ■■ A period of sustained reinforcement using a widely integrated campaign around the key messaging ■■ Empowering staff to communicate more clearly with patients and carers. The campaign, ‘Stop the Pressure’ (www.stopthepressure. com), launched in April 2012 with a string of phases, each featuring innovative communications channels, all tying in directly with the research conclusions. One of the first products was a short video animation intended to shock people (the conversion moment) about the impact of developing a PU and outline a refined and graphically enhanced, simple prevention care bundle approach (see Box 4) (Healthcare Improvement Scotland, 2011). It has been a big hit on several internet platforms and on DVD. A powerful film—The Swans’ Story—shows the impact that an avoidable PU can have on a family. Another key output is a unique online tool that simplifies all the procedures. Staff can scroll and click their way along the ‘Pressure Ulcer Path’, understanding what to do and opening documentation. This has led to all organisations across the Midlands and East regions implementing standardised
protocols. Alternative poster and pocket versions of the Path have also been distributed. The SSKIN care bundle is central to the whole programme. An interactive web page, visual guides, educational slides and 200 000 lanyard cards have made it easy for staff to access and share. Building on this, a new microsite, ‘Learning to stop the pressure’, has been created to make training and educational resources—which vary according to the users role—available together for easy access. One of the research findings was the importance of educating patients and carers about PU prevention, as their lack of knowledge was seen as a key barrier. Working with Enventure and a patient and carer couple, new research has now been conducted into the most effective ways to communicate with the general public so that they too know what to look for and how to prevent PUs. Organisations are participating in ongoing change implementation programmes to assist the clinical teams in delivering all aspects of the ambition pathway. Members of these include tissue viability nurse specialists (TVNs), directors and deputy directors of nursing, clinical nursing team staff (registered and unregistered), dieticians and other professionals allied to healthcare. Ten issues of an email marketing bulletin ‘Under the skin’ have kept senior staff engaged, and more recently an educational ‘Stop the Pressure’ board game has provided learning in a fun way.
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n Not all pressure ulcers (PUs) can be prevented (unavoidable), but many can n PU care and knowledge has increased as a result of involvement and engagement from the very highest staff levels within the health authority organisation and multifactorial modes of guideline and educational delivery n Repositioning is probably the oldest form of PU prevention and remains to this day the most important
Clinical expert working group The expert working group (EWG) came into existence in September 2011. This group was made up of TVNs, clinical commissioners and lead nurses based in the East of England (EoE) region of the NHS Midlands and East cluster. The primary goal of the group was to review the available evidence behind PU prevention and, where necessary, the management of PUs. The secondary outcome was to ensure this evidence was relevant, up to date and available as a simple resource toolkit to all multidisciplinary clinical staff wherever they were based to assist in the prevention of PUs. The EWG were all in agreement that this was an essential route to take to progress towards achieving the ambition.With the ultimate aim being all NHS organisations in NHS Midlands and East using the same processes and accompanying tools, ranging from a PU grading tool to PU prevention/management care bundles. In the reviewing of the available evidence it became clear that some areas that first appeared simple were not always straightforward. For example, in the area of risk assessment timing, what happened to patients who were complex and attending outpatients for several hours or women in maternity units? Using the latter example, the following is an illustration of the process the EWG undertook: ■■ Review of available literature ■■ Area discussed within EWG ■■ Experts in the area consulted, i.e. midwives ■■ Solution identified (screening tool in this case) ■■ Local EoE tissue viability network consulted and lobbied for their opinion on the potential solution ■■ Screening tool adapted or agreed and signed off by EWG. This process was employed for all aspects of PU prevention/ management, including the investigating and reporting of PUs. The processes and guidelines produced by the EWG in this way were made available through the ‘stopthepressure’ webpath, which makes them easily accessible to all clinical staff.
Effectiveness of the strategy In the Midlands and East, data on PU prevalence is collected on the same day each month via the NHS Safety Thermometer, for some 56 000 to 60 000 patients. The monthly Safety Thermometer census is carried out in all NHS care provided in hospitals, community healthcare, mental-health and learning-disability providers. This ‘point prevalence data’ has been collected across all organisations and therefore the improvement of care can be seen over time.
