Understanding the association between pressure ulcers and sitting in adults what does it mean for me and my carers? Seating guidelines for people,carers and health & social care professionals

The aim of the publication was to develop a practical guide for people, carers and health and social care professionals on how the research and evidence base on pressure ulcer prevention and management can be applied to those who remain seated for extended periods of time. This publication was developed at the request of the Tissue Viability Society in order to revise the original seating guidelines from 2008 as evidence and subsequent care has moved forward in relation to this area. Since 2008, the costs for the prevention and management of pressure ulcers have increased significantly and there is limited published advice from health and social care organisations on seating and preventing pressure ulcers. These guidelines have been written for:

• •People
• •Carers
• •Health and Social Care professionals
• •Education and training staff
• •Independent sector.

Who live or work in primary, secondary, and tertiary settings.     

Exploring repositioning movements in sitting with ‘at risk’ groups using accelerometry and interface pressure mapping technologies

BackgroundDespite high quality guidelines underpinning pressure ulcer care (NPUAP/EPUAP/PPPIA, 2014), pressure ulceration still poses a significant financial impact on health care services in treatment and staff costs as well as having a profound effect on the health and quality of life of individuals experiencing them. Repositioning is a key preventative technique recommended by occupational therapists and other health care professionals. The frequency and quality of repositioning movements performed by individuals, however, can be difficult to determine. This paper explores the use of technology in monitoring repositioning movements in sitting.ObjectiveTo explore the outputs of technologies such as interface pressure mapping systems and accelerometers in enabling the therapist to accurately monitor seated behaviour and enhance practice through targeted interventions to prevent sitting acquired pressure ulceration.MethodReviewing the findings of two recent research studies with ‘at risk’ cohorts (spinal cord injury; elderly orthopaedic), using accelerometry and seated interface pressures, this paper will highlight how useful this technology is in clinical practice to monitor weight shifts and repositioning behaviours.ResultBoth studies illustrated that the majority of individuals did not adhere to the frequency or magnitude of movements currently recommended to redistribute seating interface pressures. When repositioning was performed it was ineffective in reducing seated pressures.ConclusionIn an era of personalised medicine, technology has an important role to play in providing the service user, caregivers and healthcare staff with important biofeedback information about seated behaviours, particularly those that minimise the risk of developing sitting acquired pressure ulcers. This information can augment occupational therapists' clinical decision-making in maximising active pressure ulcer prevention.     

Evaluating the impact of the Tissue Viability Seating guidelines

IntroductionInternationally, guidelines are developed to ensure safe, effective, person centred, timely, efficient, and effective practice. However, their use in clinical practice is found to be variable. The Tissue Viability Society (TVS) published updated seating guidelines in 2017, yet, little is known about how these guidelines are being used.MethodsThe aim of this evaluation was to gauge the impact of the Tissue Viability Seating Guidelines on clinical practice and policy. A cross-sectional questionnaire was used to elicit the responses from anyone with an interest or role within seating and pressure ulcer prevention and management. The survey was distributed through a variety of methods including email to members of the Tissue Viability Society and social media platforms from September to December 2019.Resultsand Discussion: There were thirty-nine responses, the bulk of which were from healthcare professionals across primary and secondary care. All but one respondent was from the United Kingdom. Eleven had incorporated the latest TVS seating guidance into policy and sixteen into practice. The results of our survey demonstrates congruence with the literature as the main themes that emerged included incorporating the guidance into everyday clinical practice, education, and training, and as a resource or dissemination tool. Barriers to implementation included being unaware of the guidelines and unaware of one's own professional and collective organisational responsibility to guideline dissemination. However, many respondents were planning to incorporate the guidelines using a variety of methods.ConclusionThis survey has shown there are some examples of successful implementation of the TVS Seating guidelines. Future TVS guidelines should include implementation strategies, interventions, and goals for local champions to ensure barriers to implementation are both assessed and addressed. Future work could also include a trial of the guidelines within a pilot project.     

