International Journal of Nursing Practice

2003;

9

: 92–102

Blackwell Science, LtdOxford, UKIJNInternational Journal of Nursing Practice1322-71142003 Blackwell Science Asia Pty Ltd

92April 2003405

Pressure ulcer prevention and treatmentM Lewis et al

10.1046/j.1322-7114.2002.00405.xResearch PaperBEES SGML

Correspondence: Miss Cathy Ward, School of Nursing and Midwifery,La Trobe University, Bundoora, Vic 3086, Australia. Email:c.ward@latrobe.edu.au

✠

R E S E A R C H P A P E R

✠

Pressure ulcer prevention and treatment: transforming research findings into consensus

based clinical guidelines

Matthew Lewis BAppSc (Hons)

Research Assistant, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria, Australia

Alan Pearson RN PhD FRCNA FRCN

Professor of Nursing, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria,Australia

Cathy Ward BSc (Hons) GradDipGenCouns

Research Officer, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria, Australia

Accepted for publication May 2002

Lewis M, Pearson A, Ward C.

International Journal of Nursing Practice

2003;

9

: 92–102

Pressure ulcer prevention and treatment: Transforming research findings into consensus based clinical guidelines

The translation of research findings into practice guidelines is an important aspect in maintaining the currency of practiceand adding value to research. While there has been a large amount of published literature regarding the treatment and pre-vention of pressure ulcers, very few studies have attempted to provide clear clinical guidelines. The present study proposesa model to transform research into clinical guidelines whilst developing a series of guidelines that can be applied to a vari-ety of clinical settings.

Key words:

clinical guidelines, consensus, pressure ulcer, review.

INTRODUCTION

That the occurrence of pressure ulcer injury is a significantproblem for health care providers can be no better dem-onstrated than by the large amount of literature devotedto aspects of prevention and treatment of the problem. InAustralia alone, pressure injury is estimated to add closeto $350 million per year to health care costs.

1

Therefore,a major focus of clinicians, nurses and other health care

workers should be the improvement of risk assessmentand prevention strategies to minimise the health and finan-cial impact of pressure ulcers. Similarly, in the instanceswhere a pressure ulcer does occur, the aim should be tominimise any possible damage that results. While thereexists a large number of reviews and primary researchpapers examining the issues related to the prevention andtreatment of pressure injuries, to our knowledge, veryfew of these studies have attempted to translate their find-ings into clinically relevant and applicable guidelines.

A pressure ulcer (also referred to as a pressure sore,bedsore, or decubitus) is an injury to the skin and theunderlying tissue.

2

These injuries are generally caused by

Pressure ulcer prevention and treatment 93

pressure, shearing or friction,

3

and predominantly occurin hospital patients with reduced sensory perception, orwith reduced, or no mobility.

4,5

Because of the higherdegree of morbidity associated with the elderly popula-tion, and an ageing general population, the incidence rateof patients experiencing pressure ulcers is expected torise.

6

Pressure ulcers generally occur on bony promi-nences or regions that absorb a significant amount of pres-sure when immobile,

7

and generally become visibleduring the postoperative stay in surgical or intensive careunits.

8

While being a large problem in these units, pres-sure ulcers do not exclusively occur to these patients andoccur in any setting where a patient’s mobility is impaired,or where they are required to maintain a prone or sittingposture for an extended period.

The causes and risk factors for developing a pressureulcer are widely hypothesized, but the treatment and pre-vention of these problems are not straightforward.

3

Whilethe longer duration and greater magnitude of pressurebeing exerted on a particular body region increases thechances of developing an ulcer, variations betweenpatients have been a confounding factor in implementingsuccessful treatment approaches.

9

Incidence and prevalence data are difficult to accuratelydefine as there is no commonly accepted definition ofwhat a pressure ulcer is, and there are numerous scalesdeveloped to assess them, with no stand-out method forassessing a pressure ulcer.

5

In recent reviews, it has beensuggested that the incidence of pressure ulcers in hospitalpatients could be as high as 40%,

10

translating into longerhospital stays and significantly greater health care costs.