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The NHS Safety Thermometer is a measurement tool used to ‘measure’ the ‘harm-free care’ being delivered to organisations on a monthly basis and gives a snapshot of the four harms for all patients. The four harms are PUs, falls, CAUTIs and venous thromboembolism. Across the Midlands and East there has been support and commitment to achieve the SHA ambition to ‘eliminate avoidable category 2, 3 and 4 pressure ulcers’ from board level through to clinicians working in practice. The collection of Safety Thermometer data to measure the level of improvement was agreed and piloted across the SHA cluster from November 2011, with one primary care trust (PCT) cluster initially collecting 100% data from their area. This was repeated in December 2011 with an increased number of PCT clusters taking part until all 17 collected the baseline measurement in March 2011. This rollout allowed for the development of processes and sharing of good practice to ensure that the data collection was completely accurate, timely and that organisations learnt from each other. It also ensured executive support and early indications of where improvements needed to be made and helped to shape the work streams (NHS Midlands and East, 2011) that support the delivery of the ambition. Data collected during the October 2012 monthly census has reported that the prevalence of patients with a category 2, 3 or 4 PU has reduced from 1.7% to 1.09%, a reduction of 36% over 7 months compared to the April 2012 level. The data also demonstrates that the prevalence of the most severe PUs at category 4 has halved in the same period.
Conclusion There is still some way to go towards eliminating all avoidable PUs in the NHS Midlands and East cluster, but as the latest Safety Thermometer data shows, this multifaceted programme of change delivery is taking effect. The most senior members of the involved organisations are engaged with the ambition and teams delivering care at the patient front have clear and BJN simple processes to follow. Conflict of interest: none Anthony D, Reynolds T, Russell L (2000) An investigation into the use of serum albumin, in pressure sore prediction. J Adv Nurs 32(2): 359-65 Bales I, Padwojski A (2009) Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 18(4): 137-44 Bales I, Duvendack T (2011) Reaching for the moon: achieving zero pressure ulcer prevalence, an update. J Wound Care 20(8): 374-7 Barbanel JC, Jordan MM, Nicol SM, Clark MO (1977) Incidence of pressure sores in the Greater Glasgow Health Board area. Lancet 10(2): 548-50 Bergstrom N, Braden BJ, Laguzza A, Holman V (1987) The Braden scale for predicting pressure sore risk. Nurs Res 36(4): 205-10 Berlowitz DR, Wilking SV (1989) Risk factors for pressure sores. A comparison of cross-sectional and cohort-derived data. J Am Ger Soc 37(11): 1043-50 Defloor T, Bacquerb D, Grypdoncka MHF (2005a) The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud 42: 37-46 Defloor T, Schoonhoven L, Fletcher J et al (2005b) Statement of the European Pressure Ulcer Advisory Panel—pressure ulcer classification differentiation between pressure ulcers and moisture lesions. J Wound Ostomy Continence Nurs 32(5): 302-6 DefloorT, Clark M,Witherow A et al (2005c) EPUAP statement on prevalence and incidence: Monitoring of pressure ulcer occurrence. EPUAP Review 6(3): 74-80 Department of Health (1991) The Health of the Nation. HMSO, London Department of Health (1993) Pressure sores: A key quality indicator. HMSO, London
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Department of Health (2001) Essence of Care. Patient-focused Benchmarking for Health Care Practitioners. The Stationery Office, London Department of Health (2010) Essence of Care 2010: Benchmarks for Prevention and Management of Pressure Ulcers. London, The Stationary Office Department of Health (2011) QIPP Safe care workstream. http://webarchive. nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Quality andproductivity/QIPPworkstreams/DH_115447 (accessed 18 November 2012) Department of Health (2012) Delivering the NHS Safety Thermometer CQUIN 2012/13: A Preliminary Guide to Delivering ‘Harm Free’ Care. www.harmfreecare.org/measurement/nhs-safety-thermometer (accessed 4 December 2012) Downie F, Guy H (2012) Latest developments in the grading of pressure ulcers. Wounds UK 8(3): S13-S17 European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel (2009) Prevention of Pressure Ulcers: Quick Reference Guide. NPUAP. Washington DC Guy H (2012) Pressure ulcer risk assessment. Nursing Times 108(4): 16-20 Healthcare Improvement Scotland (2011) SSKIN Care bundle. http:// tinyurl.com/nkqgtjr (accessed 24 May 2013) Hibbs P (1988) The economic benefits of a prevention plan for pressure sores. Conference presentation. The Fourth National Pressure Sore Symposium. The Guildhall, Bath Kottner J, Gefen A, Lahmann N (2011) Weight and pressure ulcer occurrence: A secondary data