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Prevention and Management of
Pressure Ulcers
Report on the Standards Scope Engagement Exercise
February 2016
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
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© Healthcare Improvement Scotland 2016
Published February 2016
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Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
Contents
Developing the scope of the standards for the prevention and management of pressure
ulcers
4
General comments
5
Assessment and prevention of pressure ulcers
16
Management of pressure ulcers
25
3
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
Developing the scope of the standards for the prevention and management
of pressure ulcers
Background
In February 2015, Healthcare Improvement Scotland began developing standards for the prevention
and management of pressure ulcers.
In April 2015, a scoping meeting was held with key stakeholders, including the project group chair for
the prevention and management of pressure ulcers standards. Subsequently, a scoping report was
produced and published on the Healthcare Improvement Scotland website in June 2015, which
outlined the proposed broad areas for inclusion within the standards:
1. assessment and prevention of pressure ulcers
2. management of pressure ulcers
3. education and training
4. patient Information and communication
In June 2015, a 3-week scope engagement exercise took place to invite feedback on the proposed
areas. Specifically, stakeholders were asked to consider:
1. Looking at the proposed areas to be covered within the pressure ulcers standards, are these the
right areas to include?
2. Are there any other additional areas that you feel should be included within the pressure ulcers
standards?
3. Are there any additional references that we should include?
The comments arising from the scope engagement exercise were themed and taken to the project
group in August 2015. All comments have been reviewed and used to shape the development of the
draft standards. This scope engagement report details all comments along with the project group
responses.
Stakeholders
We received feedback from the following organisations:
•
ACCORD Hospice
•
Care Inspectorate
•
DM Systems Incorporated
•
Golden Jubilee National Hospital
•
HC One
•
Healthcare Improvement Scotland
•
Molynlycke Healthcare
•
12 NHS boards – Ayrshire & Arran,
Borders, Dumfries & Galloway, Fife, Forth
Valley, Grampian, Greater Glasgow and
Clyde, Highland, Lanarkshire, Lothian,
Shetland, Tayside
•
NHS Education for Scotland
•
NHS Health Scotland
•
NHSScotland QI Hub
•
Scottish Independent Hospitals
Association
•
Stirling University
•
Tissue Viability Society
We also received feedback from members of the public and individual professionals.
4
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
General comments
ID
Scope engagement comment
Response
5
From 2009 BPS add a more intense perspective
to community settings including where social
work carers and community nurses are both
involved. Who should take the lead?
Thank you for your comment. The
application of the standards across
health and social care has been
emphasised within the document. The
lead professional or organisation is for
local determination.
6
Recommend social work /personal carers
receive education on skin care a pressure ulcer
prevention as part of their induction
Thank you for your comment. The
standards are intended for all health and
social care providers and staff.
Education, training and information for
everyone are specified within Standard 2.
9
Include pressure ulcer prevention in
theatres/maternity care
Thank you for your comment. The
standards are intended to apply to all
care settings and specialties. We are
unable to list all areas in the document.
11
I think the standards potentially create a gap
that the old best practice statement tried to
occupy by showing ‘what to do.’ If the
standards are too high level then there is a risk
that the practical steps that can be taken by any
nurse will be overlooked. Then there will have
to be a supplementary piece of guidance on
what should be done….and a risk that we have a
publishing machine developing! Has the
evidence changed much since the old best
practice statements were developed to merit
anything other than a light touch refresh and
reissue?
Thank you for your comment. The
standards are intended to complement
the best practice statement, which
provides more detailed guidance on
treatment options. An update of the best
practice statement is outwith the scope
of these standards.
12
Avoiding preventable pressure ulcers is one
element of good care and related to other areas
of care such as nutrition, movement, looking
after a patient’s skin, checking for incontinence
and so on. There is a risk that this element of
care becomes a sole focus of care. If there are
to be standards should these encourage a
holistic view of patient care that connects to
these other elements? (What about generic
care standards?)
Thank you for your comment. Other
factors in the prevention of pressure
ulcers have been referenced throughout
the document. The person-centred
approach is central to the prevention and
management of pressure ulcers.
5
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comment
Response
13
Training and education – do they make a
difference? What do you mean by these? I
suggest that this is linked to general education
on the care bundle approach and that the
importance of ‘real time’ teaching and learning
in the course of daily practice is stressed.