Best practice recommendations for the prevention and treatment of venous leg ulcers: update 2006

PURPOSE: To provide the specialist in skin and wound care with an update in recommended management of venous leg ulcers. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in wound care and related disorders. OBJECTIVES: After reading this article and taking this test, the reader should be able to:Editor's note: This "Best Practice Recommendations" article is reprinted with permission from Wound Care Canada, The Official Publication of the Canadian Association of Wound Care (2006;4[1]:45-55). It is the third installment of 4 articles originally published in 2006, following the latest Nursing Best Practice Guidelines from the Registered Nurses Association of Ontario (RNAO), which are updated approximately every 3 years. In 2000, the Canadian Association of Wound Care produced and had published its first best practice recommendations for the prevention and treatment of pressure ulcers. In this article, best practice recommendations are discussed for the prevention and treatment of pressure ulcers. The evidence presented is connected to the RNAO's recommendations from its review of the literature up to the writing of its 2006 guidelines. Clinical decision-making in the treatment of pressure ulcers can be guided by the algorithm that directs the clinician to identify and treat the underlying causes, to identify and manage patient-centered concerns, and to provide for good local wound care, considering adjunctive therapies or biologically active dressings when the edge of the wound is not advancing. Finally, the recommendations advise putting into place those organizational and educational activities that support the translations of the guidelines into practice.     

Lessons learned from patients with spinal cord injury in managing pressure ulcers: A qualitative study

ObjectivesTo explore how individuals with spinal cord injury self-manage the prevention and treatment of pressure ulcers and to provide insight into experiences with self-management support.DesignQualitative study using semi-structured interview and a deductive thematic analysis.SettingCommunity.ParticipantsTwelve of the 14 participating adults with a spinal cord injury had experience with pressure ulcers, and eight of these had a current pressure ulcer.ResultsRespondents suggested to tailor treatment of pressure ulcers to patients’ individual wishes and capabilities of patients. Patients and caregivers need to be aware of the importance of determining the cause of pressure ulcers to prevent deterioration. Patients often depend on informal caregivers for follow-up and prevention, and healthcare professionals in non-SCI specialties often lack the knowledge needed to manage pressure ulcers in this specific patient group. Tailored education and peer support are important for patients to set boundaries, be assertive, and cultivate a positive attitude when dealing with pressure ulcers. It is difficult to combine treatment of severe pressure ulcers and preventive measures with work roles. Managing the social impact of pressure ulcers requires more coordination with caregivers.ConclusionsTo support self-management of pressure ulcers in patients with a spinal cord injury, they must find out which preventive measures and treatments suit them best. Healthcare professionals play an important role in the self-management of pressure ulcers and can help patients deal with the emotional and social impact of pressure ulcers. To know patient's needs and tailor their education, healthcare professionals of non SCI organizations need to have knowledge of pressure ulcers management of this specific patient group.     

Preventing pressure ulcers among wheelchair users: preliminary comments on the development of a self-administered risk assessment tool

The prevalence of pressure ulcers among permanent wheelchair users remains high. While many risk factors for pressure ulcer development in this group have been identified only a minority of these have been evaluated scientifically and it is generally acknowledged that existing risk assessment tools are inadequate for predicting risk in seated persons who use a wheelchair for mobility. A 2-year prospective study is underway to design a new self-administered pressure ulcer risk indicator to be used by non-ambulant wheelchair users and their carers in conjunction with professionals. This instrument will be designed as a result of triangulation of methods. A systematic review of available evidence Latest professional opinion A qualitative study exploring the issues from the perspective of seated persons with a history of pressure ulcers (n = 10) undertaken by one of the authors (JW) A 2-year prospective study identifying key risk factors in a sample of 160 seated persons. This paper offers an insight into the findings on the recruitment of the 160 individuals into the prospective study, which is currently collecting a large amount of data on the health, degree of disability and integrity of skin of all the participants. The paper offers an overview of the medical diagnosis, degree of physical disability, issues pertaining to continence and prevalence of pressure ulcers in this group on recruitment. Early findings suggest that the new risk indicator should include measures of degree of physical disability and ability to transfer as an integral part of self-assessment and therefore prevention of pressure ulcers. The study was due for completion in the autumn of 2002. It is envisaged that early work on the development of the tool should be complete by the summer of 2003.     

The economic impact of pressure ulcers among patients in intensive care units. A systematic review

BackgroundThe incidence and prevalence of pressure ulcers in critically ill patients in intensive care units (ICUs) remain high, despite the wealth of knowledge on appropriate prevention strategies currently available.MethodsThe primary objective of this systematic review was to examine the economic impact of pressure ulcers (PU) among adult intensive care patients. A systematic review was undertaken, and the following databases were searched; Medline, Embase, CINAHL, and The Cochrane Library. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was used to formulate the review. Quality appraisal was undertaken using the Consensus on Health Economic Criteria (CHEC)-list. Data were extracted using a pre-designed extraction tool, and a narrative analysis was undertaken.ResultsSeven studies met the inclusion criteria. Five reported costs associated with the prevention of pressure ulcers and three explored costs of treatment strategies. Four main PU prevention cost items were identified: support surfaces, dressing materials, staff costs, and costs associated with mobilisation. Seven main PU treatment cost items were reported: dressing materials, support surfaces, drugs, surgery, lab tests, imaging, additional stays and nursing care. The overall validities of the studies varied between 37 and 79%, meaning that there is potential for bias within all the included studies.ConclusionThere was a significant difference in the cost of PU prevention and treatment strategies between studies. This is problematic as it becomes difficult to accurately evaluate costs from the existing literature, thereby inhibiting the usefulness of the data to inform practice. Given the methodological heterogeneity among studies, future studies in this area are needed and these should use specific methodological guidelines to generate high-quality health economic studies.     

