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Preventing pressure ulcers in neonates, infants, children and young people

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Pressure ulcers

About

What is covered

This interactive flowchart covers the prevention and management of pressure ulcers in neonates, infants, children, young people and adults in primary care and community settings.
Pressure ulcers are caused when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply. Typically they occur in a person confined to bed or a chair by an illness and as a result they are sometimes referred to as 'bedsores', or 'pressure sores'.
All patients are potentially at risk of developing a pressure ulcer. However, they are more likely to occur in people who are seriously ill, have a neurological condition, impaired mobility, impaired nutrition, or poor posture or a deformity. Also, the use of equipment such as seating or beds which are not specifically designed to provide pressure relief, can cause pressure ulcers. As pressure ulcers can arise in a number of ways, interventions for prevention and treatment need to be applicable across a wide range of settings including community and secondary care. This may require organisational and individual change and a commitment to effective delivery.

Terms used in this interactive flowchart

This interactive flowchart covers people of all ages at risk of, or who have, a pressure ulcer. These terms are defined as follows:
  • adults: 18 years or older
  • neonates: under 4 weeks
  • infants: between 4 weeks and 1 year
  • children: 1 year to under 13 years
  • young people: 13 to 17 years.
This interactive flowchart uses the terms 'at risk' and 'at high risk' to identify people who may develop a pressure ulcer. For the purposes of this pathway:
  • Adults considered to be at risk of developing a pressure ulcer are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer.
  • Adults considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors (for example, significantly limited mobility, nutritional deficiency, inability to reposition themselves, significant cognitive impairment) identified during risk assessment with or without a validated risk assessment tool. Please note that the examples given are not exhaustive. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.
  • Neonates, infants, children and young people considered to be at risk are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer.
  • Neonates, infants, children and young people considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors (for example, significantly limited mobility, nutritional deficiency, inability to reposition themselves, significant cognitive impairment) identified during risk assessment with or without a validated risk assessment tool. Please note that the examples given are not exhaustive. Those with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.

Updates

Updates to this interactive flowchart

10 June 2015 Pressure ulcers (NICE quality standard 89) added.
11 November 2014 Parafricta Bootees and Undergarments to reduce skin breakdown in people with or at risk of pressure ulcers (NICE medical technologies guidance 20) added.
22 April 2014 Structure revised. Pressure ulcers: prevention and management (NICE guideline CG179) added which updates and replaces NICE guideline CG29 (September 2005) and NICE guideline CG7 (October 2003).
25 March 2014 The Debrisoft monofilament debridement pad for use in acute or chronic wounds (NICE medical technologies guidance 17) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on preventing and managing pressure ulcers in all age groups in primary care and community settings in an interactive flowchart

What is covered

This interactive flowchart covers the prevention and management of pressure ulcers in neonates, infants, children, young people and adults in primary care and community settings.
Pressure ulcers are caused when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply. Typically they occur in a person confined to bed or a chair by an illness and as a result they are sometimes referred to as 'bedsores', or 'pressure sores'.
All patients are potentially at risk of developing a pressure ulcer. However, they are more likely to occur in people who are seriously ill, have a neurological condition, impaired mobility, impaired nutrition, or poor posture or a deformity. Also, the use of equipment such as seating or beds which are not specifically designed to provide pressure relief, can cause pressure ulcers. As pressure ulcers can arise in a number of ways, interventions for prevention and treatment need to be applicable across a wide range of settings including community and secondary care. This may require organisational and individual change and a commitment to effective delivery.

Terms used in this interactive flowchart

This interactive flowchart covers people of all ages at risk of, or who have, a pressure ulcer. These terms are defined as follows:
  • adults: 18 years or older
  • neonates: under 4 weeks
  • infants: between 4 weeks and 1 year
  • children: 1 year to under 13 years
  • young people: 13 to 17 years.
This interactive flowchart uses the terms 'at risk' and 'at high risk' to identify people who may develop a pressure ulcer. For the purposes of this pathway:
  • Adults considered to be at risk of developing a pressure ulcer are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer.
  • Adults considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors (for example, significantly limited mobility, nutritional deficiency, inability to reposition themselves, significant cognitive impairment) identified during risk assessment with or without a validated risk assessment tool. Please note that the examples given are not exhaustive. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.
  • Neonates, infants, children and young people considered to be at risk are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer.
  • Neonates, infants, children and young people considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors (for example, significantly limited mobility, nutritional deficiency, inability to reposition themselves, significant cognitive impairment) identified during risk assessment with or without a validated risk assessment tool. Please note that the examples given are not exhaustive. Those with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.