Thank you for your comment. The role of
training and education has been clarified
within the standards along with
examples such as care bundle approach
and other training and education
packages.
14
If there are already good resources available
these need only be signposted – for the
majority of nurses learning to prevent the
preventable is what matters. I would challenge
the group to include reference to the care
bundle and parallel use of improvement
methodology – eg ‘days between’ pressure
ulcers for wards, rather than advocating old
fashioned training and education that is
resource based and delivered outside the care
environment.
Thank you for your comment. We have
signposted the relevant resources and
improvement methodology throughout
the document.
15
Whilst our work is evidence based it should not
be complex if it does not need to be. The
relationship to good care needs to be stressed
and a few key references should suffice. We
need to be clear on our role here – supplying
enough evidence to support healthcare
practitioners – ultimately to contribute to
improving the quality of healthcare and the
health of the population.
Thank you for your comment. The
standards are not intended to be
complex and the evidence supporting the
document is very concise.
18
Avoidable & Unavoidable Pressure Ulcers - how
to decide
Thank you for your comment. The
project group members have not
differentiated between avoidable and
unavoidable pressure ulcers, as the
important aspects are around
assessment, management and
prevention.
28
With reference to the Vale of Leven report,
recommendations for Tissue Viability service
provision.
Thank you for your comment. The
relevant Vale of Leven recommendations
have been considered and referenced
within the standards.
30
Roles, remit & responsibilities – clarity
regarding individual roles & responsibilities for
registered and unregistered staff, and AHPs
within healthcare. Requirements for escalation.
Thank you for your comment. Although
the standards provide generic criteria
and examples in relation to staff,
escalation, assessment and
communication, the detail around
6
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comment
Response
Assessment and communication expected.
individual roles and responsibilities is for
local determination.
31
Education & training needs to reflect roles,
remit and responsibilities.
Thank you for your comment. Standard 2
includes education and training that is
appropriate to staff roles and work place
context.
33
Expectation of level of investigation when PU
identified and then outcome / reporting of
outcome to demonstrate learning from PU
occurrence review (needs to be explicit for non
NHS healthcare providers).
Thank you for your comment. Although
the standards provide general criteria
around reporting, the detail around level
of investigation is for local
determination.
34
With reference to the Vale of Leven report,
recommendations for Tissue Viability service
provision. Structures embedded within
organisations, and responsibilities to the
broader communities.
Thank you for your comment. The
relevant Vale of Leven recommendations
have been considered and addressed
within the standards.
36
The introduction of Mepilex Border Sacrum and
Mepilex Border as dressings used as an
additional preventive therapy in the formation
of Pressure ulcers.
Thank you for your comment.
Recommendations on specific dressings
are outwith the remit of standards
development.
39
Should prevention of pressure ulcers be a stand
alone item with assessment and management
coming under one umbrella? Slight concern that
prevention and identifying those at risk could
get lost or be diluted.
Thank you for your comment. The
scoping report intended to outline the
broad themes for the standards. A
standard on prevention is presented on
its own.
40
The introduction says that tissue viability
services need reviewed. This is not being
addressed within this standard- will it be
addressed elsewhere?
Thank you for your comment. The review
of tissue viability services is outwith the
scope of these standards. The standards
focus specifically on prevention and
management of pressure ulcers.
50
Avoiding delays in people coming into care with
acute conditions – see categories above.
Ambulance services, A&E departments,
radiology and imaging departments, and
matters such as procurement of beds and
trolleys, as well as clinician and manager
training and education need to be within scope.
Thank you for your comment. The matter
of avoiding delays is outwith the scope of
the standards. Staff training and
education is addressed in Standard 2.
52
Does training and education contain advice
around equipment i.e. beds. Mattresses etc?
Thank you for your comments. Training
and education is addressed in Standard
7
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
54
Scope engagement comment
Response
Does it give details on how care home settings
can seek advice?
2. The content of pathways and protocols
for seeking specialist advice and
equipment is for local determination.
The areas that will be covered seem appropriate
but the ‘Areas that will not be covered’ seem
surprisingly specific. Might it be better to simply
state:
Thank you for your comment. The
scoping report provides a broad
overview of the areas to be included
within the standards.
“Acute and chronic wounds not due to pressure
damage” (rather than making what would need
to be a very long list of different types of
wounds?)
55
It would be good to include a section on multidisciplinary team this is fundamental to high
quality care to prevent and heal pressure ulcers.