analysis. Int J Nurs Stud 48: 1339-48 Krapfl LE, Gray M (2008) Does regular repositioning prevent skin damage? J Wound Ostomy Continence Nurs 35(6): 571-7 Langer G, Knerr A, Kuss O, Behrens J, Schlömer GJ (2003) Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev 4: CD003216. McIntyre L, May R, Marks-Moran D (2012) A strategy to reduce avoidable pressure ulcers. Nursing Times 108(29): 14-17 NHS Midlands and East (2011) Changing our NHS Together: Work streams. www.eoe.nhs.uk/page.php?page_id=209 (accessed 22 May 2013) NHS Midlands and East (2012a) Safe Care: Pressure ulcers. www. stopthepressure.com (accessed 24 November 2012) NHS Midlands and East (2012b) Definition – unavoidable pressure ulcer. www.stopthepressure.com/path/docs/Definition%20unavoidable%20 PU.pdf (accessed 24 November 2012) National Institute for Health and Care Excellence (2003) Clinical Guideline 7; Pressure ulcer prevention. NICE, London
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National Institute for Health and Care Excellence (2004) The use of pressure relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. RCN, London National Institute for Health and Care Excellence (2005) The management of pressure ulcers in primary and secondary care: A Clinical Practice Guideline. RCN, London Nixon J, Cranny G, Iglesias C et al, on behalf of the PRESSURE Trial Group (2006) Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. BMJ 17;332(7555):1413 Norton D, McLaren R, Exton-Smith AN (1962) An investigation of geriatric nursing problems in hospital. National Corporation for the Care of Old People, London. Papanikolaoua P, Lynea P, Anthony D (2007) Risk assessment scales for pressure ulcers: A methodological review. Int J Nurs Stud 44(2): 285-96. Russell L (2000) Malnutrition and pressure ulcers: nutritional assessment tools. BJN, 9(4):194-204 Scanlon E, Stubbs N (2004) Pressure ulcer risk assessment in patients with darkly pigmented skin. Prof Nurs 19(6):339-41 Sharp CA, McLaws ML (2006) Estimating the risk of pressure ulcer development: is it truly evidence based? Int Wound J 3: 344-53 The Health and Social Care Information centre (2012) NHS Safety Thermometer data: April to October 2012. www.ic.nhs.uk/services/ nhs-safety-thermometer (accessed 24 May 2013) Thurman M, Robinson M (2012) NHS Midlands & East Preventing Pressure Ulcers Research. Research Report: Phase 1, Enventure, Bradford Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T (2007) Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract 13(2): 227-35 van Gaal BGI, Schoonhoven L, Vloet LCM et al (2010) The effect of the SAFE or SORRY? Programme on patient safety knowledge of nurses in hospitals and nursing homes: A cluster randomised trial. Int J Nurs Stud 47: 1117-25 VanGilder C, MacFarlane GD, Meyer S (2008) Results of nine international pressure ulcer prevalence Surveys: 1989 to 2005. Ostomy Wound Manag 54(2): 40-54 Waterlow J (2005) Pressure Ulcer Prevention Manual. Waterlow, Taunton Webster J, Coleman K, Mudge A et al (2011) Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ Quality and Safety 20(4): 297-306
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Pressure ulcers (PUs), their cause and prevention have been discussed in the literature for many decades. Their prevention and management has been the core of a tissue viability nurse’s daily clinical and strategic workload. The important point to acknowledge is that not all PUs can be prevented but it is believed most of them can and all preventative measures must be implemented and evaluated. Initial efforts focused on establishing a baseline of incidence and prevalence. More recently, the Department of Health has proposed that PUs could be eliminated in 95% of all NHS patients and incentivised the measurement of PUs and other harms by use of the NHS Safety Thermometer through the introduction of a new initiative. A research company was commissioned to explore which communications interventions would be effective in helping health professionals to prevent and treat PUs. A campaign was subsequently set in motion to educate and inform clinical staff on the cause and prevention of PUs. Key words: Campaign ■ Pressure ulcer ■ Prevention ■ Stop the Pressure ■ Strategic Health Authority ■ Unavoidable
P
ressure ulcers (PUs), their cause and prevention have been discussed in the literature for many decades. They have captured the interest of nurses, doctors, biomedical engineers and health economists. Their prevention and management has been the core of a tissue viability nurse’s daily clinical and strategic workload. In 1988, Hibbs speculated that 95% of PUs were preventable. This estimate has neither been challenged nor confirmed since. To do so would require a full clinical and scientific understanding of the aetiology of PUs as well as an investigation into the care provided to prevent the occurrence. The latter requires evidence through documentation of all medical and nursing interventions.