Updates

Updates to this interactive flowchart

10 June 2015 Pressure ulcers (NICE quality standard 89) added.
11 November 2014 Parafricta Bootees and Undergarments to reduce skin breakdown in people with or at risk of pressure ulcers (NICE medical technologies guidance 20) added.
22 April 2014 Structure revised. Pressure ulcers: prevention and management (NICE guideline CG179) added which updates and replaces NICE guideline CG29 (September 2005) and NICE guideline CG7 (October 2003).
25 March 2014 The Debrisoft monofilament debridement pad for use in acute or chronic wounds (NICE medical technologies guidance 17) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Pressure ulcers (2014) NICE guideline CG179
Pressure ulcers (2015) NICE quality standard 89
UrgoStart for chronic wounds (2016) NICE medtech innovation briefing 82

Quality standards

Quality statements

Pressure ulcer risk assessment in hospitals and care homes with nursing

This quality statement is taken from the pressure ulcers quality standard. The quality standard defines clinical best practice in pressure ulcers care and should be read in full.

Quality statement

People admitted to hospital or a care home with nursing have a pressure ulcer risk assessment within 6 hours of admission.

Rationale

Healthcare professionals can identify people who are at risk of developing pressure ulcers by carrying out a pressure ulcer risk assessment. By doing this within 6 hours of when a person is admitted to hospital or a care home with nursing, those at risk or high risk of developing pressure ulcers can be identified without delay. Acting on the results of the risk assessments allows healthcare professionals to offer preventative treatment to people at risk, helping to reduce the number of people developing a pressure ulcer and ensuring patient safety.

Quality measures

Structure
a) Evidence of local arrangements to ensure that healthcare professionals in hospitals and care homes with nursing know how to carry out pressure ulcer risk assessments.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people admitted to hospital or a care home with nursing have a pressure ulcer risk assessment within 6 hours of admission.
Data source: Local data collection.
Process
a) Proportion of new inpatient hospital admissions that have a pressure ulcer risk assessment carried out within 6 hours of admission.
Numerator – the number in the denominator that have a pressure ulcer risk assessment carried out within 6 hours of admission.
Denominator – the number of new inpatient hospital admissions.
Data source: Local data collection.
b) Proportion of new residential admissions to care homes with nursing that have a pressure ulcer risk assessment carried out within 6 hours of admission.
Numerator – the number in the denominator that have a pressure ulcer risk assessment carried out within 6 hours of admission.
Denominator – the number of new residential admissions to care homes with nursing.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (hospitals and care homes with nursing) ensure that systems are in place for healthcare professionals to be trained in assessing pressure ulcer risk, and that they carry out and document a pressure ulcer risk assessment within 6 hours of a person being admitted to hospital or a care home with nursing.
Healthcare professionals ensure that they know how to assess a person’s pressure ulcer risk, and that they carry out and document a pressure ulcer risk assessment within 6 hours of a person being admitted to hospital or a care home with nursing.
Commissioners (clinical commissioning groups) should specify that a pressure ulcer risk assessment is carried out and documented within 6 hours of admission for all people admitted to hospital or a care home with nursing.

What the quality statement means for patients, service users and carers

People admitted to hospital or a care home with nursing have their risk of developing a pressure ulcer assessed by a healthcare professional within 6 hours of being admitted.

Source guidance

Definitions of terms used in this quality statement

Care home with nursing
The provision of 24-hour accommodation together with nursing care. This does not include residential care homes with non-nursing care.
Pressure ulcer risk assessment
An assessment of pressure ulcer risk should be based on clinical judgement and/or the use of a validated scale such as the Braden scale, the Waterlow scale or the Norton risk-assessment scale for adults and the Braden Q scale for children.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.3 and 1.2.2]
Risk of developing pressure ulcers
People considered to be at risk of developing a pressure ulcer are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer. Risk factors include:
  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • a previous or current pressure ulcer
  • malnutrition
  • the inability to reposition themselves
  • significant cognitive impairment.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.2 and 1.2.1]
High risk of developing pressure ulcers
People considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors identified during risk assessment with or without a validated risk assessment tool. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.
[Pressure ulcers (NICE guideline CG179)]

Equality and diversity considerations

The validated scale to assess the risk of pressure ulcers should be suitable for the person being assessed. For example, when assessing children it is important to use a scale such as the Braden Q scale, which is suitable for this age group.

Pressure ulcer risk assessment by community nursing services

This quality statement is taken from the pressure ulcers quality standard. The quality standard defines clinical best practice in pressure ulcers care and should be read in full.

Quality statement

People with a risk factor for developing pressure ulcers who are referred to community nursing services have a pressure ulcer risk assessment at the first face-to-face visit.