Recent research has demonstrated that some of thestandard products used in health care settings may provideinadequate protection against the development of pres-sure ulcers and may even exacerbate the risk of developingsuch an injury.

7

A wide number of interventions are avail-able, yet there is no current ‘gold standard’ programmefor the treatment and prevention of pressure ulcers. Therehave been a plethora of products explicitly marketed tocounter problems of pressure injuries, but as there hasbeen inadequate independent assessment of these prod-ucts, some researchers have been sceptical about theiradvertised efficacy. Sharp

et al

.

5

demonstrated, amongsttheir sample, that this issue was of some concern with alarge percentage of respondents advocating treatmentsoutdated many years previously, and in some cases thesehad been found to contribute to the development, ratherthan the prevention, of pressure ulcers.

A number of reviews have already been conductedexploring issues affecting pressure ulcer development andhave included a number of recommendations pertainingto the treatment and care of pressure injuries.

3,10–14

Fromthese reviews, however, there was no clear attempt toestablish clinical guidelines to:

•

Improve patient care

•

Remove the large amount of variability in practice

•

Provide clinicians with options for the implementationof the most current knowledge

Aim

The aim of this review is to combine the findings frompreviously published reviews of the pressure ulcer litera-ture and synthesise these recommendations into a plainlanguage series of guidelines that could be used to informcurrent practice, while at the same time be clinically rel-evant. Similarly, a model is put forward that could allowfor the further development of guidelines from the mostcurrent research practices. This final step seems to belacking from most current research.

METHODS

This study progressed in a number of clearly definedstages. An initial literature search was completed to iden-tify papers and reviews that had been conducted examin-ing issues affecting pressure ulcer development andtreatment. In the second stage, these documents werecompiled and reviewed for presentation to a group ofhealth care professionals. The final stage involved present-ing these recommendations to an expert reference paneland incorporating their comments into a final version ofthe recommendations presented in this paper.

Stage 1: Review method

This synthesis was unusual in that the aim was not to com-prehensively evaluate all previous research, as this hadbeen done a number of times prior to this review.

3,10–14

The major objective was to summarize the findings of pre-viously conducted reviews that examined the preventionand treatment of pressure ulcers. A narrative summary ofresearch that had been conducted in the interim was alsodeveloped, with an ultimate aim of generating a series ofpractical recommendations in the treatment and preven-tion of pressure injuries. In reviewing the literature, acommonly observed endpoint of these reviews was thepresentation of a series of recommendations. No attempthad been made, however, to develop a series of clinically

94 M Lewis

et al.

relevant guidelines that address the practicalities of theclinical setting, rather than the recommendations of prac-tice in an ‘ideal world’, reducing the full impact of theresearch. With this in mind, our aims for this stage were:

1.

To explore the options currently being recommendedto prevent the occurrence of pressure ulcers in existingreviews of the literature.

2.

To explore the options currently being recommendedto successfully treat pressure ulcers should they occur inexisting reviews of the literature.

3.

To update any existing knowledge andrecommendations with the findings of the most recentresearch.

4.

To review these findings with a multidisciplinaryreference group of health professionals that work withpressure injuries and patients at high risk of developingthese, to allow the input of clinical expertise and ajudgement of efficacy.

5.

To categorize these recommendations in a single, user-friendly document.

Inclusion criteria for literature

A number of criteria were required to be met in order forthe review or study to be included in the present review.They needed to have been conducted in a health care set-ting in the last 10 years and be in the English language. Forthe knowledge update, the articles needed to have beencompleted in the period since the last review was pub-lished and be in the English language. Only articles thatexamined products or procedures used in the preventionor treatment of pressure ulcers were included.

Search strategy

Articles were selected using the following Ovid databases:

•

Current Contents

•

Medline

•

Pre-Medline

•

CINAHL

•

EBM Reviews–Best Evidence

•

EBM Reviews–Cochrane Database of SystematicReviews

•

EBM Reviews–Databases of Abstracts of Reviews ofEffectiveness

We utilised the following search strategy to identifyboth primary research and systematic reviews that haveexamined pressure ulcers in the past:

1.