Therefore, it would be good to have some
standards for best practice in relation to interprofessional multidisciplinary team working.
Thank you for your comment. Standard 1
refers to multidisciplinary working and is
referred to throughout the document.
Best practice for interprofessional
multidisciplinary working is for local
determination.
58
Pressure ulcers also affect younger individuals
who have severe oedema, multiple skin folds,
unusual body configuration and also bariatric
patients.
Thank you for your comment. The
standards cover all people at risk of, or
identified with, a pressure ulcer.
59
Last year at age 31 due to severe oedema and
resultant no ‘thigh gap’ I developed grade 2
pressure sores.
Thank you for your comment.
60
I have also nursed bariatric patients who have
had pressure sores. The population is changing
with more and more morbidly obese patients
presenting, I feel this area should be addressed.
Thank you for your comment. The
standards cover all people at risk of, or
identified with, a pressure ulcer. It is not
possible to provide specific list of patient
groups.
62
It would be useful to specify what
standards/competency is to be expected of
nurses, midwifes and doctors when assessing
pressure ulcers.
Thank you for your comments. Specific
competencies for staff groups are for
local determination. Standard 2 provides
criteria on education and training.
I had experience of having to show my pressure
ulcers to several different midwives, a doctor
and a nurse- on several different occasionsneither of whom could make a decision on what
to do and what dressing to apply so I had to
wait three days (whilst an in-patient) to see a
tissue viability nurse before my grade 2 ulcer
8
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comment
Response
was assessed and dressed- despite me making a
recommendation of a suitable dressing from the
joint formulary for wound dressings and
explaining my rationale.
My ulcers were in a sensitive area and repeat
exposure for people to look ‘and do nothing’
but say Im not sure what to do so I’ll get
someone else to look on several occasions was
distressing, not to mention the delay in healing
time and resultant pain from the ulcers.
65
Within bullet point 1 of the above section, we
suggest it should read “prevention and
assessment”. Alternatively these could be split
into separate bullet points.
Thank you for your comment. The
scoping document provides an overview
of the areas included within the
standards. Prevention and assessment
are presented as separate sections in the
standards.
66
Overall we think the areas suggested cover the
main points around pressure ulcers. However,
consideration should be given to prevention
having a section on its own, which would be
followed by sections on assessment and
management.
Thank you for your comment. Prevention
and assessment are presented as
separate sections in the standards.
67
The third bullet point of section 4.3(a) ‘Areas for
standard development’, refers to “patient
information and communication”. This may be
helpful in an acute or community health setting,
but is not a helpful way to describe people who
use care services.
Thank you for your comment. It was
agreed following the scope engagement
exercise that there would not be a
standard specifically for information and
communication as it is woven throughout
the standards.
68
We would suggest the following links to
additional references be considered for
inclusion:
Thank you for the references. All
references have been considered. Any
references that support the standards,
rationale and criteria have been included
within the standards.
•
•
•
Care...about physical activity and the
Managing Falls and Fractures resources as
this has an impact on this issue.
The Care Inspectorate’s ‘Promoting
Continence for People living with Dementia
and Long Term Conditions’
Information on the Personal Footcare
Guidance developed by the SG around
caring for your own feet and caring for
someone else’s feet.
9
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comment
Response
•
69
Evidence on end of life care and pressure
ulcers and the approach to be
recommended with management of this
area at this time in a person’s life.
We also note that the short scoping report and
“key documents and sources” are all relate only
to current practice in Scotland. While this is
helpful, it may also be helpful to ensure that a
wider search be undertaken when the
standards are being reviewed. For example, the
NICE guideline on pressure ulcers (CG179)
published in April 2014, may help inform the
development.
Thank you for your comment. A full
literature search and review, including
recently published guidance, have been
undertaken and a wider list of references
included within the appendices.
77
To fully enhance person centred care, it would
be beneficial that there are patient stories
contained within the standards. This would
highlight the importance of:
1. Risk identification & risk assessment of
pressure ulcers.
2. Patient/family centred care
Thank you for your comment. We do not
normally include patient stories within
the standards. We do, however, make
strong reference to person-centred care
and we will be running some focus
groups with service users and carers
during consultation of the draft
standards to ensure that this is
enhanced.