Integrated care pathway: the prevention and management of pressure ulcers

The introduction of this pathway for the prevention and management of pressure ulcers was influenced by the development of the pathway for the management of a patient with a fractured neck of femur. Systematic documentation of preventative measures for patients with a fractured neck of femur helped reduce the incidence of pressure ulcers in this high-risk group. The original draft was informed by evidence-based clinical practice guidelines. This draft of the pathway was piloted, reviewed and changed in line with current evidence and comments from users. It was invaluable to pilot the pathway and review as necessary in order to make this a true workable document that would enable continuity of care, help prevent hospital-acquired pressure ulcers and be an effective teaching aid. A trust-wide retrospective audit of documentation for the prevention and management of pressure ulcers has been conducted, which found that the pathway facilitated a more concise approach to inform care than standard documentation. A further audit has been undertaken in the care of the elderly directorate which has demonstrated various ways in which the pathway had been completed. Challenges remain for the effective use of this documentation. Further education needs to be completed in order to promote multiprofessional use of the pathway. The pathway is now being integrated into others, which will increase awareness and involvement of other professional groups in this important aspect of patient care. Ongoing audit will take place to assess the impact upon patient outcomes.     

Seating and pressure ulcers: Clinical practice guideline

Pressure ulcers (bedsores) often develop following prolonged sitting especially where people are immobile or are unable to feel discomfort due to injury or disease. This guideline provides health professionals with specific recommendations intended to minimise any risk of developing pressure ulcers when their clients are seated. The guideline covers sitting when people are acutely ill in hospital and, more commonly, where people have a long-term need for prolonged sitting for example after spinal injury. Particular focus is placed upon the need to make sure the physical size and shape of the seat is appropriate for the seated individual. Guidance is provided upon areas where seated individuals require information to help them minimise pressure ulcer development. The advantages and disadvantages of different cushion materials are described.     

Pressure ulcers in neonates and children: an NPUAP white paper

Acutely ill and immobilized neonates and children are at risk for pressure ulcers, but a paucity of evidence-based research exists on which to base guidelines for clinical practice. Most prevention and treatment protocols for pressure ulcers in the pediatric population are extrapolated from adult practice. Clinical practice guidelines for prevention and treatment of pressure ulcers that specifically address the needs of the pediatric population are needed. The purpose of this article is to highlight the research that is currently available and to identify gaps that need to be addressed so that science-based, age-appropriate prevention and treatment pressure ulcer guidelines can be developed.     

A study to evaluate factors for inclusion in a new self-assessed risk indicator for persons who use a wheelchair for mobility

A preliminary analysis of a 2-year prospective study of the health, degree of physical disability and skin integrity of 160 permanently seated persons is presented in this paper. The study was undertaken to inform the development of a self-managed risk assessment tool for the prevention of pressure ulcers in permanently seated individuals. The results of this study offer further insight into the challenges of pressure ulcer prevention and the role of education and self management in achieving this.     

A survey of pressure ulcer education within pre-registration radiography courses

The prevention of pressure ulcers and the management of people with pressure ulcers is multi-disciplinary, though in many places it is considered a nursing problem. Radiography environments are a potential cause of pressure ulcers. This paper describes the results of a survey of pre-registration radiography education institutions regarding the education provision on the prevention of pressure ulcers within radiography environments. The survey comprised two parts--a desk top review of course prospectuses and a postal questionnaire. Course prospectuses for 23 of the 24 institutions were examined for specific mention of prevention and management of pressure ulcers but none was found. All 24 institutions in the United Kingdom were invited to respond to a questionnaire survey, and 14 replied (58% response rate). Responses covered both diagnostic and therapeutic radiography programmes. Nine institutions specifically identify teaching on pressure ulcers, with the majority of education appearing in year 1 of the course, with some courses providing further material later in the programme. The survey confirms anecdotal evidence reported in a previous study that radiographers have little training in the prevention and management of patients at risk of developing pressure ulcers during radiographic procedures. Thirteen out of 14 institutions stated that no final year student project had considered the prevention and management of pressure ulcers in radiography environments.     

