CriterionExceptionDefinition of terms
1.The individual’s plan of care contains a classification/grade for all pressure ulcers using the European Pressure Ulcer Advisory Panel (EPUAP) classification system.NoneThe grade of ulcers should be clearly documented in the plan of care to be available to the inter- disciplinary team. Pressure ulcers should be given a grade of 1–4. Pressure ulcers should not be reverse graded in that a healing grade 4 pressure ulcer should be described as such and not as a grade 3 pressure ulcer.
2.A pressure ulcer that is identified as a grade 2 or above is documented as a clinical incident.NoneThe reporting should follow trust procedure for reporting of clinical incidents.
3.Individuals with pressure ulcers have their ulcer assessed initially (within six hours) and the assessment is ongoing. The assessment is supported by tracings and or a photograph of the ulcer.NoneThe ulcer is assessed for cause, site/location, dimensions, stage/grade, exudates (amount and type), local signs of infection, pain, wound appearance, appearance of surrounding skin, undermining/tracking (sinus or fistula), and odour. Clinical experts are involved as appropriate – e.g. tissue viability nurse.
4.Individuals with pressure ulcers have access to appropriate pressure- relieving support surfaces or strategies throughout a 24-hour period. This includes all surfaces used by the individual, including mattresses and cushions.NoneSupport surfaces include all surfaces used by an individual, which will include mattresses for beds (including theatre trollies), and cushions for chairs and wheelchairs. Strategies include the use of repositioning to minimise prolonged pressure on the body.
5.Individuals with grade 1–2 pressure ulcers have a high-specification foam mattress/cushion as a minimum and are very closely observed for deteriorations. Individuals have a documented repositioning regime.Those in whom this is contraindicated. Those with perceived or further deterioration. Need input from clinician.Repositioning is documented in the plan of care.
6.Individuals with grade 3–4 pressure ulcers have alternating pressure overlay or sophisticated low pressure support as a minimum and are closely observed.Those in whom this is contraindicated – i.e due to patient weight or issues of safety. Where a replacement system or alternative support may be indicated.Repositioning is documented in the plan of care.
7.Individuals with pressure ulcers have their ulcers dressed with modern wound dressings to create the optimum wound healing environment.Those individuals in whom these dressings are contraindicated.

Patient informed choice.
The dressing should be documented in the plan of care with rationale for its use. Choice of dressings should be based on the ulcer assessment, general skin assessment, treatment objective, risk of adverse events, patient preference, dressing characteristics, and manufacturer’s indications for use. Decisions about choice should be made by registered health care professionals. Examples of modern dressings are: hydrocolloids, hydrogels, hydrofibres, foams, films, alginates and soft silicones.

From: 8, Audit criteria

Cover of The Management of Pressure Ulcers in Primary and Secondary Care
The Management of Pressure Ulcers in Primary and Secondary Care: A Clinical Practice Guideline [Internet].
NICE Clinical Guidelines, No. 29.
Royal College of Nursing (UK).
London: Royal College of Nursing (UK); 2005 Sep 22.
Copyright © 2005, Royal College of Nursing.

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