Heidi Guy is Tissue Viability Clinical Nurse Specialist at East and North Herts NHS Trust and Honorary Lecturer, University of Hertfordshire; Fiona Downie is Nurse Consultant Tissue Viability at Papworth Hospital NHS Foundation Trust, Cambridge and a Senior Lecturer Tissue Viability at Anglia Ruskin University, Cambridge; Lyn McIntyre is Deputy Director – Patient Experience at NHS England (Midlands and East); and Jeremy Peters is Head of Corporate Communications at NHS Property Services Ltd Accepted for publication: April 2013
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The important point to acknowledge is that not all PUs can be prevented, but it is believed most of them can and all preventative measures must be implemented and evaluated. In 1991, the Department of Health (DH) advised there was a 6.7% prevalence rate (see Box 1) of people with PUs. A more thorough review (DH, 1993) reported prevalence rates ranging from 2.7% to 42.7%. While it is accepted that comparing prevalence studies is difficult, this range of difference has also been supported in more recent reviews (Vanderwee et al, 2007; van Gilder et al, 2008). Most frequently, published prevalence studies include hospital populations only. However, in 1977 Barbanel et al published a prevalence of 8.8% across both acute and primary care settings. In 1991, the DH initially proposed an annual reduction of 5–10% in incidence (see Box 1) and suggested that the first task towards achieving this was for health authorities to establish a baseline of incidence and prevalence. Some 21 years later, the DH (2011) has proposed that PUs could be eliminated in 95% of all NHS patients and incentivised the measurement of PUs and other harms by use of the NHS Safety Thermometer (The Health and Social Care Information Centre, 2012) through the introduction of a new Commissioning for Quality and Innovation (CQUIN) initiative goal (DH, 2012). The Safety Thermometer demonstrated a prevalence rate of patients with category 2–4 PU (see Box 2) of 5.39% in October 2012. This equates to 8833 people in 477 English organisations, both NHS and private, acute and community. Box 1. Differentiation between incidence and prevalence Prevalence ■■ This
is the number of people in a given population at a given time who have a pressure ulcer present (Defloor et al, 2005c) ■■ Period prevalence measures the number of people over a defined period of time ■■ Point prevalence measures the number of people on a set date, usually one particular day Incidence ■■ This
is the number of people who develop a new pressure ulcer in a given population over a defined time period. (Defloor et al, 2005c) ■■ When making comparisons between pressure ulcer rates it is important to ensure that the measuring rate is the same. Incidence might be seen as a means of measuring healthcare standards because it reflects the development of new pressure ulcers, whereas prevalence will take into account those patients who had existing pressure ulcers
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Abstract
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Category 1: non-blanchable erythema Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category 1 may be difficult to detect in individuals with dark skin tones. May indicate ‘at-risk’ persons Category 2: partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanguinous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates deep tissue injury). This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration or excoriation Category 3: full thickness skin loss Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.The depth of a category/stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and category/stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable Category 4: full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a category/stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable Unstageable/unclassified: full thickness skin or tissue loss—depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a category/stage 3 or 4. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed Suspected deep tissue injury—depth unknown Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment
Of these people, 2007 (22%) were reported as having a new incidence of a PU. So, is 5.39% a true decline since the 6.7% reported in 1991 and is it good enough? After several decades of increasing awareness and two decades of international, national and governmental guidance (DH, 2001; NICE, 2003; NICE, 2005; European Pressure Ulcer Advisory Panel/ National Pressure Ulcer Advisory Panel (EPUAP/NPUAP), 2009; DH 2010) the question must be asked—why were they not all prevented? The Strategic Health Authority (SHA) cluster of NHS Midlands and East (2012a), which provides health care for
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15 million people, established a formal ambition to eliminate avoidable category 2–4 PUs (McIntyre et al, 2012). It is a reasonable assumption that if a PU is avoidable and can be prevented, then it should be prevented. To support the strategy to eliminate avoidable PUs, a definition of ‘unavoidable’ (NHS Midlands and East, 2012b) has been adopted (see Box 3). This definition recognises that there are certain circumstances and clinical conditions that may result in the unavoidable development of PU. It also recognises that there are certain accepted preventative strategies that need to be in place to prevent a PU occurring and only if these are all used and re-evaluated for effectiveness can it be clearly shown that any PU that subsequently developed, despite these interventions, is unavoidable. This requires documented evidence of care interventions to include: ■■ Risk assessment ■■ Skin inspection ■■ Pressure reducing/relieving equipment ■■ Repositioning ■■ Management of incontinence and moist skin ■■ Nutritional support. These care interventions are not new. All of the above have been extensively researched or discussed in the literature over the past few decades.
Risk assessment Norton et al (1962) is the first published risk assessment tool to guide nurses to identify those patients who may be at particular risk of PU development. Since then, many other risk assessment tools have been devised for generalist and specialist areas (Guy, 2012), most notably the Waterlow (2005) and Braden (Bergstrom et al, 1987) scores. Risk assessment is not a new concept and while a numerical tool is not always entirely reliable (Papanikolaou et al, 2007) and whether it is better than clinical judgement has been challenged (Webster et al, 2011), it formalises assessment and is an auditable action. It has long been an accepted precursor to PU prevention.
