Pressure ulcers remain a significant healthcare problem, with an incidence rate of around 4.5% of all patients being reported with a pressure ulcer (NHS Safety Thermometer, 2019). While pressure ulcers can be painful and debilitating to the patient, treating them imposes a high financial burden on the NHS, of around £3.8 million a day (NHS Improvement, 2018). Thus, improving the prevention, management and reporting of pressure ulcers is essential.
With many policies, strategies and guidance available, both locally and nationally, to help address issues of pressure damage (prevention, management and reporting), there appears an overall lack of consistency, and these inconsistencies and lack of standardisation are evident in various aspects, from reporting to the use of terminology.
In 2018, NHS Improvement released a document entitled ‘Pressure ulcers: revised definition and measurement’, to provide clarity on various issues around pressure ulcers. This comprehensive document includes 30 recommendations expected to be implemented across NHS England by April 2019. It aims to support a consistent approach to measuring, defining and reporting pressure ulcers, and is designed to be consistent with current approaches to all types of pressure damage, thereby supporting learning. This article provides an overview of ‘Pressure ulcers: revised definition and measurement’ (NHS Improvement, 2018).
A closer look at the document
The 18-page document is divided into three tables covering the following:
New pressure ulcer definition
With no previously agreed definition of a pressure ulcer, a concise definition has been produced for use in practice and for staff education. It is hoped that this definition will be supported by academic institutions.
‘A pressure ulcer is localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful’.
Clarification on terminology
To ensure continuity and accuracy in documentation and reporting, it has been recommended that pressure damage only be referred to as ‘pressure ulcers’ and not ‘pressure sores’, ‘bed sores’ or ‘decubitus ulcers’.The severity of the damage will be classified by categories, replacing the former terminology of ‘grade’ or ‘stage’.
The causative factor of the pressure damage will be also captured, with pressure ulcers relating to medical devices identified by using the notation (d). For example, category 2 PU (d) will denote a category 2 pressure ulcer in which the pressure damage was caused by a medical device.The definition of medical device-related damage is ‘pressure ulcers that result from the use of devices designed and applied for diagnostic or therapeutic purposes’ (NHS Improvement, 2018).
When recording pressure areas on admission to care, it is important to note that the new abbreviation ‘POA’ will be used to refer to a ‘pressure ulcer on admission’. A POA will be identified during the initial skin assessment undertaken on the patient when they have been first admitted to the nurse’s service; ideally, this should occur within the first 6 hours. A new pressure ulcer refers to one that has first been identified within the current episode of care. Table 1 summarises the accepted terminology. The points referenced refer directly to the recommendation number within the full document.
To ensure that pressure damage is not double-reported, the NHS number must always be used; this replaces previous identification numbers, such as hospital number or date of birth.
| Point | Terminology used | Confirmation of terminology and definition |
|---|---|---|
| 1 | Pressure ulcer (PU) | The term ‘pressure ulcer’ should be used, abbreviated to PU. It replaces ‘pressure sore’, ‘bed sore’ and ‘decubitus ulcer’ |
| 12, 13 | Category | The term ‘category’ will be used to describe the severity of pressure damage. It replaces ‘grade’ and ‘stage’ |
| 2 | PU definition | ‘A pressure ulcer is localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device) resulting from sustained pressure (including pressure associated with shear). The damage can present as intact skin or as an open ulcer that may be painful’ (NHS Improvement, 2018) |
| 4 | PU (d) definition (medical device) | ‘Pressure ulcers that result from the use of devices designed and applied for diagnostic or therapeutic purposes’ |
| 11 | New PU | A new pressure ulcer within a setting is defined as being first observed within the current episode of care |
| 9 | Pressure ulcer on admission (POA) | This is a pressure ulcer that is observed during the initial skin assessment undertaken when the patient/client is first admitted to the service (usually within 6 hours of admission to care) |
| Point | Terminology used | Confirmation of terminology and definition |
|---|---|---|
| 9 | POA | This is a PU that is observed during the initial skin assessment undertaken when the patient/client is first admitted to the service (usually within 6 hours of admission to care) |
| 3, 4, 16 | PU(d): medical device-related PU | PU developed due to a medical device should be referred to as a ‘medical device-related pressure ulcer’ and recorded and reported as PU(d) |
| 18 | NHS number | When reporting pressure or moisture damage, the NHS number should be used. This replaces the use of hospital numbers, date of birth or other unique identifications |
| 23 | Number of patients with a PU | Reporting the number of patients with a PU, supporting a greater range of pressure damage being reported |
| 24 | Report ALL PUs | PUs were previously defined as ‘avoidable’ or ‘unavoidable’. With this definition no longer used, all PUs need reporting |
| 25 | Report MASD (in addition to PU) | Reporting MASD should be counted in addition to the pressure damage |
| 26 | Reporting combination of MASD and PU | If damage is caused by both pressure and MASD, reporting should be linked to the category of the pressure damage |
| 27 | Reporting DTIs and unstageable PUs | Unstageable and DTI ulcers require weekly review by a clinician who has the appropriate skills |
POA: pressure ulcer on admission; PU: pressure ulcer; MASD: moisture-associated skin damage; DTI: deep tissue injury
In a change from previous data collection, it is now recommended that the number of patients with pressure ulcers be reported. This should provide a clearer picture of the range of damage occurring and to how many patients (Table 2).