Rationale

People in community care settings who have 1 or more risk factors for pressure ulcers and have been referred to community nursing services should have a pressure ulcer risk assessment to help identify the need for preventative action. Risk factors include limited mobility, loss of sensation, previous or current pressure ulcers, malnutrition and cognitive impairment. It is important to carry out the pressure ulcer risk assessment at the person’s first face-to-face visit with community nursing services to ensure patient safety.

Quality measures

Structure
a) Evidence of local arrangements to ensure that healthcare professionals from community nursing services know how to perform pressure ulcer risk assessments.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people with 1 or more risk factors for pressure ulcers referred to community nursing services have a pressure ulcer risk assessment at the first face-to-face visit.
Data source: Local data collection.
Process
Proportion of referrals to community nursing services for people with 1 or more risk factors for pressure ulcers in which a pressure ulcer risk assessment is carried out at the first face-to-face visit.
Numerator – the number in the denominator in which a pressure ulcer risk assessment is carried out at the first face-to-face visit.
Denominator – the number of referrals to community nursing services for people with 1 or more risk factors for pressure ulcers.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (community care) ensure that systems are in place for healthcare professionals from community nursing services to be trained in assessing pressure ulcer risk and that, if a person has 1 or more risk factors, they carry out a pressure ulcer risk assessment at the first face-to-face visit.
Healthcare professionals from community nursing services ensure that they know how to assess a person’s pressure ulcer risk and that, if a person has 1 or more risk factors, they carry out a pressure ulcer risk assessment at the first face-to-face visit.
Commissioners (clinical commissioning groups) should specify that community nursing services carry out a pressure ulcer risk assessment at the first face-to-face visit for all people with 1 or more risk factors for pressure ulcers that are referred to them.

What the quality statement means for patients, service users and carers

People referred to community nursing services who have 1 or more risk factors for pressure ulcers have their risk of developing a pressure ulcer assessed at the first face-to-face visit.

Source guidance

  • Pressure ulcers (2014) NICE guideline CG179, recommendations 1.1.2 and 1.2.1 (key priority for implementation)

Definitions of terms used in this quality statement

Pressure ulcer risk assessment
An assessment of pressure ulcer risk should be based on clinical judgement and/or the use of a validated scale such as the Braden scale, the Waterlow scale or the Norton risk-assessment scale for adults and the Braden Q scale for children.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.3 and 1.2.2]
Risk of developing pressure ulcers
People considered to be at risk of developing a pressure ulcer are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer. Risk factors include:
  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • a previous or current pressure ulcer
  • malnutrition
  • the inability to reposition themselves
  • significant cognitive impairment.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.2 and 1.2.1]

Equality and diversity considerations

The validated scale to assess the risk of pressure ulcers must be suitable for the person being assessed. For example, when assessing children it is important to use a scale such as the Braden Q scale, which is suitable for this age group.

Pressure ulcer risk reassessment

This quality statement is taken from the pressure ulcers quality standard. The quality standard defines clinical best practice in pressure ulcers care and should be read in full.

Quality statement

People have their risk of developing pressure ulcers reassessed after a surgical or interventional procedure, or after a change in their care environment following a transfer.

Rationale

Pressure ulcer risk status is not constant and is likely to change during the course of care. A pressure ulcer risk assessment should be repeated if there is a change in a person’s clinical status. However, changes in clinical status can be difficult to define. Specific instances where a reassessment should be carried out to ensure patient and service user safety have been identified as after a surgical or interventional procedure in hospital, and after a person’s care environment changes following a transfer in any setting.

Quality measures

Structure
a) Evidence of local arrangements to ensure that healthcare professionals know how to carry out a risk assessment to reassess the risk of developing pressure ulcers.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people who have had a surgical or interventional procedure, or who have been transferred between care environments, have their pressure ulcer risk reassessed afterwards.
Data source: Local data collection.
Process
a) Proportion of inpatient hospital interventional or surgical procedures that have a pressure ulcer risk reassessment carried out while the person is in hospital.
Numerator – the number in the denominator that have a pressure ulcer risk reassessment carried out after the interventional or surgical procedure while the person is in hospital.
Denominator – the number of inpatient hospital interventional or surgical procedures.
Data source: Local data collection.
b) Proportion of changes in care environment following a transfer that have a pressure ulcer risk reassessment carried out afterwards.
Numerator – the number in the denominator that have a pressure ulcer risk reassessment carried out after the change in care environment.
Denominator – the number of changes in care environment following a transfer.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care, community care, hospitals and care homes with nursing) ensure that systems and protocols are in place for healthcare professionals to be trained in assessing pressure ulcer risk and that they carry out a pressure ulcer risk reassessment after an interventional or surgical procedure in hospital, or after a change in care environment following a transfer.
Healthcare professionals ensure that they know how to assess a person’s pressure ulcer risk, and that they carry out a pressure ulcer risk reassessment after an interventional or surgical procedure in hospital, or after a person’s care environment changes following a transfer.
Commissioners (NHS England area teams, clinical commissioning groups) ensure that a pressure ulcer risk reassessment is carried out for all people after a surgical or interventional procedure in hospital, or after a change in care environment following a transfer in all settings.