Preventative interventions Skin inspection of all bony areas will highlight to nursing staff the early signs of pressure damage. Webster et al (2011) suggest it is more useful than a risk assessment tool. Looking for reddened areas is key. If noted, then care interventions need to be re-evaluated. Skin inspections need to be undertaken as often as possible in relation to the risk of the patient and the outcomes documented. Patients with a darker skin colour may well be at increased risk of PU development (Scanlon and Stubbs, 2004; van Gilder et al, 2008) because their skin will not present with a reddened area. Other changes in skin tone or temperature may need to be considered (EPUAP/NPUAP, 2009). The support surface has long been recognised as playing a part in the prevention of PUs (Norton et al, 1962). Studies over the years that have compared pressure-reducing foam mattresses with standard foam mattresses have consistently demonstrated that fewer patients develop PUs on the former (NICE, 2004). Despite some evidence that patients nursed
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Box 2. International NPUAP/EPUAP pressure ulcer classification system 2009
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The definition of an unavoidable pressure ulcer has been defined in full elsewhere (NHS Midlands and East, 2012b), but to summarise: If all risk assessments, preventative interventions and continuous re-evaluations of implemented care have been instigated and a pressure ulcer develops, then it may be deemed unavoidable. There may be some other conditions and circumstances that lead to the development of an unavoidable pressure ulcer
on alternating pressure-relieving mattresses are less likely to develop a PU than those nursed on standard foam, there is also evidence that patients may still develop PU on alternating mattresses (Nixon et al, 2006). Thus, the mattress (or chair cushion) only forms part of the prevention plan and must sit alongside regular repositioning. Immobility is thought to be one of the major risk factors for PU development. Barbanel et al (1977) found that PUs were most likely to be found in the more immobile patients. This has been supported by many researchers since (Sharp and McClaws, 2006). If a person can move independently at frequent enough intervals, they are unlikely to develop a PU. Repositioning is probably the oldest form of PU prevention and remains to this day the most important (Norton et al, 1962; DeFloor et al, 2005a; Krapfl and Gray, 2008). More recently, the confusion between moisture and pressure damage has been recognised (DeFloor et al, 2005b; Downie and Guy, 2012). Perhaps it could be conjectured that the prevalence figures of today cannot be compared to those of decades ago because many category 2 ulcers may have been moisture lesions. Today, these two distinctly separate aetiological lesions are diagnosed differently and moisture lesions are possibly less frequently identified as PUs. However, this risk factor was included in the Norton (1962) risk assessment and others since, as moisturedamaged skin is at increased risk of pressure damage. Hence, interventions must be put in place to protect the skin from body fluids. Poor nutritional status has long been associated with a higher risk of PU development (Berlowitz and Wilking, 1989; Langer et al, 2003) and Waterlow (2005) was first to include this risk in her assessment tool. The relationship between low serum albumin and PU risk has been debated for many years. Anthony et al (2000) demonstrated that serum albumin may be a useful predictor for PU development but suggested further studies were needed. In 2000, Russell reviewed several papers dating back to the 1980s that demonstrated correlation between low serum albumin, malnutrition and low body mass index (BMI) with PU development. More recently, Kottner et al (2011) found that PUs occurred significantly more often in people with a low BMI. Box 4: The SSKIN care bundle Surface Skin inspection Keep your patients moving Incontinence/moisture Nutrition
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Over the decades, all of the above have been explored and promoted as key preventative interventions. These elements have been the standard of PU prevention the world over. In recent years they have become the core of PU prevention care bundles (Healthcare Improvement Scotland, 2011). Yet PUs are still occurring. Perhaps these are the 5% that were not preventable, or perhaps elements of the care pathway are not being delivered. What is it that makes the difference in PU prevention? In 2009, Bales and Padwojski successfully eradicated hospital-acquired PUs for 1 month in a 300-bed community hospital after a management priority programme was introduced. A follow-up report demonstrated sustainability for both the programme and near consistent eradication of PUs (Bales and Duvendack, 2011). All of the aforementioned care interventions are included in the programme as well as other educational and motivational drivers and senior management involvement and engagement. So is it these additional factors that matter? The education about what is needed to be undertaken to prevent PUs has been delivered widely and increasingly now for over five decades. It is well recognised that education can be a poor driver for change (van Gaal, 2010). Clearly, more is needed to ensure the delivery and effectiveness of preventative interventions. Bales and Padwojski (2009) and Bales and Duvendack (2011) have demonstrated that it can be achieved in one hospital organisation but there is little evidence in the literature of a wider attempt to introduce a preventative programme. This is what is happening in NHS Midlands and East. The care delivery elements of the programme are not new, they constitute all that has been mentioned so far and certainly many if not all organisations were already using these interventions for preventative patient care. What is making the difference now is involvement and engagement from the very highest staff levels within the health authority organisation and multifactorial modes of guideline and educational delivery.