‘Randomised controlled trials’ or ‘Randomizedcontrolled trials’ or ‘Randomized’ or ‘Random’ or

‘Double blind’ or ‘Single blind’ or ‘Clinical trial’ or‘Comparative study’ or ‘RCT’ or ‘Review’.

2.

‘Pressure ulcer’ or ‘Pressure ulcers’ or ‘Pressure sores’or ‘Pressure sore’ or ‘Bed sores’ or ‘Bed sore’ or ‘Bedsore’or ‘Bedsores’ or ‘Decubitis ulcer’ or ‘Decubitis ulcers’ or‘Decubitis’.

This search strategy was modified to suit the specificcriteria of each of the relevant databases, but due to wordand space restraints, only the generic search is included.From this search, reviews were selected for the firstphase, and primary research was selected for the secondphase of the study.

Stage 2: Compiling recommendations

From the reviews identified,

3,10–14

any recommendationsformed were taken from each paper and compiled into anew document. Similar recommendations were sorted toremove any duplication and to streamline the document asgreatly as possible. These recommendations were thencompiled into general categories formed in response tocategories emerging from the literature. These were riskassessment, treatment of previously existing pressureulcers, skin care, skin inspection, pressure relieving andredistributing devices, seating, pressure ulcer/woundcare, infection and pressure ulcers, operative repair, edu-cation and training, and continuous quality improvement.

Knowledge update

Since the date of the last review (2000) a number of arti-cles had been published exploring a range of interventionsand treatments for pressure injury. These studies were ofvarying quality and were, by no means, comprehensive.However, they provided additional recourse for treatmentand needed to be regarded in any strategy for pressureinjury prevention and care.

The identified articles fell into two general categories.The first category, pressure relief devices and optimalpositioning,

2,6–9,15–18

explored a range of pressure relievingdevices and postures in an aim to prevent the occurrenceof pressure injury and to remove constant pressure onbody regions prone to developing pressure sores. The sec-ond category, topical agents and wound dressings,

19–24

considered the use of topical agents in the treatment ofpressure sores.

While it is recognised that the reviewed studies werenot all ‘gold standard’ randomized controlled trials, it isbelieved that observational studies also play an importantrole in the research effort, and need to be considered. This

Pressure ulcer prevention and treatment 95

is somewhat against the predominant thinking in conduct-ing systematic reviews, but this approach allowed for awider scope of studies to be consulted. A large number ofstudies were filtered as they were not suited to this reviewThey addressed issues apart from pressure ulcer develop-ment and treatment or did not report on the efficacy of agiven treatment. The aim of this stage of the review wasessentially to highlight the more recent areas of research.In keeping with this aim, the reviewed studies were sum-marized and appraised according to the strength of theirfindings and limitations of their methodology.

While these interventions by no means identified a sin-gular, best practice route for the prevention and care ofpressure sores, the reviews all concluded individually thatthe factors they identified should be carefully consideredwhen faced with patients either at risk of developing pres-sure sores, or patients with existing injuries.

Unfortunately, while pressure relieving instruments(for example, beds and cushions ) have been reviewed, thenumber of options available and differences in equipmentavailable in different geographic locations precludes acomprehensive comparative analysis of the relative effi-cacy of each of these products. As a consequence, no rec-ommendations could be made regarding the mosteffective individual products.

Stage 3: Developing consensus

It is generally recognized, both in the literature and anec-dotally, that the problem of pressure ulcer developmentand treatment is multifactorial and successful strategies tocounter these types of injury involve the input and collab-oration of a wide range of health care professionals. It isalso acknowledged that primary health care settings maybe markedly different to the research environment, inwhich the focus is on the problem under consideration,and for which extraneous factors are largely controlled. Tosuccessfully translate research findings into clinical prac-tice, there needs to be input from these sectors to increaseacceptance of the changes and to incorporate the practi-calities of the setting into the ultimate aims of the change.Consistent with previously conducted research pro-grammes, it was determined that the most effective wayof achieving this level of professional input was to developa multidisciplinary expert reference group to review find-ings and provide feedback regarding the acceptability ofthese findings.