What the quality statement means for patients, service users and carers

People who have had an operation or investigation in hospital have an assessment afterwards to see if they are at risk of developing a pressure ulcer.
People who are discharged from hospital, or who move wards while they are in hospital, have an assessment afterwards to see if they are at risk of developing a pressure ulcer.

Source guidance

Definitions of terms used in this quality statement

Pressure ulcer risk assessment
An assessment of pressure ulcer risk should be based on clinical judgement and/or the use of a validated scale such as the Braden scale, the Waterlow scale or the Norton risk-assessment scale for adults and the Braden Q scale for children.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.3 and 1.2.2]
Change in care environment following a transfer
Examples of a change in a person’s care environment following a transfer include:
  • when moving between wards in a hospital
  • on discharge from hospital to a care home, or their own home.
[Expert consensus]

Equality and diversity considerations

The validated scale to assess the risk of pressure ulcers must be suitable for the person being assessed. For example, when assessing children it is important to use a scale such as the Braden Q scale, which is suitable for this age group.

Skin assessment

This quality statement is taken from the pressure ulcers quality standard. The quality standard defines clinical best practice in pressure ulcers care and should be read in full.

Quality statement

People have a skin assessment if they are identified as high risk of developing pressure ulcers.

Rationale

Whenever a person has a pressure ulcer risk assessment that shows they are at high risk of developing pressure ulcers, a follow-up skin assessment should be carried out. A clinical assessment of the skin by a healthcare professional, taking into account any pain reported by the person, may predict the development of a pressure ulcer. The results of the skin assessment can be used to offer suitable preventative interventions to people who are at high risk of developing pressure ulcers. A skin assessment needs to be repeated whenever a person is identified as at high risk as a result of a pressure ulcer risk assessment, to take account of any changes to the skin and to ensure patient and service user safety.

Quality measures

Structure
Evidence of local arrangements to ensure that people have a skin assessment if they are identified as high risk of developing pressure ulcers.
Data source: Local data collection.
Process
Proportion of pressure ulcer risk assessments with an identification of high risk that have a follow-up skin assessment.
Numerator – the number in the denominator with a skin assessment carried out following the pressure ulcer risk assessment or reassessment.
Denominator – the number of pressure ulcer risk assessments with an identification of high risk.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care, community care, hospitals and care homes with nursing) ensure that healthcare professionals are trained to carry out skin assessments, and that they carry out a skin assessment if a person is identified as high risk of developing pressure ulcers.
Healthcare professionals ensure that they know how to carry out a skin assessment, and that they carry out a skin assessment if a person in their care is identified as high risk of developing pressure ulcers.
Commissioners (NHS England area teams, clinical commissioning groups) should specify that a skin assessment is carried out if a person is identified as high risk of developing pressure ulcers.

What the quality statement means for patients, service users and carers

People identified as high risk of developing pressure ulcers are offered a skin assessment by a healthcare professional to check their skin for signs of pressure ulcers. The skin assessment should be carried out every time they are identified as high risk following an assessment or reassessment of pressure ulcer risk.

Source guidance

  • Pressure ulcers (2014) NICE guideline CG179, recommendations 1.1.5 (key priority for implementation) and 1.2.3

Definitions of terms used in this quality statement

Risk of developing pressure ulcers
People considered to be at risk of developing a pressure ulcer are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer. Risk factors include:
  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • a previous or current pressure ulcer
  • malnutrition
  • the inability to reposition themselves
  • significant cognitive impairment.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.2 and 1.2.1]
High risk of developing pressure ulcers
People considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors identified during risk assessment with or without a validated risk assessment tool. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.
[Pressure ulcers (NICE guideline CG179)]
Skin assessment for adults
A skin assessment in adults should take into account:
  • any pain or discomfort reported by the patient
  • skin integrity in areas of pressure
  • colour changes or discoloration
  • variations in heat, firmness and moisture (for example because of incontinence, oedema, dry or inflamed skin).
[Pressure ulcers (NICE guideline CG179) recommendation 1.1.5]
Skin assessment for neonates, infants, children and young people
A skin assessment in neonates, infants, children and young people should take into account:
  • skin changes in the occipital area (back of the head)
  • skin temperature
  • the presence of blanching erythema (redness on the skin that goes away when pressed with the fingers) or discolored areas of skin.
[Pressure ulcers (NICE guideline CG179) recommendation 1.2.3]

Equality and diversity considerations

Consideration should be given to people with cognitive and behavioural difficulties who may have problems reporting pain when performing the skin assessment.
Healthcare professionals should be aware that non-blanchable erythema (redness on the skin that doesn’t go away when pressed with the fingers) may present as colour changes or discoloration, particularly in darker skin tones or types.

