Evidence categories (I-IV) and recommendation grades (A-D and 1-3) are defined at the end of the Major Recommendations field.
Risk Assessment and Prevention
Identifying Individuals Vulnerable to or at Elevated Risk of Pressure Ulcers
3 - Assessing an individual's risk of developing pressure ulcers should involve both informal and formal assessment procedures.
3 - Risk assessment should be carried out by personnel who have undergone appropriate training to recognise the risk factors that contribute to the development of pressure ulcers and know how to initiate and maintain correct and suitable preventative measures.
3 - The timing of risk assessment should be based on each individual case. However, it should take place within 6 hours of the start of admission to the episode of care.
3 - If an individual is considered not to be vulnerable to or at elevated risk of pressure ulcers on initial assessment, reassessment should occur if there is a change in an individual's condition that increases risk (see recommendations under "Risk Factors" below).
3 - All formal assessments of risk should be documented/recorded and made accessible to all members of the interdisciplinary team.
Use of Risk Assessment Tools
1 - Risk assessment tools should only be used as an aide memoire and should not replace clinical judgment.
If use of a risk assessment tool is preferred (to assist clinical judgment), it is recommended that a scale that has been tested for use in the same specialty is chosen.
Risk Factors
2 - An individual's potential to develop pressure ulcers may be influenced by the following intrinsic risk factors, which therefore should be considered when performing a risk assessment:
- Reduced mobility or immobility
- Sensory impairment
- Acute illness
- Level of consciousness
- Extremes of age
- Vascular disease
- Severe chronic or terminal illness
- Previous history of pressure damage
- Malnutrition and dehydration
2 - The following extrinsic risk factors are involved in tissue damage and should be removed or diminished to prevent injury: pressure, shearing, and friction.
2 - The potential of an individual to develop pressure ulcers may be exacerbated by the following factors, which therefore should be considered when performing a risk assessment: medication and moisture to the skin.
Patient Factors to Consider in Selecting Pressure-relieving Device
D - Decisions about which pressure-relieving device to use should be based on cost considerations and an overall assessment of the individual. Holistic assessment should include all of the following and should not be based solely on scores from risk assessment tools:
- Identified levels of risk
- Skin assessment
- Comfort
- General health state
- Lifestyle and abilities
- Critical care needs
- Acceptability of the proposed pressure-relieving equipment to the patient and/or carer
Provision for All Individuals Vulnerable to Pressure Ulcers
B - All individuals assessed as being vulnerable to pressure ulcers should, as a minimum provision, be placed on a high-specification foam mattress with pressure-relieving properties
Patients at Elevated Risk of Developing Pressure Ulcers
D - Although there is no research evidence that high-tech pressure relieving mattresses and overlays are more effective than high-specification (low-tech) foam mattresses and overlays, professional consensus recommends that consideration should be given to the use of alternating pressure or other high-tech pressure-relieving systems:
- As a first-line preventative strategy for people at elevated risk as identified by holistic assessment
- When the individual's previous history of pressure ulcer prevention and/or clinical condition indicates that he or she is best cared for on a high-tech device
- When a low-tech device has failed
Patients Undergoing Surgery
D - All individuals undergoing surgery and assessed as being vulnerable to pressure ulcers should, as a minimum provision, be placed on either a high-specification foam theatre mattress or other pressure-redistributing surface.
Repositioning and 24-hour Approach to Provision of Pressure-Relieving Devices
D - The provision of pressure-relieving devices needs a 24- hour approach. It should include consideration of all surfaces used by the patient
D - Support surface and positioning needs should be assessed and reviewed regularly and determined by results of skin inspection, patient comfort, ability, and general state. Thus repositioning should occur when individuals are on pressure relieving devices
D - The management of a patient in a sitting position is also important. Even with appropriate pressure relief, it may be necessary to restrict sitting time to less then 2 hours until the condition of an individual with elevated risk changes
Coordinated Time Specified Approach
D - A pressure ulcer reduction strategy should incorporate a coordinated approach to the acquisition, allocation, and management of pressure-relieving equipment. The time elapsing between assessment and use of the device should be specified in this strategy.
Education and Information-giving
D - All healthcare professionals should be educated about:
- Pressure ulcer risk assessment and prevention
- Selection, use, and maintenance of pressure-relieving devices
- Patient education and information giving
D - Individuals vulnerable to or at elevated risk of developing pressure ulcers and their carers should be informed verbally and in writing about:
- The prevention of pressure ulcers using pressure-relieving strategies
- The use and maintenance of pressure-relieving devices
- Where they can seek further advice and assistance
Definitions:
Evidence Categories
I: Evidence from:
- meta-analysis of randomised controlled trials, or
- at least one randomised controlled trial
II: Evidence from:
- at least one controlled study without randomisation, or
- at least one other type of quasi-experimental study
III: Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies
IV: Evidence from expert committee reports or opinions and/or clinical experience of respected authorities
Recommendation Grades
A: Directly based on category I evidence
B: Directly based on:
- category II evidence, or
- extrapolated recommendation from category I evidence
C: Directly based on:
- category III evidence, or
- extrapolated recommendation from category I or II evidence
D: Directly based on:
- category IV evidence
- extrapolated recommendation from category I, II, or III evidence
Grading Scheme
Evidence
1: Generally consistent finding in a majority of multiple acceptable studies
2: Either based on a single acceptable study, or a weak or inconsistent finding in multiple acceptable studies
3: Limited scientific evidence that does not meet all the criteria of acceptable studies or absence of directly applicable studies of good quality. This includes expert opinion.