With these factors in mind, a list of health care disci-plines involved in the treatment of those with pressure

ulcers was developed to offer input into the shaping of theguidelines. As pressure injuries may originate at any stageduring an episode of care, from admission through to dis-charge, it was important that we included health care pro-fessionals involved in all stages of care. These includedplastic surgeons, physicians, dermatologists, geriatricians,spinal medical practitioners, spinal nurses, physiothera-pists, occupational therapists, dieticians, pharmacists,burns and plastic surgery nurses, critical care nurses,orthopaedic nurses, surgical nurses, gerontologicalnurses, medical nurses, wound care nurses and nursingmanagers.

The expert reference group met for a full day, wherethey were presented with a copy of the recommendationsfrom the previously conducted reviews and the narrativesummaries of the knowledge update. The group was takenthrough each of the recommendations throughout themorning session to ensure that they were understood andto resolve any ambiguities. A number of multidisciplinarysubgroups were then formed to review the recommenda-tion documents and suggest any improvements or alter-ations. These were then reported back to the group in theafternoon session. Due to time constraints, the alterationsto the recommendations as suggested by the consensusgroup were made after the meeting.

A copy of these modified recommendations was thensent out to the group via e-mail or conventional mail fortheir final perusal and comment. These final commentswere integrated into the final recommendations includedin the present study.

Also presented to the consensus groups were a series oftreatment algorithms for pressure ulcers, leg ulcers,dressings and pressure ulcer prevention taken fromMakklebust and Sieggreen.

25

It was hoped that ultimatelythese could be modified to incorporate suggestions fromthe expert reference group and provide decision pathwaysfor the treatment and prevention of pressure ulcers. Theseproved to be overly complex, and agreement was unableto be achieved through the expert reference group. Thesewere not included in the current study, but it is acknowl-edged that the use of such tools may be effective in indi-vidual settings.

FINAL RESPONSE OF EXPERT REFERENCE GROUP ON DRAFT

CLINICAL GUIDELINES

The recommendations as modified by the expert refer-ence group are presented below. It should be noted that

96 M Lewis

et al.

they are of varying levels of detail. This is due to the fociof the literature reviews consulted and the recommenda-tions drawn from these.

Risk assessment

1a.

All patients on presentation, until assessed formally,should be considered at risk.

b.

All patients should have a risk assessment within onehour of admission following a significant clinical event oralteration in condition, and at regular intervals,dependent on the patient’s condition. (Daily or weekly ifthe patient is identified as at high risk of developing apressure ulcer or if they already have a pressure ulcer).

c.

Assessment should involve both formal and informalassessment procedures conducted by staff who havetraining to recognise the risk factors that contribute to thedevelopment of pressure ulcers, and know how to initiateand maintain correct and suitable preventive measures.This initial assessment should also consider the values andlifestyle of the patient and care-giver when establishinggoals. Increased attention should be given to patients withmobility or activity deficits.

2a.

The timing of risk assessment should beindividualised, but it should ideally take place within anhour of presentation to the episode of care or as soon aspossible.

b.

This assessment should address level of mobility,incontinence, nutritional status, sensory impairment,level of consciousness and neurological status, as well as acomplete history, and physical and psychosocialexamination assessing mental status and cognitiveability.

c.

After initial risk assessment of the above factors iscompleted, and when time permits, social support,alcohol and/or drug abuse, culture and other stressorsshould also be evaluated. Particular attention should bepaid to patients’ level of mobility; sensory impairment;acute or chronic illness; level of consciousness; vasculardisease; severe chronic or terminal illness; previoushistory of pressure damage, malnutrition and dehydrationas they are key risk factors in the development of pressureulcers.

d.

Weight, medication status and history, skin moisturelevels and comorbidity (for example, diabetes) should alsobe examined.

3.

Patients should be classified in one of the followingcategories: low, medium or high risk as defined by theassessment tool used.

Assessment if a pressure ulcer already exists

1a.

After the initial risk assessment, the damaged areashould be graded with a uniform grading system, such asthe Braden,

26

Norton

27

or Gosnell

28

Scales. This willinvolve assessing and documenting the location, size,shape, depth, tissue type and exudate of the wound, aswell as the condition of the surrounding skin (forexample, maceration) and pain level.

b.