Advice on repositioning

This quality statement is taken from the pressure ulcers quality standard. The quality standard defines clinical best practice in pressure ulcers care and should be read in full.

Quality statement

People at risk of developing pressure ulcers receive advice on the benefits and frequency of repositioning.

Rationale

Repositioning, where the person moves into a different position in a chair or bed, aims to reduce or stop pressure on the area at risk. To improve patient experience, health and social care professionals should advise people at risk of developing pressure ulcers (or their carers, as appropriate) about the importance of frequent repositioning, and that it may help to prevent pressure ulcers. The frequency of repositioning advised should be appropriate for the individual person and their wishes and needs. For safety reasons, repositioning is recommended at least every 6 hours for adults at risk, and every 4 hours for adults at high risk. For children and young people at risk, repositioning is recommended at least every 4 hours, and more frequently for those at high risk.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people at risk of developing pressure ulcers are given advice on the benefits and frequency of repositioning.
Data source: Local data collection.
Process
a) Proportion of adults newly identified as being at risk of developing pressure ulcers that are given advice to change position at least every 6 hours.
Numerator – the number in the denominator, or their carers, who receive advice to change position at least every 6 hours.
Denominator – the number of adults newly identified as being at risk, but not at high risk, of developing pressure ulcers.
Data source: Local data collection.
b) Proportion of adults newly identified as being at high risk of developing pressure ulcers that are given advice to reposition at least every 4 hours.
Numerator – the number in the denominator, or their carers, who receive advice to change position at least every 4 hours.
Denominator – the number of adults newly identified as being at high risk of developing pressure ulcers.
Data source: Local data collection.
c) Proportion of children and young people newly identified as being at risk or high risk of developing pressure ulcers that are given advice to change position at least every 4 hours.
Numerator – the number in the denominator, or their carers, who receive advice to change position at least every 4 hours.
Denominator – the number of children and young people newly identified as being at risk or high risk of developing pressure ulcers.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (primary care, community care, hospitals and care homes with nursing) ensure that people who are at risk of developing pressure ulcers are given advice on the benefits of repositioning and frequency of repositioning according to their level of risk.
Health and social care practitioners ensure that they give people at risk of developing pressure ulcers advice about the benefits of repositioning and the frequency of repositioning according to their level of risk.
Commissioners (NHS England area teams, clinical commissioning groups and local authorities) should specify that people who are at risk of developing pressure ulcers are given advice on the benefits of repositioning and frequency of repositioning according to their level of risk.

What the quality statement means for patients, service users and carers

People who are at risk of developing pressure ulcers should receive advice about changing their position regularly, how changing position can help reduce the risk of developing a pressure ulcer, and how frequently they should change position (according to their individual risk of developing a pressure ulcer).

Source guidance

  • Pressure ulcers (2014) NICE guideline CG179, recommendations 1.1.8 (key priority for implementation), 1.1.9, 1.2.5, 1.2.6, 1.2.8 and 1.2.11

Definitions of terms used in this quality statement

Risk of developing pressure ulcers
People considered to be at risk of developing a pressure ulcer are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer. Risk factors include:
  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • a previous or current pressure ulcer
  • malnutrition
  • the inability to reposition themselves
  • significant cognitive impairment.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.2 and 1.2.1]
High risk of developing pressure ulcers
People considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors identified during risk assessment with or without a validated risk assessment tool. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.
[Pressure ulcers (NICE guideline CG179)]

Equality and diversity considerations

The advice on repositioning needs to be appropriate to the individual and take into account their needs and those of their carers. This is especially the case for people with degenerative conditions, impaired mobility, neurological impairment, sensory impairment, and cognitive and behavioural difficulties. The advice should also be age-appropriate, taking into account the needs of children and young people, and their parents or carers.

Help with repositioning

This quality statement is taken from the pressure ulcers quality standard. The quality standard defines clinical best practice in pressure ulcers care and should be read in full.

Quality statement

People at risk of developing pressure ulcers, who are unable to reposition themselves, are helped to change their position.