78
Under section 4.3 suggest an amendment to the
1st and 2nd bullet points to read:
• Risk assessment and prevention of pressure
ulcers. ( this provides clarity regarding what
we are assessing)
• Assessment, diagnosis and treatment of
pressure ulcers. (this keeps terminology in
line with other published pressure ulcer
standards)
• Education and training of Registered Nurses
and Support workers. (This has to be clear
on standards applied to each group of staff)
Thank you for your comment. The
scoping report outlined the broad
headings which form the basis of
individual standards. Please refer to the
standards for the detail under each
section.
79
Skin Excoriation due to moisture is not
mentioned either in areas to be included or
excluded. Suggest this is given some
consideration as it is a fairly common skin
occurrence and occasions can be misinterpreted
as “bedsores”
As already stated diabetes inpatients within
acute hospitals is an issue but this problem will
also transcend into care homes, social care and
Thank you for your comment. Moisture
lesions have been included within the
standards.
82
10
Thank you for your comment. The
standards cover all people at risk of, or
identified with, a pressure ulcer. We are
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comment
Response
community settings.
unable to provide standards on specific
conditions.
Although diabetes is my main focus this
problem of acquired heel ulceration also effects
other vulnerable groups such as vascular
patients, patients in theatre, the frail, the
elderly and the malnourished.
86
The scope does not specify those patients who
are immune compromised – particularly
diabetic patients where sensory periphery
neuropathy can have an adverse effect resulting
in development of pressure heel ulcers.
Podiatry have concerns that this group of
vulnerable patients may be overlooked in the
hospital settings, nursing homes etc.
Thank you for your comment. The
standards cover all people at risk of, or
identified with, a pressure ulcer. It is not
possible to provide a list of specific
patient groups.
87
Guidance for health boards on organisational
expectations of prevention and management –
defining ownership of responsibility including
availability of equipment, management,
reporting and training
Thank you for your comment. We have
included a standard on leadership and
governance, and this is also addressed
throughout the standards.
92
Monitoring and maintaining standards
Thank you for your comment. This has
been included within the standards.
109
Training to support those carrying out the care
to assess and provide pressure relieving devices
timeously and appropriately
Thank you for your comment. These
areas have been incorporated into the
standards.
113
Further comments on scope: 4.3a bullet point,
change to wording
Thank you for your comment. The
scoping report outlines the broad themes
within the standards. The final wording
of standard statements was agreed
during development.
1) Should this be assessment of risk - on its
own
2) Strategies for the prevention of pressure
ulcers
3) Management of pressure ulcers
4) Enabling patients/carers
5) Staff Education
114
4.3 b
Moisture lesions should also be an exclusion or
have a section within the document with a
specific definition for staff to so that there is
some consistency in the definition to exclude as
a pressure ulcer.
Is there to be any mention of avoidable or
unavoidable ulcers and a definition/criteria?
11
Thank you for your comment. The
project group members have decided to
include moisture lesions. After
discussion, it was not agreed to
differentiate between avoidable and
unavoidable.
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comment
Response
116
1) Governance, reporting and documentation
– principles.
Thank you for your comment. The
project group members have included
this within Standard 1.
118
The scoping exercise definition of a pressure
ulcer, states that pressure ulcers mainly occur in
older people and reads as if it is older people
with other conditions not other conditions as
well, it also does not include neurological or
vascular conditions, perhaps the NICE definition
would be more useful:-
Thank you for your comment. The
Healthcare Improvement Scotland
project team has included a different
definition of pressure ulcers within the
introductory section of the standards.
This has been taken from the Healthcare
Improvement Scotland tissue viability
‘Pressure ulcers are caused when an area of skin webpage and reference to older people
and the tissues below are damaged as a result
has been removed.
of being placed under pressure sufficient to
impair its blood supply. Typically they occur in a
person confined to bed or a chair by an illness
and as a result they are sometimes referred to
as ‘bedsores’, or ‘pressure sores’.
All patients are potentially at risk of developing
a pressure ulcer. However they are more likely
to occur in people who are seriously ill, have a
neurological condition, impaired mobility,
impaired nutrition, or poor posture or a
deformity. Also, the use of equipment such as
seating or beds which are not specifically
designed to provide pressure relief, can cause
pressure ulcers. As pressure ulcers can arise in a
number of ways, interventions for prevention
and treatment need to be applicable across a
wide range of settings including community and
secondary care. This may require organisational
and individual change and a commitment to
effective delivery.