Grading could be accompanied by tracings of thewound or photographs with the appropriatemeasurements.

c.

The likely aetiology should also be documented foraudit and prevention purposes.

2.

Pain management should include adequate analgesiaand elimination or control of the source of pain.

3.

Assessment of resources and support is required toplan for continuing care. Clinicians need to take steps toactively prevent pressure ulcers and their associatedcomplications of contractures and increased spasticity.

4.

All risk or wound assessments should be documentedor recorded in the patient’s file and reviewed at leastweekly, or following critical events. Documentationshould be made accessible to all members of theinterdisciplinary team.

Nutritional care recommendations

1.

Nutritional assessment by a dietitian is to beperformed on admission for patients with an existingpressure ulcer and for patients at high risk of pressureinjury, and malnutrition (for example, underweight orwith a history of poor intake).

2.

A weekly nutritional review is required for the abovegroup of patients.

3.

Ensure adequate nutritional intake.

4.

Nutritional support is required if oral intake isinadequate or weight loss occurs. This may include the useof oral supplements and enteral nutrition.

5.

Patients should be weighed regularly. Involuntaryweight loss of

≥

5 kg in a 3-month period indicates risk ofmalnutrition.

6.

Use vitamin and/or mineral supplements if specificnutritional deficits are suspected or diagnosed.

Use of risk assessment scales

1.

Risk assessment tools should only be used as a guideand should complement clinical judgement. Theassessment apparatus chosen should be able to

Pressure ulcer prevention and treatment 97

accommodate advances in technology and treatment. Allassessments should be documented.

2.

The scale must be validated, allow for information tobe passed on at shift changes, should be used uniformlyacross a given institution and should include all thoseinvolved in the provision of care.

Skin assessment

1a.

Daily systematic skin inspections should be performedfor all patients and the results should be documented.

b.

While considering other regions, particular attentionshould be paid to:

•

The skin over bony prominences

•

Over the heels

•

Toes

•

Sacrum

•

Ischial tuberosities

•

Elbows

•

Shoulders

•

Temporal and occipital regions of skull

•

Greater trochanters

•

Parts of the body affected by antiembolic stockings

•

Parts of the body where pressure, friction and shearingis exerted in the course of an individual’s daily livingactivities; and where there are external forces exertedby equipment and clothing

•

Areas around or under name tags, prosthetics,orthotics, skin traction, oxygen appliances, i. v. access,tapes and other objects that are in contact with the skin

c.

Skin changes should be documented and action plansdeveloped.

2.

Skin should be cleansed with an appropriate cleanserwith a pH range of 4.5–6.5, which contains a surfactant(for example, QV wash) and patted dry when exposed toall bodily fluids or other soiling.

3.

Action should be taken to prevent recurrent soiling byexamining the diet and medications, and by implementingappropriate continence aids. Appropriate barriers shouldbe used to prevent skin coming into contact with excreta.

4.

Moisturisers can be helpful for dry skin and should beapplied as soon as possible after bathing. The moisturisershould be non-perfumed and non-irritating.

Skin inspection

1.

Individuals or their carers should be encouraged,following education, to inspect the individual’s skin.Patients should still be fully assessed by appropriate staffon a regular basis.

2a.

Those caring for patients should be vigilant for skinchanges which may indicate pressure ulcer development:

•

Persistent erythema

• Non-blanching erythema

• Blisters

• Discolouration

• Localized heat

• Localized oedema

• Localized indurationb. In those with darkly pigmented skin, carers andpatients should be alert for purplish/bluish localized areasof skin, localized heat which, if tissue becomes damaged,is replaced by coolness, localized oedema and localizedinduration.3. Patients and their carers should be vigilant for areas ofpain, discomfort, loss of movement and numbness.