NHS Midlands and East’s ambition to eliminate all avoidable pressure ulcers Communications The work to deliver this ambition has been supported by an integrated communications campaign aimed at frontline staff, based on the findings of unique market research. Enventure Research, a market research company working with the public sector, were commissioned in January 2012 to explore which communications interventions would be effective in helping health professionals to prevent and treat PUs. Using quantitative (paper and online questionnaires) and qualitative techniques (focus groups), they investigated current knowledge, attitudes and perceptions of frontline staff (Thurman and Robinson, 2012). The response to the quantitative element of this research was good, with nearly 1600/287 000 (+/- 2.5% of the 95% confidence interval) staff sharing their detailed views (Thurman and Robinson, 2012). There was a real passion among staff to prevent PUs, but there was a need to bridge the knowledge and experience gap. Of the respondents, 92% believed a well-researched and planned campaign could be successful if hard hitting, direct, simple and using atypical approaches.
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Box 3: Definition of unavoidable pressure ulcer
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These findings continue to form the basis of all phases of the Stop the Pressure campaign. A multidisciplinary communications project group was formed and, after looking closely at the findings, decided the following would be instrumental in driving the campaign: ■■ Key messaging ■■ A ‘conversion moment’ approach ■■ A period of sustained reinforcement using a widely integrated campaign around the key messaging ■■ Empowering staff to communicate more clearly with patients and carers. The campaign, ‘Stop the Pressure’ (www.stopthepressure. com), launched in April 2012 with a string of phases, each featuring innovative communications channels, all tying in directly with the research conclusions. One of the first products was a short video animation intended to shock people (the conversion moment) about the impact of developing a PU and outline a refined and graphically enhanced, simple prevention care bundle approach (see Box 4) (Healthcare Improvement Scotland, 2011). It has been a big hit on several internet platforms and on DVD. A powerful film—The Swans’ Story—shows the impact that an avoidable PU can have on a family. Another key output is a unique online tool that simplifies all the procedures. Staff can scroll and click their way along the ‘Pressure Ulcer Path’, understanding what to do and opening documentation. This has led to all organisations across the Midlands and East regions implementing standardised
protocols. Alternative poster and pocket versions of the Path have also been distributed. The SSKIN care bundle is central to the whole programme. An interactive web page, visual guides, educational slides and 200 000 lanyard cards have made it easy for staff to access and share. Building on this, a new microsite, ‘Learning to stop the pressure’, has been created to make training and educational resources—which vary according to the users role—available together for easy access. One of the research findings was the importance of educating patients and carers about PU prevention, as their lack of knowledge was seen as a key barrier. Working with Enventure and a patient and carer couple, new research has now been conducted into the most effective ways to communicate with the general public so that they too know what to look for and how to prevent PUs. Organisations are participating in ongoing change implementation programmes to assist the clinical teams in delivering all aspects of the ambition pathway. Members of these include tissue viability nurse specialists (TVNs), directors and deputy directors of nursing, clinical nursing team staff (registered and unregistered), dieticians and other professionals allied to healthcare. Ten issues of an email marketing bulletin ‘Under the skin’ have kept senior staff engaged, and more recently an educational ‘Stop the Pressure’ board game has provided learning in a fun way.