Rationale

A lack of mobility and sensation are risk factors for developing pressure ulcers. If a person is unable to reposition themselves, health and social care professionals should help them to change their position, to prevent the development of pressure ulcers. For some people, repositioning equipment may be needed. The frequency of repositioning should be appropriate for the individual and their wishes and needs. For safety reasons, repositioning is recommended at least every 6 hours for adults at risk, and every 4 hours for adults at high risk. For children and young people at risk, repositioning is recommended at least every 4 hours, and more frequently for those at high risk.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people who are unable to reposition themselves at the appropriate frequency are helped to do so.
b) Evidence of local arrangements to ensure that repositioning equipment is available to help with repositioning people who are unable to reposition themselves.
Data source: Local data collection.
Process
a) Proportion of adults at risk of developing pressure ulcers and needing help to change their position who have a plan for repositioning every 6 hours.
Numerator – the number in the denominator who have a plan for repositioning every 6 hours.
Denominator – the number of adults at risk, but not high risk, of developing pressure ulcers who need help to change their position.
Data source: Local data collection.
b) Proportion of adults at high risk of developing pressure ulcers and needing help to change their position who have a plan for repositioning every 4 hours.
Numerator – the number in the denominator who have a plan for repositioning every 4 hours.
Denominator – the number of adults at high risk of developing pressure ulcers who need help to change their position.
Data source: Local data collection.
c) Proportion of neonates, infants, children and young people at risk or high risk of developing pressure ulcers and needing help to change their position who have a plan for repositioning every 4 hours.
Numerator – the number in the denominator who have a plan for repositioning every 4 hours.
Denominator – the number of neonates, infants, children and young people at risk or high risk of developing pressure ulcers who need help to change their position.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (community care, hospitals and care homes with nursing) ensure that training in repositioning techniques and use of repositioning equipment are provided for health and social care practitioners so that they can help to reposition people at risk of pressure ulcers if they are unable to reposition themselves.
Health and social care practitioners ensure that they know how to reposition people safely, and that they help people at risk of developing pressure ulcers with repositioning if they are unable to reposition themselves.
Commissioners (clinical commissioning groups and local authorities) should specify that help to change position is given to people in all settings who are at risk of developing pressure ulcers and are unable to reposition themselves.

What the quality statement means for patients, service users and carers

People at risk of developing pressure ulcers who are unable to reposition themselves are helped to change their position at a frequency that is appropriate for their level of risk, and according to their wishes and needs.

Source guidance

  • Pressure ulcers (2014) NICE guideline CG179, recommendations 1.1.8 (key priority for implementation), 1.1.9 and 1.2.5

Definitions of terms used in this quality statement

Risk of developing pressure ulcers
People considered to be at risk of developing a pressure ulcer are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer. Risk factors include:
  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • a previous or current pressure ulcer
  • malnutrition
  • the inability to reposition themselves
  • significant cognitive impairment.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.2 and 1.2.1]
High risk of developing pressure ulcers
People considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors identified during risk assessment with or without a validated risk assessment tool. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.
[Pressure ulcers (NICE guideline CG179)]
People who need help to change their position
Some people may not be able to reposition themselves and need help to do so. This may be for several reasons, including certain physical or mental health conditions.

Equality and diversity considerations

Help with repositioning needs to be tailored to the individual and takes into account their needs and those of their carers. This is especially the case for people with degenerative conditions, impaired mobility, neurological impairment, sensory impairment, and cognitive and behavioural difficulties, who may have problems understanding the reasons why they are being repositioned. Help with repositioning should also be age-appropriate, taking into account the needs of children and young people, and their parents or carers.

Information on preventing pressure ulcers

This quality statement is taken from the pressure ulcers quality standard. The quality standard defines clinical best practice in pressure ulcers care and should be read in full.

Quality statement

People at high risk of developing pressure ulcers, and their carers, receive information on how to prevent them.

Rationale

Many pressure ulcers are preventable. Much of the preventative care needed takes place in a person’s own home and needs to be delivered regularly to ensure patient safety. Healthcare professionals should give information to people at high risk of developing pressure ulcers (and their carers, as appropriate) about preventative care that may stop pressure ulcers from developing. To improve patient experience, information about preventing pressure ulcers should be appropriate to the individual person and their carers. Information should include the causes and signs of pressure ulcers and how they affect health and quality of life. It should also include a demonstration of how to use equipment that may be supplied, and what people can do to help prevent pressure ulcers from developing.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people at high risk of developing pressure ulcers, and their carers, receive information on how to prevent them.
Data source: Local data collection.
Process
a) Proportion of people newly identified at high risk of developing pressure ulcers who receive information on how to prevent them.
Numerator – the number in the denominator, or their carer, that receive information on how to prevent pressure ulcers.
Denominator – the number of people newly identified at high risk of developing pressure ulcers.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care, community care, hospitals and care homes with nursing) ensure that systems are in place for healthcare professionals to give tailored information on preventing pressure ulcers to people who are at high risk of developing pressure ulcers (and to their carers, as appropriate).
Healthcare professionals ensure that they give people who are at high risk of developing pressure ulcers, (and to their carers, as appropriate), tailored information on how to prevent them.
Commissioners (NHS England area teams and clinical commissioning groups) should specify that tailored information on preventing pressure ulcers is given to people who are at high risk of developing pressure ulcers, (and to their carers, as appropriate).