120
Education/ training should include, patients,
carers and staff.
Thank you for your comment. Standard 2
outlines education and training, and
information for staff, people and their
representatives.
121
Ensure that there are links to the FFNC
standards. We are not sure if it is the remit of
these standards to formally include nutrition
when they are already outlined very robustly
elsewhere, but would want ensure that through
these standards that this is made reference to.
Thank you for your comment. The
standards reference other Healthcare
Improvement Scotland standards where
appropriate.
125
There is a developing link between people
developing pressure ulcers and adult support
and protection issues which has been
Thank you for your comment. Adult
support and protection issues are
12
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comment
Response
highlighted in some areas during large scale
investigations under adult support and
protection. Many areas are now considering the
inclusion of a threshold around when a pressure
ulcer becomes an adult protection issue. It
would be useful and in line with practitioners
legal duties for the new HIS standard to include
a statement for those treating pressure ulcers
regarding when a referral under the Adult
Support and Protection (Scotland) Act 2007
would be required.
outwith the scope of the standards.
127
Education and training- patient, carers, family
and private care providers to be included
Thank you for your comment. All groups
have been included within Standard 2
“Education, Training and Information”.
128
Secure units – HMP Prisons and young
offenders to be included. Practice nursing and
GPs.
Thank you for your comment. The
standards are intended to apply to all
care settings and specialties. We are
unable to list all areas specifically.
132
does the scope include people’s own homes
under ‘community settings’?
Thank you for your comment. It is agreed
that homes are included within the
standards.
136
Will ‘education and communication’ include
what is expected of effective communication
between staff during periods of transition, eg
between wards/hospitals/discharges to care
homes/own homes etc and between acute and
community staff?
Thank you for your comment.
Communication during transition
between staff involved is included within
the standards.
137
There needs to be reference to the strategic
leadership of pressure ulcers as part of a tissue
viability service within a NHS Board or other
settings. A strategic policy along with associated
action plan should be included within the first
standard.
Thank you for your comment. This has
been included under Standard 1
“Leadership and Governance”.
139
Outputs from scrutiny/inspection processes
should be recognised and captured within local
improvement plans
Thank you for your comment. This has
been captured throughout the standards
particularly within the examples of
evidence sections.
140
The standards should clearly outline the role of
tissue viability teams / specialist registered
nurses who have specialist knowledge, training
Thank you for your comments. We have
made reference to specialty teams.
However, specific details relating to their
13
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comment
Response
and expertise and their remit, e.g. specialist
advice, review of patients, investigation of
clinical incidents and complaints and education
and training of staff. It should be clear who is
providing expert advice, writing treatment plans
and devising and delivering specialist education
and training to members of staff is
appropriately trained and possesses a
recognised specialist post-registration
qualification (reference to Vale of Leven
recommendation 23).
roles and responsibilities are for local
determination and outwith the scope of
these standards.
141
In relation to ‘assessment and prevention’
section, could the standards clearly state that
initial and on-going assessment, referrals as well
as care planning should be undertaken by a
registered nurse? When undertaking multifactorial assessments, the clinical knowledge,
judgement and experience of a staff nurse is
necessary. These tasks cannot be undertaken by
a support worker, however HCSWs should be
following and undertaking certain identified
aspects of care under the direction of the
registered nurse.
Thank you for your comment. The
standards are applicable to all settings
within health and social care. The project
group members agreed that this would
be for local determination. There is a
criterion within Standard 6 specifically on
grading of an identified pressure ulcer to
be carried out by a registered health
professional.
142
If other types of ulcers and wounds are not
being included, could there be clear referral to
other guidance/standards for the management
of these?
Thank you for your comments. The
standards refer to other standards and
guidance where appropriate.
144
Although I think in the opening paragraph we
should remove ‘older people’ it is not just older
people who develop pressure areas or require
assessment.
Thank you for your comment. The
definition of pressure ulcers has been
amended for the standards.
149
In this section possibly mention a summary of
the risk factors which from reflection of
previous incidents has been the driver for
change. I notice it discusses factors such as age,
poor nutrition etc. However, human factors are
key also. My guess is there will be incidents in
the past around lack of communication, poor
record keeping, lack of K&U of offloading
devices available, non sharing of risk factors
such as poor vascular status, diabetes etc etc
Thank you for your comment. Risk factor
assessment and learning has been
included within the standards.