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n Not all pressure ulcers (PUs) can be prevented (unavoidable), but many can n PU care and knowledge has increased as a result of involvement and engagement from the very highest staff levels within the health authority organisation and multifactorial modes of guideline and educational delivery n Repositioning is probably the oldest form of PU prevention and remains to this day the most important
Clinical expert working group The expert working group (EWG) came into existence in September 2011. This group was made up of TVNs, clinical commissioners and lead nurses based in the East of England (EoE) region of the NHS Midlands and East cluster. The primary goal of the group was to review the available evidence behind PU prevention and, where necessary, the management of PUs. The secondary outcome was to ensure this evidence was relevant, up to date and available as a simple resource toolkit to all multidisciplinary clinical staff wherever they were based to assist in the prevention of PUs. The EWG were all in agreement that this was an essential route to take to progress towards achieving the ambition.With the ultimate aim being all NHS organisations in NHS Midlands and East using the same processes and accompanying tools, ranging from a PU grading tool to PU prevention/management care bundles. In the reviewing of the available evidence it became clear that some areas that first appeared simple were not always straightforward. For example, in the area of risk assessment timing, what happened to patients who were complex and attending outpatients for several hours or women in maternity units? Using the latter example, the following is an illustration of the process the EWG undertook: ■■ Review of available literature ■■ Area discussed within EWG ■■ Experts in the area consulted, i.e. midwives ■■ Solution identified (screening tool in this case) ■■ Local EoE tissue viability network consulted and lobbied for their opinion on the potential solution ■■ Screening tool adapted or agreed and signed off by EWG. This process was employed for all aspects of PU prevention/ management, including the investigating and reporting of PUs. The processes and guidelines produced by the EWG in this way were made available through the ‘stopthepressure’ webpath, which makes them easily accessible to all clinical staff.
Effectiveness of the strategy In the Midlands and East, data on PU prevalence is collected on the same day each month via the NHS Safety Thermometer, for some 56 000 to 60 000 patients. The monthly Safety Thermometer census is carried out in all NHS care provided in hospitals, community healthcare, mental-health and learning-disability providers. This ‘point prevalence data’ has been collected across all organisations and therefore the improvement of care can be seen over time.
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The NHS Safety Thermometer is a measurement tool used to ‘measure’ the ‘harm-free care’ being delivered to organisations on a monthly basis and gives a snapshot of the four harms for all patients. The four harms are PUs, falls, CAUTIs and venous thromboembolism. Across the Midlands and East there has been support and commitment to achieve the SHA ambition to ‘eliminate avoidable category 2, 3 and 4 pressure ulcers’ from board level through to clinicians working in practice. The collection of Safety Thermometer data to measure the level of improvement was agreed and piloted across the SHA cluster from November 2011, with one primary care trust (PCT) cluster initially collecting 100% data from their area. This was repeated in December 2011 with an increased number of PCT clusters taking part until all 17 collected the baseline measurement in March 2011. This rollout allowed for the development of processes and sharing of good practice to ensure that the data collection was completely accurate, timely and that organisations learnt from each other. It also ensured executive support and early indications of where improvements needed to be made and helped to shape the work streams (NHS Midlands and East, 2011) that support the delivery of the ambition. Data collected during the October 2012 monthly census has reported that the prevalence of patients with a category 2, 3 or 4 PU has reduced from 1.7% to 1.09%, a reduction of 36% over 7 months compared to the April 2012 level. The data also demonstrates that the prevalence of the most severe PUs at category 4 has halved in the same period.
Conclusion There is still some way to go towards eliminating all avoidable PUs in the NHS Midlands and East cluster, but as the latest Safety Thermometer data shows, this multifaceted programme of change delivery is taking effect. The most senior members of the involved organisations are engaged with the ambition and teams delivering care at the patient front have clear and BJN simple processes to follow. Conflict of interest: none Anthony D, Reynolds T, Russell L (2000) An investigation into the use of serum albumin, in pressure sore prediction. J Adv Nurs 32(2): 359-65 Bales I, Padwojski A (2009) Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 18(4): 137-44 Bales I, Duvendack T (2011) Reaching for the moon: achieving zero pressure ulcer prevalence, an update. J Wound Care 20(8): 374-7 Barbanel JC, Jordan MM, Nicol SM, Clark MO (1977) Incidence of pressure sores in the Greater Glasgow Health Board area. Lancet 10(2): 548-50 Bergstrom N, Braden BJ, Laguzza