Tissue Viability Clinical Nurse Specialist/Dermatology Treatment Unit Clinical Manager
Last updated: July 2001
The NHS National Institute of Clinical Excellence (NICE) has recently published its clinical guidelines on "Pressure ulcer risk assessment and prevention" . Launched throughout the UK in April 2001, these long awaited recommendations have been heralded as "an important tool in the quest to promote evidence based practice" . But what are they and how will they influence the provision of care in this country?
It is a sad indictment of the current state of care in the UK that the government feels it necessary to set out a national framework for the prevention of pressure related damage. The aetiology of pressure ulcers has been recognised for many years and both local and national initiatives have been available to educate professionals in pressure sore prevention. Conferences have been organised on the subject and literally hundreds, if not thousands of articles and books have entered the libraries of the world. However, the problem of pressure ulcers persists and the costs, both personal and financial, keep rising. It is against this backdrop that the National Health Service Executive (UK) commissioned the development of the guidelines.
In 1997 the Royal College of Nursing (RCN) was invited to produce an evidence-linked national guideline to be used throughout healthcare settings in the UK. This multi-professional, multi-agency collaboration made significant progress prior to the setting up of the NICE framework in April 1999. Their work was subsequently inherited by NICE and brought within its review process. The now published guidelines form a brief synopsis of the full technical report published by the RCN in December 2000 .
The clinical guidelines on pressure ulcer prevention are aimed at all healthcare professionals in the UK and, because of its availability on the internet, will be seen to be of significance to other providers throughout the wider healthcare community. The hard copy version of the document has been distributed widely via the NHS network, specialist professional organisations such as the Tissue Viability Society, and patient advocacy groups.
The guidelines are set out in a relatively short document, which contains sections on the main aspects of pressure ulcer prevention:
identifying individuals 'at risk'
use of risk assessment scales
use of aids
education and training
The recommendations are given as a series of evaluated statements; each statement is accompanied by a numerical key (1-3) to indicate the relative strength of grading of the statement. A score of 1 indicates a finding in a majority of multiple acceptable studies, while a score of 3 indicates limited scientific evidence and expert opinion. It is of note that of the 33 statements given, four are graded at level 2 (either based on a single acceptable study, or a weak or inconsistent finding in multiple acceptable studies), only one is deemed level 1 and the remaining 28 are all level 3.
The guidance also includes sections on implementation and areas for further research. An appendix provides information for patients and carers which could be adapted by healthcare professionals for use as information booklets.
The treatment of pre-existing pressure ulcers is outside the scope of this guidance and is therefore not covered.
The guidelines are designed to be simple, clear and concise. The format of the best practice and research-based statements is direct and enhances the impact of the content by leaving little room for debate. This means that it is possible to disseminate the information easily and subsequent audit of clinical practice against the statements should be straightforward. The order of the sections appears logical and the reader is led through the process of assessment and practice.
The guidance is in itself an aide-memoire to the processes involved in pressure ulcer prevention and is laid out in a simple format for clinicians, managers and carers alike. However, a flow diagram identifying key decision processes would have been useful for quick reference and of great benefit to those adapting the key points for clinical use. These are included in the technical version of the report but have been subsequently omitted from the more widely distributed guideline format.
The section on patient information is written in plain language and is easy to understand. It also contains some useful line diagrams of 'at risk' body areas.
For professionals who wish to question the evidence base and the process employed by the panel in producing the guidelines it is necessary to study the RCN Clinical Practice Guidelines . This is a much more substantial document providing much greater depth and technical detail. Here again, the authors have adopted a clear, structured approach and there is a full reference list of both the relevant research articles considered and the selection process itself.
The guidance statements are accompanied by expanded explanatory statements, which help in the interpretation of the consensus recommendations and their application to clinical practice. They also indicate the level of agreement by the members of the consensus group, which is useful when assessing the relative strength of reliability of the responses. In addition, there is detailed guidance on the process of clinical audit, indicating what aspect of each statement should be audited and how it should be undertaken.
The use of pressure relieving and redistributing surfaces is at the cornerstone of most pressure ulcer prevention strategies and policies. Many of the items of equipment used to help prevent damage among the 'at risk' population are expensive and, from a strategic standpoint, they most likely constitute the biggest single part of any trust's expenditure on pressure ulcer prevention. There is, undoubtedly, a lack of research on the efficacy and cost benefits of various pressure reducing and relieving equipment and this is clearly stated. For this reason, recommendations are not given on this important area of practice and clinicians are left questioning whether current interventions are justified.
However, the RCN guidance does attempt to address this difficult issue. Whilst acknowledging the lack of hard data, it provides useful advice on areas where pressure relieving and redistributing equipment should be used. Work is currently underway to provide additional information and a further document is anticipated in 2002.
The NICE guidance states that there is generally little scientific research work carried out on the prevention of pressure ulcers and that further studies are needed if strength is to be given to the consensus statements. This is borne out by the lack of level 1 evidence within the guidance. The review of pressure redistributing and support surfaces will help to address this deficiency. However, clinicians and researchers alike will need to focus their efforts to ensure that standards in research are improved and the body of knowledge is expanded in this field.
The effect of these guidelines is yet to be realised. At face value they do not appear to provide us with new information, having been compiled from existing research and expert opinion. However, it is anticipated that they will greatly influence care in the UK and health professionals are advised to take the guidelines "fully into account when exercising their clinical judgement". The section on implementation further states that current practice, procedure and policy should be measured and amended in line with these guidelines. Most healthcare providers already have pressure ulcer prevention policies and for them the document will provide an opportunity to update and revise these stategies. For areas that have not developed such tools, particularly within the independent sector, the guidelines will provide an essential starting point in the quest for better practice. However, it is recommended that both the NICE guidelines and RCN technical report be consulted.
It has been argued that pressure related tissue damage is a multidisciplinary issue and yet for too long, the development of pressure damage among patients has been seen as a failure of nursing care. Multidisciplinary collaboration, as in the consensus groups formed to develop and validate the guidelines, has gone a long way to tackle this problem. Certainly, by moving the guidelines from the RCN to the NICE framework, it will ensure that the findings and recommendations will reach a wider audience and capture the imaginations of professions other than nurses.
As national guidance, the recommendations of NICE will have implications throughout the healthcare sector. Together with 'The Essence of Care' clinical benchmarks  they will provide the basis of audit both within organisations and ultimately between healthcare providers. Clinical quality standards will be measured with reference to the guidance by organisations such as The Commission for Health Improvement, while clinical governance boards and legal departments will no doubt watch developments with interest. More importantly, the information published within the guidance is now in the public domain and healthcare consumers have a right to expect quality in service. This document has now set the standard against which our care will be ultimately measured.
1. National Institute for Clinical Excellence. Inherited Clinical Guideline B. Pressure Ulcer Risk Assessment and Prevention. National Institute for Clinical Excellence, April 2001.
2. Rycroft-Malone J. Pressure ulcer risk assessment and prevention- new guidelines for practice. Primary Health Care 2000; 10(9): 32-3.
3. Rycroft-Malone J, McInness E. Pressure Ulcer Risk Assessment and Prevention: Technical Report. London: RCN, December 2000.
4. Department of Health. The Essence of Care: Patient focused benchmarking for health care practitioners. London: HMSO, 2001.