Unstageable pressure ulcers and deep tissue injury (DTI) should be reviewed weekly by a clinician with the appropriate skills; this is subject to local interpretation, with many job descriptions written to address service needs. It will be the responsibility of each trust to identify staff deemed to meet this description.
It is widely accepted that moisture-associated skin damage (MASD) can occur alone or in conjunction with a pressure ulcer. The associated risk factors of both MASD and pressure ulcers are very similar. Additionally, skin damaged by moisture is at an increased risk of pressure damage because of the swelling that occurs in the stratum corneum, making it more susceptible to damage by shear forces (Beeckman et al, 2015). If both MASD and a pressure ulcer coexist, the reporting should be documented under the category of the pressure ulcer.
Monitoring and reporting of pressure damage and MASD are to remain focused on identifying the cause, thus allowing this factor to be appropriately addressed. Reporting is not an exercise in apportioning blame; it is an exercise in learning through understanding. The aim is to remove the cause of damage, whether it is pressure or moisture.
The new recommendations acknowledge that a pressure ulcer is a pressure ulcer, and all pressure damage should be reported, regardless of stage of life. It is recommended that pressure ulcers occurring in patients identified as being at the end of life no longer be referred to as ‘Kennedy ulcers’, but that they should be reported as any other pressure ulcer, supporting true and accurate data.
Research suggests that between 80 and 95% of all pressure ulcers are avoidable (NHS Stop the Pressure, 2019), and best practice stipulates that the same evidence-based care should be delivered to all patients. The previous exercise in determining whether the pressure damage was avoidable or unavoidable allowed some trusts to focus on proving that the incident was unavoidable, rather than using the process to support positive learning outcomes.
Many staff are familiar with the ‘72-hour rule’, which stipulates that if pressure damage occurs during the first 72 hours of the patient being under someone’s care, it can be attributed to their previous care setting. This has led to many issues occurring when reviewing complex patient pathways. Recording and reporting all pressure ulcers will enhance learning outcomes, positively impacting future patient care. It is recommended that only pressure ulcers identified at initial skin assessment upon admission to care be identified as occurring under different care. These will be referred to as POAs, as defined above and reported accordingly (Table 3).
Current overarching national and international guidance will continue to be recommended. For example, guidance from the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA) covering category 1–4 pressure ulcers, DTIs and unstageable pressure ulcers remains relevant and practicable (Table 4).
Changes recommended to the reporting of pressure and moisture damage acknowledge that this will impact reporting figures, with an anticipated increase in the numbers reported (Table 5). This increase should reflect true and accurate data, allowing a clear picture of damage to be available and supporting the initiation of appropriate action.
Identifying whether the pressure ulcer was due to a medical device will provide a clear picture as to the amount of damage that medical devices such as braces, wheelchairs or a catheter, for example, are responsible for. Splitting the reporting of pressure ulcers and/or pressure ulcers caused by medical devices will support learning for preventative approaches to be actioned in the future.