What the quality statement means for patients, service users and carers

People who have a high risk of developing pressure ulcers are given information by a healthcare professional about preventing pressure ulcers from developing. This should be tailored to the person’s needs, and should include advice about the causes and early signs of pressure ulcers, and information on how pressure ulcers can affect health and quality of life. The information should also include a demonstration of how to use any equipment (for example, any mattresses or cushions) that may be supplied, and information about what people can do to help prevent pressure ulcers from developing.

Source guidance

Definitions of terms used in this quality statement

Risk of developing pressure ulcers
People considered to be at risk of developing a pressure ulcer are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer. Risk factors include:
  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • a previous or current pressure ulcer
  • malnutrition
  • the inability to reposition themselves
  • significant cognitive impairment.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.2 and 1.2.1]
High risk of developing pressure ulcers
People considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors identified during risk assessment with or without a validated risk assessment tool. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk. [Pressure ulcers (NICE guideline CG179)]
Information
The information should include:
  • the causes of pressure ulcers
  • the early signs of pressure ulcers
  • ways to prevent pressure ulcers
  • the effect of having a pressure ulcer (for example, for general health, treatment options and the risk of developing pressure ulcers in the future)
  • a demonstration of techniques and equipment used to prevent a pressure ulcer.
[Pressure ulcers (NICE guideline CG179) recommendation 1.3.2]

Equality and diversity considerations

The information provided needs to be tailored to the individual. This is especially the case for people with degenerative conditions, impaired mobility, neurological impairment, sensory impairment, cognitive and behavioural difficulties, impaired tissue perfusion and differing skin tones and types. The information should also be age-appropriate, taking into account the needs of children and young people and their parents or carers.

Pressure redistribution devices

This quality statement is taken from the pressure ulcers quality standard. The quality standard defines clinical best practice in pressure ulcers care and should be read in full.

Quality statement

People at high risk of developing pressure ulcers are provided with pressure redistribution devices.

Rationale

Pressure redistribution devices work by reducing or redistributing pressure, friction or shear forces. Devices include high-specification mattresses, pressure redistribution cushions and equipment that offloads heel pressure. The type of device a person needs will depend on their circumstances, for example, their mobility, the results of the skin assessment, their level of risk, the site that is at risk, the person’s weight and the person’s general health. Using pressure redistribution devices as soon as possible can prevent pressure ulcers developing and help to treat them if they do arise, ensuring patient safety and improving the experience of people at high risk of pressure ulcers.

Quality measures

Structure
Evidence of local arrangements to provide pressure redistribution devices for people at high risk of developing pressure ulcers.
Data source: Local data collection.
Process
Proportion of people newly identified as being at high risk of developing pressure ulcers who receive a pressure redistribution device.
Numerator – the number in the denominator who receive a pressure redistribution device.
Denominator – the number of people newly identified as being at high risk of developing pressure ulcers.
Data source: Local data collection.
Outcomes
a) Waiting times from the identified need for a pressure redistribution device to the time the device is requested.
b) Waiting times from the time the pressure redistribution device is requested to the time the device is received.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners and commissioners

Service providers (primary care, community care, hospitals and care homes with nursing) ensure that people at high risk of developing pressure ulcers in all settings are provided with pressure redistribution devices when they need them.
Health and social care practitioners ensure that people at high risk of developing pressure ulcers in their care are provided with pressure redistribution devices.
Commissioners (NHS England area teams, clinical commissioning groups and local authorities) should specify that pressure redistribution devices are available and provided for people at high risk of developing pressure ulcers.

What the quality statement means for patients, service users and carers

People who have a high risk of developing pressure ulcers are given 'pressure redistributing equipment'. This term is used to describe any item, such as a mattress or an overlay (a layer placed on top of a mattress), that either spreads out the pressure or removes pressure regularly from different parts of the body. (They may also be called 'pressure reducing', 'pressure relieving' or 'pressure redistributing devices'.) If you use a wheelchair or sit for long periods of time, you may also be offered a special cushion. Babies, children and young people at risk of developing a pressure ulcer on the back of the head should have a special pillow or pad.

