Prevention of pressure ulcers

Challenges to face

The prevalence of pressure ulcers is reported to vary from 5 to 48 % in nursing homes and from 10 to 33 % in home health care services. The proportion of patients considered at risk is 26.1 % in short-term care for the elderly and 34.7 % in nursing homes and dementia care, respectively. The challenge picture must be read in light of the fact that the included studies and projects extend over a period of 14 years and have used different methods in the mapping.

Pressure ulcers are most often located to the sacrum and heels. Risk may be related to the patient’s age, diagnosis (especially diabetes), nutritional status, care needs, physical and psychological functioning, health professionals’ competence and attitudes, and the health service’s system and resources. The consequences of pressure ulcers are pain, decreased activity, and reduced experience of psychological well-being and health. In people with diabetes, pressure ulcers are also associated with amputations and increased mortality. In addition to human costs, pressure ulcers entail considerable use of resources and financial costs for the health care service.

Effects and experiences of interventions

Interventions to prevent pressure ulcers are sorted into the following categories: 1) Identifying and reducing risk, 2) Equipment and technology, 3) Interventions to enhance competencies, 4) Competence-enhancing measures and 5) The package of interventions for the prevention of pressure ulcers, recommended by the Norwegian Patient Safety Programme.

The following experiences are described for these categories:

Identifying and reducing risk: The Braden scale is the most widely used tool in risk assessment of pressure ulcers in municipal health and care services. Standardized tools have traditionally been used little in Norway. It is challenging to judge whether one tool is better than another or better than assessments based on health professionals’ experience and discretion. More systematics and the use of tools can provide benefits in terms of both workload and quality but should be followed by clinical assessments. Among concrete measures to reduce risk, pressure relief in the form of mattresses and regimes for repositioning are the most basic and effective measures for preventing pressure ulcers. Regular skin inspection is important for at-risk patients, but there is little evidence that general skin inspection and skin care are effective. PH balanced soap washing can have a preventative effect. Massage to stimulate blood circulation should be avoided. Energy- and protein-rich diets are beneficial for healing processes and can also have a preventive effect. Person-centred care and a holistic approach are important principles in successful initiatives.

Equipment and technology: There are a number of technological mattresses that either shape according to the patient’s weight and provide a uniform pressure distribution, or provide pressure distribution by constantly changing the pressure in different parts of the mattress. The latest innovation is a cradle-like mattress that provides change of position without the patient being manually turned over by another person. Other examples of technologies are close fitting clothing that provides wheelchair pressure relief, and local pressure-chamber treatment. The use of telemedicine is reported to provide increased competence in wound assessment, better documentation quality and more streamlined communication between service levels. For patients, healthcare professionals’ expertise, accessibility of services and continuity appear to be more important than the technology used.

Interventions to enhance competencies: Measures have been taken to increase health professionals’ competence in the use of tools to assess the risk of pressure ulcers. The use of e-learning programs is recommended. A pocket version of the Braden scale is seen as useful because it simplifies and streamlines mapping in nursing homes. Information tailored to patients’ and relatives’ needs is also created. Different types of collaboration between service levels or professions contribute to better treatment for patients and to increased awareness and motivation among clinicians. Still, many challenges related to competence appear unresolved. Systematic pressure ulcer prevention in municipalities is affected by part-time issues, oral information transfer, inadequate documentation and unclear procedures for knowledge-based practice. In general, nurses report interest in preventing pressure ulcers, but their level of knowledge may be insufficient.

The package of interventions for the prevention of pressure ulcers, recommended by the Norwegian Patient Safety Programme: Little is known about how the patient safety program’s package of measures ‘prevention of pressure ulcers’ is received and made use of in the municipalities. The package consists of seven measures that unite evidence- based knowledge from an expert panel with specialist procedures for the prevention and treatment of pressure ulcers in hospitals and nursing homes. It is claimed that the measures package has contributed to greater awareness of pressure ulcer prevention work in Norway, but documentation is lacking on this.

More knowledge is needed on the following topics

• Pressure ulcer prevention in home care services
• Patients’ and relatives’ experiences of pressure ulcer prevention
• Patients’ and relatives’ user involvement in pressure ulcer prevention
• Organization of pressure ulcer prevention as knowledge-based practice
• Interdisciplinary cooperation in the prevention of pressure ulcers