Pressure ulcer prevention and treatment knowledge of Jordanian nurses

AimsThe aims of the study were to determine: (1) Jordanian nurses' level of knowledge of pressure ulcer prevention and treatment of hospitalized patients based on guidelines for pressure ulcer prevention and treatment. (2) Frequency of utilization of pressure ulcer prevention and treatment interventions in clinical practice. (3) Variables that are associated with nurses' utilization of pressure ulcer prevention and treatment interventions.BackgroundPressure ulcers are common and previous studies have shown education, knowledge and attitude affect implementation of interventions.MethodsA cross-sectional survey design was used to collect data from 460 nurses between June 2010 and November 2010. We used a questionnaire, which was informed by earlier work and guidelines, to collect data about nurses' knowledge and practice of pressure ulcer prevention and treatment.Results/findingsKnowledge and education show an association with implementation of prevention, and demographic variables do not. Similarly knowledge and type of hospital showed an association with implementing treatment. Of concern the use of “donuts” and massage are reported in use.ConclusionAlthough pressure ulcer care is well known by nurses, inappropriate pressure ulcer interventions were reported in use.     

Seated buttocks anatomy and its impact on biomechanical risk

AimThe objective of this study was to describe the amount, types, and shapes of tissue present in the buttocks during sitting (i.e., seated buttocks soft tissue anatomy), and the impact of seated buttocks soft tissue anatomy on biomechanical risk.Materials and methodsThe buttocks of 35 people, including 29 full-time wheelchair users with and without a history of pelvic pressure ulcers were scanned sitting upright on 3” of flat HR45 foam in a FONAR Upright MRI. Multi-planar scans were analyzed to calculate bulk tissue thickness, tissue composition, gluteus maximus coverage at the ischium, the contour of the skin, and pelvic tilt.ResultsBulk tissue thickness varied from 5.6 to 32.1 mm, was composed mostly of adipose tissue, and was greatest in the able-bodied cohort. Skin contours varied significantly across status group, with wheelchair users with a history of pressure ulcers having tissue with a peaked contour with a radius of curvature of 65.9 mm that wrapped more closely to the ischium (thickness at the apex = 8.2 mm) as compared to wheelchair users with no pressure ulcer history (radius of curvature = 91.5 mm and apex thickness = 14.5 mm). Finally, the majority of participants presented with little to no gluteus coverage over their ischial tuberosity, regardless of status group.ConclusionsThis study provides quantitative evidence that Biomechanical Risk, or the intrinsic characteristic of an individual's soft tissues to deform in response to extrinsic applied forces, is greater in individuals at greater risk for pressure ulcers.     

Preventing recurrence after surgical repair of pressure injuries in patients with spinal cord injury: Effects of a presurgical and postsurgical wheelchair seating intervention by experts

ObjectivePressure injuries in people with spinal cord injury or dysfunction (SCI/D) are known to have a high recurrence rate. As a countermeasure, we perform surgery after adjusting the wheelchair and cushion with the intervention of a seating expert. The effectiveness of seating interventions in postsurgical recurrence prevention was examined.Materials and methodsIn this retrospective analysis, the participants were 19 patients with SCI/D who underwent pressure injury surgical treatment in the gluteal region from 2005 to 2018. The patients with conventional rehabilitation were assigned to Group 1 (n = 8), and those with seating intervention by experts in addition to conventional rehabilitation were assigned to Group 2 (n = 11). The main outcome measure was the presence or absence of recurrence 3 years after the surgery. The recurrence rate was compared between the two groups.ResultsThe recurrence rates were 18% with seating intervention and 75% without; there was a significant difference (p = 0.025). The recurrence odds ratio was 13.5.ConclusionThis study suggests that presurgical seating evaluation and assessment by experts, postsurgical rehabilitation based on presurgical evaluation and assessment, and routine follow-up and seating adjustment according to changes are efficacious for preventing postsurgical pressure injury recurrence in patients with SCI/D.     