14
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
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Scope engagement comment
Response
155
However my only comment would be that I
don’t like the definition used in section 3, where
it talks about PUs occurring in older people, but
the scope of the standards says that it will cover
all ages. And apart from the focus on older
people, I think the definition needs to be reworded e.g. pressure ulcers are areas of tissue
damage that CAN occur in ......
Thank you for your comment. The
definition of pressure ulcers has been
amended for the standards.
158
Where reference is made in the document to
“education”, it could be worth stating the target
groups
Thank you for your comment. The
standards are intended for all health and
social care professionals involved in the
prevention and management of pressure
ulcers.
15
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
Assessment and prevention of pressure ulcers
ID
Scope engagement comments
Response
10
Prevention and Treatment of Pressure Ulcers
2014 European pressure ulcer advisory panel,
pan pacific pressure injury alliance and national
pressure ulcer advisory panel
Thank you for the reference. All
references have been considered and
included where relevant.
17
Reporting of Pressure Ulcers
Thank you for your comment.
Reporting of pressure ulcers has been
included within the standards.
19
Device related Pressure Ulcers
Thank you for your comment. The
standards cover the assessment,
management and prevention of all
pressure ulcers regardless of how they
are acquired.
23
This may come under ‘education and training’
but I think the necessity of recording pressure
ulcer incidents and guidance on the reporting of
these pressure ulcers should be included.
Thank you for your comment. This has
been included within the standards.
25
The reference list has a good variety of current
key sources. However, I think the 2014 Scottish
Adapted EPAUP Grading Tool should be
included, perhaps as an appendix.
Thank you for the reference. The
Scottish Adapted EPUAP Grading Tool
has been referenced within the
standards.
27
Incidence reporting and investigation around
pressure ulcers, Datix, REI, SAER.
Thank you for your comment. This has
been included within the standards.
32
I presume the management of PU relates to the
clinical management of PU rather than the
leadership and management of PU
development – think this needs to be explicit in
regard of audit, monitoring, compliance with
standards, action on identification of PU,
minimum level of input patient with suspected /
actual PU should expect – reporting of
outcomes.
Thank you for your comment. The
standards differentiate between clinical
management and organisational
leadership and management.
48
My comments relate to prevention, education
and training, and are also relevant to data
collection and analysis, and improvement
science.I have studied the epidemiology of
pressure ulcers – long ago but the key messages
have not altered. The received wisdom in
prevention is a function of quality of care for
Thank you for your comment. High risk
groups are included within the
standards.
16
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comments
Response
people already in care. The key opportunities in
prevention should be joined by:
1. The general health of the at-risk population
– people with long-term conditions and
who are vulnerable to progressive or
recurrent neurological conditions, vascular
disease and orthopaedic trauma.
49
2. Rapid detection of people who may be
vulnerable and who encounter an acute
problem, their social and informal personal
care and networks. That is a function of
effective integrated social and health care
with good local networks and information
sharing.
Thank you for your comment. Rapid
detection as described is outwith the
scope of the standards.
53
From a podiatry point where we are looking at
ulcer prevention one of my observations is
around maleolar ulceration and in some cases
toe ulceration. Feet are neglected when the
checks are being made and unfortunately some
toe ulceration is present after admission which
with some care the risk could have been
established and preventative devices regimes
put in place. For those with Diabetes CPR
should cover this but those who have arterial
disease or neuropathy are often not picked up
on. One of the questions we all aske when
looking at a red area or ulcer is is it sore? We
then take the feedback and base anything on
that In neuropathy this will always be
something like it’s fine. We need to get into the
habit of checking for neuropathy then checking
for vulnerable areas with the neurological
status in mind. This is possibly more pertinent
in feet. Possible neurological impairment
maybe due to higher level injury, alcoholism or
B12 anaemia, which in the main are not
apparent to the eye.
Thank you for your comment. The
standards cover all people at risk of, or
identified with, a pressure ulcer. It is
outwith the remit of the standards to
go into detail for specific patient
populations.
56
NPUAP, EPUAP, et al. (2014). Prevention and
treatment of pressure ulcers: clinical practice
guideline. E. Haesler. Osborne Park, Western
Australia, Cambridge Media.
Thank you for the reference. All
references have been considered and
included where relevant.
