Knowing doesn't equal doing in preventing pressure ulcers

1 April 2010

International guidelines aim to counter rise in pressure ulcers

Globally, pressure ulcer prevalence is set to rise in the coming decades as the at-risk population increases.

Experts from both Europe and the US have collaborated to recently publish international guidelines for both pressure ulcer prevention and management, which offer evidence-based recommendations to health care professionals.

Carol Tweed, former joint chair of the New Zealand Wound Care Society pressure ulcer working party, said the literature highlighted that more than 95 per cent of pressure ulcers are preventable.

She says one of the key tools to prevent these potentially fatal wounds was pressure ulcer risk assessment supported by ongoing planning, delivery and evaluation of care.

Guidelines developed in the UK by the Royal College of Nursing and published by the National Institute of Clinical Excellence recommended patients receive an initial risk assessment within six hours of admission.

These guidelines recommend a “structured risk assessment” on admission and the development of a prevention plan for individuals identified being at risk.

Tweed says risk assessment tools take into account a variety of key prognostic factors that have been identified by research to increase risk of pressure ulcer development. These include level of mobility, build or weight, sensory perception nutrition, current skin condition and compounding risk factors such as other illnesses.

She said pressure ulcer management is an integral and vital part of patient care, with the incidence set to rise with an increase in the high-risk populations of older people and people immobilised through disability or illness.

Tweed said prevention is the key as once deep tissue injury has occurred “it doesn’t matter whether they are put on the best mattress and given the best care in the world, the damage is done”.

She said the first signs of a pressure ulcer are usually persistent redness on the bottom or heel and it may take up to 10 days from the first damage occurring to the pressure ulcer appearing. “So preventative care is so, so important.”

The international evidence-based ‘quick reference’ guidelines on preventing and treating pressure ulcers were released late last year and are the result of a four-year collaboration between the European Pressure Ulcer Advisory Panel (EPUAP) and the American-based National Pressure Ulcer Advisory Panel (NPUAP). The guidelines include a common international definition and classification system for pressure ulcers.

The quick reference guide of the full guidelines can be downloaded from


Fiona Cassie talks to pressure ulcer expert Carol Tweed about her research into how education impacted on pressure ulcer prevention at an ICU

High levels of nurse knowledge doesn’t ensure low levels of pressure ulcers, research at a New Zealand intensive care unit found.

Researcher Carol Tweed* said her findings backed the research literature that ‘knowing’ doesn’t always lead to ‘doing’ when it comes to clinical practice. The main barriers identified that prevented nurses using their knowledge to prevent pressure ulcers were a lack of staff and a lack of specialist support surfaces.

Tweed – a UK-trained nurse who has specialised in wound care research and consultancy work for medical devices companies – assessed the pressure ulcer knowledge and quality of documentation in a cohort of 62 nurses in an ICU for her masters degree.

She found the nurses’ baseline knowledge of pressure ulcers was high and further improved after an education programme she provided, but returned to the baseline level 20 weeks after the programme.

On the same three occasions she tested the nurses’ knowledge she also examined 40 sets of patient records. She found despite nurses being knowledgeable, overall documentation of pressure ulcers was poor and the prevalence of recorded pressure ulcers was high during all three audits.

Tweed also anecdotally identified wide variations in recording for the same patient. Typically, one nurse would record in detail the colour, size and location of a pressure ulcer and document a plan of care followed by several days of another nurse recording nothing beyond “all cares given”. The first nurse would then return to document that the ulcer had deteriorated substantially. “So what’s been happening in those three days?” Tweed wondered.

She said by virtue of the patient being critically ill in ICU there were occasions when the emphasis was on life-saving interventions rather than frequent repositioning for prevention of pressure ulcers. Additionally, many factors that contribute to pressure ulcer development were frequently the norm for ICU patients – such as restricted mobility, chronic disease, advanced age, impaired sensory perception, altered tissue perfusion and malnutrition – making them a highly susceptible patient population. Placing the patient on admission to ICU on a high-risk preventive support surface is a necessary part of holistic care, Tweed said.

When nurses were asked what constraints they felt prevented them from carrying out appropriate pressure ulcer prevention strategies, more than half highlighted a lack of staff and insufficient specialist support surfaces. (Tweed said the unit in question now had better access to specialist equipment and a hospital-wide pressure ulcer prevention policy.)

The next most common constraints identified were a lack of staff knowledge (but this reduced from 40 per cent to 24 per cent after the education programme) and a patient’s unstable condition. About a quarter said a lack of a pressure ulcer policy was also a constraint.

Tweed was under way with her University of Wales masters on ‘Wound Healing and Tissue Repair’ before moving to New Zealand in 2003 and completing her masters in 2005.

She said she wasn’t surprised to find the disparity between knowledge and practice as this finding had also emerged from other health profession research.

The district health board where the research was undertaken had since adopted and actively supported a pressure ulcer prevention policy. But she said there were still a number of DHBs that did not even have a nurse specialist in the area of wound care.