The effect of a pressure ulcer prevention care bundle on nursing workload costs

AimThis study investigated the effect of care under the guidance of a pressure ulcer prevention care bundle on pressure ulcer incidence rates and on nursing workload costs.Design, setting, and participantsThis prospective pre-post interventional study was conducted in an anesthesia and reanimation intensive care unit. The sample consisted of 16 nurses and 84 patients.MethodsThe study was conducted in two periods: (1) nursing workload of pre-care bundle period and (2) nursing workload of post-care bundle period. In the collection of data, 6 forms (the demographic data forms, the Braden scale, nurse information form, the care bundle follow-up form and nursing workload follow-up form) were administered. The main outcomes of the study; Pressure ulcer incidence rate was evaluated with Form V, and nursing workload costs were evaluated with Form VI. These forms were evaluated daily by the nurses. In the first period (15.09.2018–30.11.2018), pressure ulcer incidence rates and nursing workload costs were evaluated before training. Then, the researcher trained nurses on how to prevent pressure ulcers and use the care bundle. The care bundles components were risk assessment, skincare, activity, in-service training, nutrition, wetness/incontinence and support surface management, and keeping records. In the second period (01.12.2018–15.02.2019), pressure ulcer incidence rates and nursing workload costs were evaluated after the training. The outcomes of the two periods regarding the incidence of pressure ulcers and nursing workload costs were compared.ResultsThe pressure ulcer incidence rates before and after the care bundle were 22.1 and 13.0 per 100 patient-day, respectively. There was a decrease in pressure ulcer incidence rates after the care bundle, but it wasn't significant (p = 0.138). The total workload cost of pressure ulcer prevention was significantly lower after the care bundle than before (p = 0.001).ConclusionThe pressure ulcer incidence rates were lower after the care bundle than before, albeit insignificantly. The total pressure ulcer prevention workload costs were significantly lower after the care bundle than before. The reduction in pressure ulcer incidence and workload cost indicates that the use of care bundle is effective. Healthcare professionals in intensive care units should use a pressure ulcer prevention care bundle more often.     

Evidence map of recommendations on diabetic foot ulcers care：A systematic review of 22 guidelines

BackgroundDiabetic foot ulcers (DFUs) are one of the major complications of diabetes, representing a leading cause of hospitalization and non-traumatic lower limb amputations. Clinical practice guidelines (CPGs) are statements that include recommendations intended to improve patients' outcomes by providing recommendations for key clinical issues with alternative care options. The aim of this study is to systematically review CPGs on DFUs care and generate an evidence-map for visualizing research trends and gaps in the CPGs.MethodsA search of the PubMed, Embase, and Web of Science, guideline databases and website of diabetes society was performed to include the diabetic CPGs. We exacted the basic information, methodological quality and reporting quality of CPGs, recommendations for DFUs care by the Excel 2016. Four researchers evaluated the methodological and reporting quality of diabetic foot CPGs by AGREE Ⅱ instrument and RIGHT checklist. The bubble plot format of evidence map was reduced by R (3.5.1) software.Results22 CPGs proved eligible, which included 10 diabetic foot guidelines and 12 comprehensive diabetes guidelines. According to the recommendations of diabetic CPGs, current standard of care for DFUs care mainly involves offloading of pressure, wound care, choice of shoes and adjunctive treatment. Recommendations on offloading of pressure and wound care were consistent in 22 CPGs. However, there were some conflicts on adjunctive treatment recommendations and recommendations for choice of shoes were not accurate.ConclusionThere is mixed quality evidence of CPGs for DFUs care, and some recommendations are inconsistent. This evidence map could provide new perspectives in presentation of evidence and help us know the need for future research to address the current gaps, as well as areas of opportunity for CPG development.     

Best practice recommendations for the prevention and treatment of pressure ulcers: update 2006

PURPOSE: The purpose of this article is to enhance the professional nurses' knowledge of the best practice recommendations for the prevention and treatment of pressure ulcers. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in wound care. OBJECTIVES: After reading this article and taking this test, the reader should be able to: 1. Interpret the pathway to assess and treat pressure ulcers. 2. Differentiate the Registered Nurses' Association of Ontario (RNAO) levels of evidence. 3. Identify the scientific evidence for treatment recommendations.     

Skin blood flow dynamics and its role in pressure ulcers

Pressure ulcers are a significant healthcare problem affecting the quality of life in wheelchair bounded or bed-ridden people and are a major cost to the healthcare system. Various assessment tools such as the Braden scale have been developed to quantify the risk level of pressure ulcers. These tools have provided an initial guideline on preventing pressure ulcers while additional assessments are needed to improve the outcomes of pressure ulcer prevention. Skin blood flow function that determines the ability of the skin in response to ischemic stress has been proposed to be a good indicator for identifying people at risk of pressure ulcers. Wavelet spectral and nonlinear complexity analyses have been performed to investigate the influences of the metabolic, neurogenic and myogenic activities on microvascular regulation in people with various pathological conditions. These findings have contributed to the understanding of the role of ischemia and viability on the development of pressure ulcers. The purpose of the present review is to provide an introduction of the basic concepts and approaches for the analysis of skin blood flow oscillations, and present an overview of the research results obtained so far. We hope this information may contribute to the development of better clinical guidelines for the prevention of pressure ulcers.