The recommendations state that all category 2 and above damage should be reported, along with deep tissue injury, POAs and unstageable pressure ulcers. Additionally, the number of patients with pressure ulcers needs reporting along with any MASD. This comprehensive capture of data will provide baseline information for further prevention strategies to be developed.
| Point | Term | Reason for discontinuation |
|---|---|---|
| 5,17 | Kennedy ulcer | Pressure damage at the end of life is to be recorded as a pressure ulcer |
| 10 | Avoidable/unavoidable | All pressure damage to be investigated to support appropriate and timely learning and action |
| 14 | 72-hour rule | Pressure ulcer on admission will be used to identify and report pressure damage on admission to care |
| Point | Term to cease | Reason for discontinuation |
|---|---|---|
| 6 | Cat 1, 2, 3, 4 | Recommended to follow NPUAP, EPUAP and PPPIA guidelines incorporating categories 1–4 |
| 7 | DTI | Recommended to follow NPUAP, EPUAP and PPPIA guidelines incorporating DTI |
| 8 | Unstageable | Recommended to follow NPUAP, EPUAP and PPPIA guidelines incorporating unstageable ulcers |
| 29 | Incident | No change from definition used in NHS Stop the Pressure programme |
| 29 | Serious incident framework | Recommended to continue following the overarching policy of the serious incident framework, which is to support learning to prevent reoccurrence |
NPUAP: National Pressure Ulcer Advisory Panel; EUPAP: European Pressure Ulcer Advisory Panel; PPPIA: Pan Pacific Pressure Injury Alliance; DTI: deep tissue injury
| Point | Term | Reason for practice to stop |
|---|---|---|
| 15,19, 24 | All cat 2 and above | All category 2 and above pressure damage (regardless of cause; avoidable and unavoidable) |
| 16 | Device related | Use notation (d) to identify pressure ulcers caused by medical devices. Example of recording: category 2 PU (d) |
| 20 | Unstageable | Should be reported into local monitoring |
| 21 | DTI | Should be reported into local monitoring |
| 22 | POA | Should be reported into local monitoring |
| 23 | Number of patients with PUs | Should be reported into local monitoring |
| 25 | All MASD in addition to PUs | Count and record in addition to PUs |
| 26 | Combination damage: PU and MASD | Damage caused by both pressure damage and MASD should be reported under the category of the PU |
| 28 | Serious incident reporting | Only PUs that meet criteria set out by NHS Stop the Pressure should be reported to clinical commissioners |
DTI: deep tissue injury; PU: pressure ulcer; POA: pressure ulcer on admission; MASD: moisture-associated skin damage
Previously, not all trusts reported MASD, and with this now recommended, interesting data will become available identifying the true numbers of patients who experience this painful condition, as will evidence to demonstrate whether this damage occurred alone or in conjunction with pressure damage.
The concept of reporting into local policy can remain slightly ambiguous, as this could refer to data capture on Datix, the NHS Safety Thermometer or StEIS (Strategic Executive Information System) to name but three; the ability to cross-reference data using the NHS number will be advantageous.
Point 29 recommends that the definition used by NHS Stop the Pressure (2019) for serious incidents continue being used, and that there should be no amendment to the serious incident framework used by Stop the Pressure.
Point 30 provides a table demonstrating actions to be taken to support implementation of these recommendations.
Conclusion
The workable document ‘Pressure ulcers: revised definition and measurement’ provides clarity on previously ambiguous areas around pressure damage and MASD. The supporting rationale for each recommendation clearly explains why changes are required, with an overall aim to achieve an open and honest approach to the management of pressure and moisture damage. The newly introduced definitions should support clinicians in practice, and eliminating the previous definitions of ‘avoidable’ and ‘unavoidable’ not only eradicates a culture of blame but also supports investigations into the cause of damage, whereby it can be addressed in a timely manner, and the best care outcomes for the patient can be ensured. Clarity on the damage expected to be reported supports data collection and, thereby, the planning and implementation of prevention strategies.
Some concepts, such as ‘a clinician with appropriate skills’, and ‘incorporate into local monitoring systems’ remain open to interpretation and seem to be designed to support existing systems and identified skill sets within a workforce. In the future, the NHS may stipulate how and where pressure ulcer data are reported, perhaps creating a national database to record incidence specifically for all pressure damage and MASD (rather than relying on NHS Safety Thermometer and Datix summaries) (Collier, 2019). Capturing annual prevalence data at a national level may also provide a snapshot picture of the true extent of damage, supporting further work on treatment and prevention strategies.
The ‘Pressure ulcers: revised definition and measurement’ document has been produced to effectively address key issues, remove blame and ensure that best practice is implemented in a timely manner in pressure ulcer management. Learning how and why damage has occurred, whether from a bony prominence, a medical device or moisture, allows full and transparent investigations and understanding into how to address issues, while preventing future damage.