Pressure relieving, redistributing devices and other

management strategies1. Shearing, pressure and friction are key risk factorsresulting in the development of pressure ulcers and shouldbe eliminated or minimized where possible.2. Patients and carers should be taught correct methodsfor redistributing weight or relieving pressure themselves.3a. Repositioning is recommended for rotating pressure-prone areas.b. Frequency should be based on skin inspection by aqualified individual and should increase if skindiscolouration occurs, rather than follow a rigid schedule(that is, turn every 2 h).c. The repositioning schedule should consider theindividual’s medical condition, comfort, overall plan ofcare and the support surface used.d. The use of a written repositioning and evaluationschedule should be implemented for each patientidentified as being at risk in order to maintain the efficacyof this intervention.e. Small movements, such as straightening legs or armsand adding or removing a pillow, can be incorporated intothe repositioning schedule.f. This repositioning schedule should be incorporatedinto the patient’s plan of care.4. Positioning should avoid direct pressure on bonyprominences, previously damaged tissue, and otherregions sensitive to pressure ulcer damage where it can beavoided. Carers should have knowledge of these riskfactors.

98 M Lewis et al.

5. Dynamic support surfaces (such as a large cellalternating pressure mattress, a low air loss or air fluidizedbed, or other pressure redistributing systems) should beconsidered if patients are assessed as having a moderate tohigh risk of developing a pressure ulcer.6. Pillows and foams can be used to reduce contactbetween bony prominences and support surfaces.7. Carers should be made aware of the potentiallyharmful effects of massage and doughnut pressurerelieving devices. These interventions should be avoided.8. Unless dictated by patient comfort and acuity, bedheads should be no higher than 30∞ from horizontal.9. Lifting devices and aids such as slide sheets, slings orsleeves should be used to move patients, reducing frictionand shearing damage, but should not be left under thepatient.10. At risk patients should be placed on a low pressuresupport system (air, water or foam mattresses) and not onstandard foam mattresses.11. As resources allow, standard foam mattresses shouldbe replaced with pressure reduction mattresses.12a. Decisions about which pressure redistributingdevice to use should be based on an overall assessment ofthe individual, not solely on the basis of scores from riskassessment scales.b. Assessment should include level of risk, comfort, thepatient’s own preferences, general health and length ofsurgery (that is, if > 2 h, then they should be used).13. Pressure redistributing overlays should be used on theoperating table and all trolleys and casualty trolleys forindividuals assessed to be at risk of pressure ulcerdevelopment.14. Repositioning should continue to occur whenindividuals are on pressure redistributing devices.15. The benefits of a pressure redistributing deviceshould not be undermined by prolonged chairsitting.16. High specification foam over standard hospital foam isrecommended to enhance pressure relief in the operatingtheatre.17a. Massaging of bony prominences and the followingshould not be used as pressure relieving aids:

• Water-filled gloves

• Synthetic sheepskins

• Genuine sheepskins

• Doughnut-type devicesb. Sheepskins may provide comfort but should beavoided as a pressure relieving intervention.

18. The use of wheelchair cushions, heel pressurerelieving devices, encouraging mobility or activity appearto benefit patients and should be continued.

Seating1. Advice from adequately qualified health careprofessionals, with specific knowledge and expertise inthe area of pressure ulcer prevention measures, should besought about correct seating positions and pressure reliefwhen sitting.2. Positioning and repositioning of individuals who spendsubstantial periods of time in a chair or wheelchair shouldtake into account patient position and weight distribution.Care should also be taken when transferring the patient toavoid damage from shearing and friction.3. Pressure relieving seat cushions should be used when apatient is sitting out of bed. Seating in sling type chairsshould be avoided or minimized.4. Individuals who are considered to be at risk ofdeveloping pressure ulcers should sit out of bed for shortsessions only, according to their tolerance and results ofassessments (no greater than two hours).

Pressure ulcer care1. If the patient’s condition warrants it, devitalized ornecrotic tissue should be debrided. The choice of methodis based on the patient’s condition, goals and availableclinical expertise. Sharp debridement is considered inurgent cases. Autolytic debridement should be performedwith caution if the pressure ulcer is infected.2. Pressure ulcers should be cleansed at each dressingchange with normal saline or tap water at roomtemperature, using minimal mechanical force. Skincleansers or antiseptic agents should be avoided.3. A dressing should be chosen that keeps the woundmoist, prevents maceration of surrounding skin and avoidsdesiccation of the wound bed. Dead space is eliminated byloosely filling all cavities to manufacturers instructionswith dressing materials.4. Healed pressure ulcers remain fragile and vulnerableto breakdown. These areas, especially if they involveregions that have body weight applied to them, must havea gradual mobilization programme developed to increasesitting or lying times.