Source guidance

  • Pressure ulcers (2014) NICE guideline CG179, recommendations 1.1.13 (key priority for implementation), 1.1.14, 1.1.17, 1.2.17, 1.2.18, 1.2.20, 1.2.21, 1.4.9, 1.4.12, 1.5.10, 1.5.11 and 1.5.12

Definitions of terms used in this quality statement

Risk of developing pressure ulcers
People considered to be at risk of developing a pressure ulcer are those who, after assessment using clinical judgement and/or a validated risk assessment tool, are considered to be at risk of developing a pressure ulcer. Risk factors include:
  • significantly limited mobility (for example, people with a spinal cord injury)
  • significant loss of sensation
  • a previous or current pressure ulcer
  • malnutrition
  • the inability to reposition themselves
  • significant cognitive impairment.
[Pressure ulcers (NICE guideline CG179) recommendations 1.1.2 and 1.2.1]
High risk of developing pressure ulcers
People considered to be at high risk of developing a pressure ulcer will usually have multiple risk factors identified during risk assessment with or without a validated risk assessment tool. Adults with a history of pressure ulcers or a current pressure ulcer are also considered to be at high risk.
[Pressure ulcers (NICE guideline CG179)]
Pressure redistribution devices
Pressure redistribution devices include different types of high-specification mattresses and overlays, pressure redistribution cushions and seating, and equipment that offloads heel pressure.
[Pressure ulcers (NICE full guideline CG179)]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Offer timely, tailored information to people who have been assessed as being at high risk of developing a pressure ulcer, and their family or carers. The information should be delivered by a trained or experienced healthcare professional and include:
  • the causes of a pressure ulcer
  • the early signs of a pressure ulcer
  • ways to prevent a pressure ulcer
  • the implications of having a pressure ulcer (for example, for general health, treatment options and the risk of developing pressure ulcers in the future).
Demonstrate techniques and equipment used to prevent a pressure ulcer.
Take into account individual needs when supplying information to people with:
  • degenerative conditions
  • impaired mobility
  • neurological impairment
  • cognitive impairment
  • impaired tissue perfusion (for example, caused by peripheral arterial disease).
NICE has written information for the public explaining its guidance on pressure ulcers.
Provide training to healthcare professionals on preventing a pressure ulcer, including:
  • who is most likely to be at risk of developing a pressure ulcer
  • how to identify pressure damage
  • what steps to take to prevent new or further pressure damage
  • who to contact for further information and for further action.
Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure ulcer. Training should include:
  • how to carry out a risk and skin assessment
  • how to reposition
  • information on pressure redistributing devices
  • discussion of pressure ulcer prevention with patients and their carers
  • details of sources of advice and support.
Develop and document an individualised care plan for those who have been assessed as being at high risk of developing a pressure ulcer, taking into account:
  • the outcome of risk and skin assessment
  • the need for additional pressure relief at specific at-risk sites
  • their mobility and ability to reposition themselves
  • other comorbidities
  • patient preference.

Parafricta Bootees and Undergarments

The following recommendations are from NICE medical technologies guidance on Parafricta Bootees and Undergarments to reduce skin breakdown in people with or at risk of pressure ulcers.
Parafricta Bootees and Undergarments show potential to reduce the development and progression of skin damage caused by friction and shear in people with, or at risk of, pressure ulcers. However, more evidence for their effectiveness in clinical practice is needed to support the case for routine adoption of Parafricta Bootees and Undergarments in the NHS.
Research is recommended to address uncertainties about the claimed patient and system benefits of using Parafricta Bootees and Undergarments. This should take the form of comparative research against standard care, preferably carried out in a hospital. The research should include development of criteria to recognise people who would most benefit from the technology in both hospitals and community care. NICE will explore the development of appropriate further evidence, in collaboration with the technology sponsor and with clinical and academic partners, and will update this guidance if and when substantive new evidence becomes available.

The Debrisoft monofilament debridement pad

The following recommendations are from NICE medical technologies guidance on the Debrisoft monofilament debridement pad for use in acute or chronic wounds.
The case for adopting the Debrisoft monofilament debridement pad as part of the management of acute or chronic wounds in the community is supported by the evidence. The available evidence is limited, but the likely benefits of using the Debrisoft pad on appropriate wounds are that they will be fully debrided more quickly, with fewer nurse visits needed, compared with other debridement methods. In addition, the Debrisoft pad is convenient and easy to use, and is well tolerated by patients. Debridement is an important component of standard woundcare management as described in this interactive flowchart and foot care for people with diabetes.
The Debrisoft pad is indicated for adults and children with acute or chronic wounds. The available evidence is mainly in adults with chronic wounds needing debridement in the community. The data show that the device is particularly effective for chronic sloughy wounds and hyperkeratotic skin around acute or chronic wounds.
The Debrisoft pad is estimated to be cost saving for complete debridement compared with other debridement methods. When compared with hydrogel, gauze and bagged larvae, cost savings per patient (per complete debridement) are estimated to be £99, £152 and £484 respectively in a community clinic and £222, £347 and £469 respectively in the home.

Versajet II hydrosurgery system

Glossary

Paths in this pathway

Pathway created: January 2012 Last updated: August 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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