A, Holman V (1987) The Braden scale for predicting pressure sore risk. Nurs Res 36(4): 205-10 Berlowitz DR, Wilking SV (1989) Risk factors for pressure sores. A comparison of cross-sectional and cohort-derived data. J Am Ger Soc 37(11): 1043-50 Defloor T, Bacquerb D, Grypdoncka MHF (2005a) The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud 42: 37-46 Defloor T, Schoonhoven L, Fletcher J et al (2005b) Statement of the European Pressure Ulcer Advisory Panel—pressure ulcer classification differentiation between pressure ulcers and moisture lesions. J Wound Ostomy Continence Nurs 32(5): 302-6 DefloorT, Clark M,Witherow A et al (2005c) EPUAP statement on prevalence and incidence: Monitoring of pressure ulcer occurrence. EPUAP Review 6(3): 74-80 Department of Health (1991) The Health of the Nation. HMSO, London Department of Health (1993) Pressure sores: A key quality indicator. HMSO, London
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Department of Health (2001) Essence of Care. Patient-focused Benchmarking for Health Care Practitioners. The Stationery Office, London Department of Health (2010) Essence of Care 2010: Benchmarks for Prevention and Management of Pressure Ulcers. London, The Stationary Office Department of Health (2011) QIPP Safe care workstream. http://webarchive. nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Quality andproductivity/QIPPworkstreams/DH_115447 (accessed 18 November 2012) Department of Health (2012) Delivering the NHS Safety Thermometer CQUIN 2012/13: A Preliminary Guide to Delivering ‘Harm Free’ Care. www.harmfreecare.org/measurement/nhs-safety-thermometer (accessed 4 December 2012) Downie F, Guy H (2012) Latest developments in the grading of pressure ulcers. Wounds UK 8(3): S13-S17 European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel (2009) Prevention of Pressure Ulcers: Quick Reference Guide. NPUAP. Washington DC Guy H (2012) Pressure ulcer risk assessment. Nursing Times 108(4): 16-20 Healthcare Improvement Scotland (2011) SSKIN Care bundle. http:// tinyurl.com/nkqgtjr (accessed 24 May 2013) Hibbs P (1988) The economic benefits of a prevention plan for pressure sores. Conference presentation. The Fourth National Pressure Sore Symposium. The Guildhall, Bath Kottner J, Gefen A, Lahmann N (2011) Weight and pressure ulcer occurrence: A secondary data analysis. Int J Nurs Stud 48: 1339-48 Krapfl LE, Gray M (2008) Does regular repositioning prevent skin damage? J Wound Ostomy Continence Nurs 35(6): 571-7 Langer G, Knerr A, Kuss O, Behrens J, Schlömer GJ (2003) Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev 4: CD003216. McIntyre L, May R, Marks-Moran D (2012) A strategy to reduce avoidable pressure ulcers. Nursing Times 108(29): 14-17 NHS Midlands and East (2011) Changing our NHS Together: Work streams. www.eoe.nhs.uk/page.php?page_id=209 (accessed 22 May 2013) NHS Midlands and East (2012a) Safe Care: Pressure ulcers. www. stopthepressure.com (accessed 24 November 2012) NHS Midlands and East (2012b) Definition – unavoidable pressure ulcer. www.stopthepressure.com/path/docs/Definition%20unavoidable%20 PU.pdf (accessed 24 November 2012) National Institute for Health and Care Excellence (2003) Clinical Guideline 7; Pressure ulcer prevention. NICE, London
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National Institute for Health and Care Excellence (2004) The use of pressure relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. RCN, London National Institute for Health and Care Excellence (2005) The management of pressure ulcers in primary and secondary care: A Clinical Practice Guideline. RCN, London Nixon J, Cranny G, Iglesias C et al, on behalf of the PRESSURE Trial Group (2006) Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. BMJ 17;332(7555):1413 Norton D, McLaren R, Exton-Smith AN (1962) An investigation of geriatric nursing problems in hospital. National Corporation for the Care of Old People, London. Papanikolaoua P, Lynea P, Anthony D (2007) Risk assessment scales for pressure ulcers: A methodological review. Int J Nurs Stud 44(2): 285-96. Russell L (2000) Malnutrition and pressure ulcers: nutritional assessment tools. BJN, 9(4):194-204 Scanlon E, Stubbs N (2004) Pressure ulcer risk assessment in patients with darkly pigmented skin. Prof Nurs 19(6):339-41 Sharp CA, McLaws ML (2006) Estimating the risk of pressure ulcer development: is it truly evidence based? Int Wound J 3: 344-53 The Health and Social Care Information centre (2012) NHS Safety Thermometer data: April to October 2012. www.ic.nhs.uk/services/ nhs-safety-thermometer (accessed 24 May 2013) Thurman M, Robinson M (2012) NHS Midlands & East Preventing Pressure Ulcers Research. Research Report: Phase 1, Enventure, Bradford Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T (2007) Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract 13(2): 227-35 van Gaal BGI, Schoonhoven L, Vloet LCM et al (2010) The effect of the SAFE or SORRY? Programme on patient safety knowledge of nurses in hospitals and nursing homes: A cluster randomised trial. Int J Nurs Stud 47: 1117-25 VanGilder C, MacFarlane GD, Meyer S (2008) Results of nine international pressure ulcer prevalence Surveys: 1989 to 2005. Ostomy Wound Manag 54(2): 40-54 Waterlow J (2005) Pressure Ulcer Prevention Manual. Waterlow, Taunton Webster J, Coleman K, Mudge A et al (2011) Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ Quality and Safety 20(4): 297-306
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