Infection and pressure ulcers1. Wound cleansing and debridement is performed tominimise bacterial load. If cellulitis or sepsis is suspected

Pressure ulcer prevention and treatment 99

a swab for quantitative bacterial analysis or biopsy shouldbe obtained. Osteomyelitis should be excluded.2. Topical antiseptic agents that damage tissue should beavoided. Topical antiseptic agents that do not damagetissue are appropriate in heavily colonised, non-healingwounds. For patients with infections, appropriatesystemic antibiotics should be used according to antibioticguidelines.

Operative repair of pressure ulcers1. Pre-operative planning and counselling should includefactors that might impair healing or lead to recurrence.2. Post-operative care must ensure pressure relief to theoperative site until the wound is healed. Tolerance of theoperative site must be gradually developed and monitoredclosely. Positioning postoperatively must actively preventthe development of secondary complications, such ascontractures. Preventing recurrence of pressure ulcersrelies on education and encouragement to adhere to dailyskin examination, pressure reduction and intermittentrelief techniques and adequate hydration and nutrition.3. Carers need to be educated in the correct usage ofprescriptions and dressings as use of these may reduce thenumber of patients undergoing surgical repair.

Education and training1a. All health care workers involved in patient careshould be trained in pressure ulcer risk assessment andprevention.b. Training should be updated every six to twelve months.c. These skills should then be passed on to their localhealth care teams.2. An interdisciplinary approach to the training andeducation of health care professionals should be adopted.This should be systematically implemented and updatedacross an organization and needs to be adaptable totechnological or therapeutic advances.3. Training and education programs should includestrategies to implement a risk management program thatencompasses the following:

• Risk factors for pressure ulcer development

• Pathophysiology of pressure ulcer development

• The limitations and potential applications of riskassessment tools

• Skin assessment

• Skin care

• Selection of pressure redistributing equipment

• Use of pressure redistributing equipment

• Maintenance of pressure redistributing equipment

• Methods of documenting risk assessments andprevention activities

• Positioning to minimise pressure, shearing and frictiondamage, including the correct use of manual handlingdevices

• Roles and responsibilities of interdisciplinary teammembers in pressure ulcer management

• Policies and procedures

• Procedures when transferring individuals between caresettings

• Patient education

• Information giving4. Patients and their carers should be informed andeducated about risk assessment and resulting preventionstrategies, and be provided with appropriate writteninformation.5. Patient/carer education should include providingwritten information on the following:

• The risk factors associated with developing pressureulcers

• The sites that are of the greatest risk of pressuredamage

• How to inspect skin and recognize skin changes

• How to care for skin

• Methods for pressure relief

• Movement techniques

• Where to find further advice and assistance if required

• An emphasis on the need for immediate visits to ahealth care professional should signs of damage benoticed. The importance of early intervention shouldbe stressed

6. This education should ultimately be written in aneasily accessible document, such as a resource manual orbrochure, available to both patients and carers and writtenin plain language that is easy to comprehend for all of theintended audience in a range of languages.

Continuous quality improvement1. Appropriate education programs for all relevant levelsof staff, patients and other carers should include:

• Aetiology and risk factors

• Risk assessment tools

• Skin assessment

• Selection and/or use of support surfaces

• Skin care

• Positioning

• Documentation

100 M Lewis et al.

2. Documented policies and procedures on prevention ofpressure ulcers should be implemented, incorporatingpatient management systems using a uniform pressureulcer assessment tool.3. Incidence and prevalence rates should be calculatedprior to implementation of guidelines and again afterimplementation for audit and quality assurance purposes.4. The effect of these programs on variability in practiceand clinical outcomes should be subject to ongoingmonitoring using point of prevalence surveys andequipment audits.5. When a pressure ulcer occurs, thought should be givenas to how and whether it could have been avoided, andprocedures reviewed accordingly. An incident formshould be completed and a copy given to the pressureulcer prevention committee.6. Equipment involved in pressure ulcer preventionneeds to be regularly checked, maintained and all stafffully trained in its operation.7. Methods of measuring and grading pressure ulcersaccurately are required to strengthen both research andpractice.8. Research should be encouraged to examine therelative effectiveness of individual interventions and theirimpact on patients’ quality of life.9. Key performance indicators need to be nominated,they should be independently audited and follow acontinuous quality cycle, in order to evaluate theeffectiveness of any implementation.

