Background to commissioning the Guideline

NICE (or the Institute) worked collaboratively with the RCN Quality Improvement Programme to develop this Guideline on the management of pressure ulcers in primary and secondary care for use in the NHS in England and Wales. This follows referral of the topic by the Department of Health and the Welsh Assembly Government and the identification of pressure ulcer treatment as a priority topic for nurses by RCN members. The RCN Institute, through its Quality Improvement Programme, has a long-standing and well-respected reputation for national guideline development and implementation work. It has established strong links with key organisations in the field of evidence-based information, both nationally (SIGN) and internationally (GIN and JBI).

The Guideline will provide recommendations for good practice based on the best available evidence to the Guideline Development Group of clinical and cost-effectiveness. This Guideline follows on from the recently published NICE guideline Risk assessment and prevention of pressure ulcers (NICE, 2001) and a guideline on the use of pressure-relieving support surfaces (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care completed in October 2003. It is anticipated that these inter-related topics will provide a compilation of NICE guidance on pressure ulcer care and will form part of the Wound Care Suite of related guidance.

The Institute’s clinical guidelines will support the implementation of National Service Frameworks (NSFs) in those aspects of care where a framework has been published. The statements in each NSF reflect the evidence that was used at the time the framework was prepared. The clinical guidelines and technology appraisals published by the Institute after an NSF has been issued will have the effect of updating the framework.

Clinical guidelines have been defined as systematically developed statements that assist clinicians, patients and carers in making decisions about appropriate treatments for specific conditions and aspects of care.

3.1. Clinical need for the guideline

The presence of a pressure ulcer creates a number of significant difficulties – psychologically, physically and clinically – to patients, carers and their families. Clinicians working in a variety of clinical and non-clinical settings, including primary care and acute trusts, also face challenges when providing holistic, person-centred services for the assessment and treatment of pressure ulcers. These challenges include clinical decisions on methods of assessment and treatments to be used for individuals with an existing pressure ulcer.

Pressure ulcers are more likely to occur in those who: are seriously ill; are neurologically compromised (i.e. individuals with spinal cord injuries); have impaired mobility (Allman, 1997; Berlowitz and Wilking, 1990; Berlowitz et al., 1997; Bianchetti et al., 1993) or who are immobile (including those wearing a prostheses, body brace or plaster cast); suffer from impaired nutrition (Ek et al., 1990, 1991; Casey, 1997; Banks, 1998; Casey, 1998a,b), obesity (Gallagher, 1997), poor posture, or use equipment such as seating or beds which do not provide appropriate pressure relief. Pressure ulcers affect sub-groups in society, including those with spinal cord injury (Krause, 1997; Elliot, 1999; Vesmarovich et al., 1999; Kirsch, 2001), the elderly (Hefley and Radcliffe, 1990; Waltman et al., 1991; Krainski, 1992; Orlando, 1998; Pase and Hoffman, 1998; Spoelhof, 2000; Thomas, 2001; Ronda and Falce, 2002) and pregnant mothers (Prior, 2002). Pressure ulcers have been associated with an increased incidence of infection including osteomyelitis (Darouiche et al., 1994).

Research indicates that pressure ulcers represent a major burden of sickness and reduced quality of life for patients, their carers (Hagelstein and Banks, 1995; Franks et al., 1999; Franks et al., 2002) and their families (Benbow, 1996; Elliott et al., 1999). Often patients require prolonged and frequent contact with the health care system, and suffer much pain (Emflorgo, 1999; Freeman, 2001; Flock, 2003; Healy, 2003; Manfredi et al., 2003), discomfort and inconvenience (Franks et al., 1999).

The presence of pressure ulcers has been associated with a two- to four-fold increase of risk of death in older people in intensive care units (Thomas et al., 1996; Clough, 1994; Bo et al., 2003).

Estimates on pressure ulcer incidence and prevalence from hospital-based studies vary widely according to the definition and grade of ulcer, the patient population and care setting. Based on data that are available, new pressure ulcers are estimated to occur in 4–10% of patients admitted to acute hospitals in the UK (Clark and Watts, 1994), the precise rates depending on case mix. In the community, new pressure ulcers affect an unknown proportion of people as reliable data is not available.

The financial costs to the NHS are considered to be substantial (Bennett et al., 2004). In 1993, the estimated cost of preventing and treating pressure ulcers in a 600-bed general hospital was between £600,000 and £3 million a year (Touché Ross, 1993). The cost of treating a grade 4 pressure ulcer was calculated in 1999 to be £40,000 a year (Collier, 1999). More recent cost data suggest that treating ulcers varies from £1,064 for a grade 1 ulcer to £10,551 for a grade 4 ulcer with total costs in the UK estimated as being £1.4–£2.1 billion annually, equivalent to 4% of the total NHS expenditure (Bennett et al., 2004).

3.2. What are pressure ulcers?

Pressure ulcers, commonly referred to as pressure sores, bed sores, pressure damage, pressure injuries and decubitus ulcers, are areas of localised damage to the skin, which can extend to underlying structures such as muscle and bone (Allman, 1995, 1997). Damage is believed to be caused by a combination of factors including pressure, shear forces, friction and moisture (Allman, 1997). Pressure ulcers can develop in any area of the body (Rycroft-Malone and McInnes, 2000). In adults damage usually occurs over bony prominences, such as the sacrum. Presentation in infants and children is more likely to occur, for example, on the occipital area or ears (Willock et al., 1999; Murdock, 2002; Jones et al., 2001).

3.3. Groups at risk

• Those who are seriously ill, neurologically compromised, i.e. individuals with spinal cord injuries, have impaired mobility or who are immobile (including those wearing a prosthesis, body brace or plaster cast), or who suffer from impaired nutrition, obesity, poor posture, or use equipment such as seating or beds which do not provide appropriate pressure relief.
• Older people and pregnant women are also at risk.

3.4. Interventions under consideration

The guideline will consider interventions such as: pressure-relieving support surfaces and supports, including specialised seating and postural support; dressings; removal of devitalised or contaminated tissue (debridement); surgery; nutritional support; electrotherapy; therapeutic ultrasound; low-level laser therapy; topical negative pressure (TPN); and topical antimicrobials.