DISCUSSION AND CONCLUSIONSThe incidence and prevalence of pressure injury inAustralian health care settings is of significant concern tohealth care professionals, and has a large financial impacton the health care system, adversely affecting patients’quality of life and extending hospital stays.29 For these rea-sons it was of paramount importance that the issues affect-ing the development and onset of pressure ulcers beaddressed and the focus turned more toward the imple-mentation of research findings in health care settings,rather than continuing with primary research into theproblem.

It was apparent when compiling the recommendationsthat formed the basis for the current study, that a largenumber of recommendations would be impractical inmost health care settings due to time or financial factors.The multidisciplinary expert reference group, used in thepresent study to provide the clinical grounding for the rec-

ommendations, identified a number of concerns that needto be raised. The first relates to the increasing medico-legal implications surrounding the use of guidelines andthe concern that a number of the guidelines put forwardwould be difficult to achieve, at best, and unworkable inthe worst case. In either case, a failure to achieve the iden-tified benchmark may have legal ramifications. Anecdotalevidence from members of the consensus group hasshown that where a patient’s quality of life is affected, ashas been evidenced recently in the United States with thediminished role of the Agency for Health Care Policy andResearch. The second concern relates to the great level ofdisparity between working environments throughout thehealth care industry. Whilst some recommendationswould be easily integrated into the procedures of certainareas, their general application was seen to be much morecumbersome.

The reference group identified a need to include a cat-egory that had not been identified in the reviews con-sulted. Specifically, the assessment and maintenance ofgood nutrition was identified to be an important factor inthe prevention of pressure ulcer development. This mightreflect some failings of the initial search strategy and mightindicate that it was too focused.

After gaining feedback from the expert referencegroup and our own review of the methods used, a numberof suggested improvements were raised that wouldstrengthen our model. The primary concern was thata large amount of information was required to beevaluated in a short amount of time by the expertreference group. This could be easily overcome in futureby e-mailing or posting, in advance, the literature relevantto the project. A second concern related to the complex-ity of some of the information presented to be evaluated.This criticism related to the attempt to reach consensususing the decision algorithms. Their complexity made itimpossible to achieve some form of consensus, and ulti-mately they were not included in the final report. Figure 1displays the model that we plan to use in future studies,incorporating the suggested changes of the expert refer-ence group.

Overall, the project achieved some rather ambitiousaims in incorporating a wide variety of health care profes-sionals’ views with the most recent research findings relat-ing to the prevention and treatment of pressure ulcers. Insome respects, these aims were overly ambitious consid-ering the volume of information to be evaluated and thelength of time taken to fully discuss the issues pertinent to

Pressure ulcer prevention and treatment 101

the topic and complexity of surrounding issues. Furtherattempts at incorporating professional opinion withresearch findings would benefit by providing, in advance,copies of any reading material and ensuring that the com-plexity of the items to be evaluated is such that consensuscan be achieved.

ACKNOWLEDGEMENTSThe authors would like to acknowledge the support andinput of all of the members of the expert reference groupfor their time and input.

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Figure 1. Flow chart representation of the revised consensusmodel.

Recommendationsfrom

reviews

New knowledgefrom intervening

period

Stage 2: Compile recommendations

Stage 1: Conduct initial literature review

Select review topic

Compilerecommendations

Select expertreference

group

Distributerecommendations

document

Provide opportunityfor feedback

General reviewof document

Divide intogroups

for review

Generaldiscussion of

alterations

Make alterationsto

recommendationsdocument

Meeting

Set meeting date

Stage 3: Develop consensus

Distribute to group members

Compile final document

Distributerecommendationsfor final comment

102 M Lewis et al.

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