IHI (2011). How-to Guide: Prevent Pressure
17
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comments
Response
Ulcers. Cambridge, MA: , Institute for
Healthcare Improvement
61
Camden, S. (2008) Pressure Ulcers, CMS
Changes, and patients of Size: What are the
issues? Bariatric Times available at
http://bariatrictimes.com/pressure-ulcers-cmschanges-and-patients-of-size-what-are-theissues/ last accessed 23.06.2015
Thank you for the reference. All
references have been considered and
included where relevant.
64
Within the section 4.3(a) ‘Areas for standard
development’, we are unclear if diabetic foot
ulcers caused by pressure are intended to be
included.
Thank you for your comment. The
standards cover all people at risk of, or
identified with, a pressure ulcer. It is
outwith the remit of the standards to
go into detail for specific patient
populations.
80
National Pressure Ulcers Advisory Panel
Thank you for the reference. All
references have been considered and
included where relevant.
European Pressure ulcer Advisory Panel and
Pan Pacific Pressure Injury Alliance
Prevention and Treatment of Pressure Ulcers:
Quick Reference Guide
Emily Haesler (ED), Cambridge Media: Perth
Australia 2014
National Institute for Clinical Excellence (NICE)
Pressure Ulcer: Prevention & Management of
Pressure Ulcer. (2014)
81
As Diabetes Foot Coordinator for Scotland and
the person who set up the Scottish Diabetes
Foot Action Group (which is a group supported
by the Scottish Government) I carried out a
‘snap shot’ inpatient Audit of 1,048 inpatients
with diabetes in Acute hospitals across Scotland
in November 2013, which revealed;
2.4% of in patients with diabetes developed a
new foot lesion whilst in hospital.
57% of in patients had not had their feet
checked. 60% who were discovered to be at risk
of developing a foot ulcer did not have any
pressure relief in place. (Scottish Diabetes Foot
Action Group 2013)
I feel that this very vulnerable group of patients
needs to be highlighted to prevent the
18
Thank you for your comment. The
standards cover all people at risk of, or
identified with, a pressure ulcer. It is
outwith the remit of the standards to
list all specific patient groups.
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comments
Response
development of avoidable pressure ulcers
(generally around the heel area).It is
unacceptable in a climate of ‘Zero tolerance’
and current national initiatives that such a
problem exists. I am sure highlighting this
within the document would help raise
awareness and hopefully go a long way to
eradicating this not only very costly problem
but would improve the QOL of the patient in
our care.
83
I have launched an inpatient campaign called
CPR for diabetic feet. This is to try and ensure
on admission to hospital;
Thank you for the reference. All
references have been considered and
included where relevant.
All patients with Diabetes have their feet
Checked
If they are at risk they would have their feet
Protected
If they have an existing problem they are
Referred
This is a simple campaign which is supported by
the Scottish Government and Diabetes UK are
looking to adopt within their inpatient
campaign for the whole of the UK. As I have
stated this campaign is at present targeted at
patients with diabetes but I do see it expanding
to the other vulnerable groups of patients and
could for these groups simply become CPR for
‘at risk’ feet.
89
Possibly management of darker skin
pigmentation in relation to assessment and
prevention
Thank you for your comment. Skin
colour change is referred to in Standard
3.
94
The (a) inclusive, multi-disciplinary
development and (b) universal enforcement of
pressure ulcers prevention programs (PUPPs)
for the assessment and prevention of pressure
ulcers are key ingredients required to enable
best outcomes.
Thank you for your comment. The
standards address working across
professions and settings. In addition,
the standards reference improvement
work to support the prevention of
pressure ulcers.
95
Heel Pressure Ulcers (HPUs) are more easily
treatable and entirely preventable with an
effective PUPP (see #1) and properly applied
Thank you for your comment. The
standards cover all people at risk of, or
identified with, a pressure ulcer. It is
19
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comments
Response
and monitored specialty support surface
devices for the heel that (a) completely elevate
the heel by redistributing pressure along the
calf, while (b) offering forefoot support to
maintain the foot at neutral dorsi-flexion, and
(c) providing enough lower leg support to
enable partial flexion of the knee at complete
rest
outwith the remit of the standards to
list all specific patient groups.
96
Even if only page 27 of the
EPUAP/NPUAP/PPPIA Guidelines is replicated,
the new PU Standards be far more practical,
effective, and congruent with current global
best practices than existing NICE Guideline 179.
Thank you for the reference. All
references have been considered and
included where relevant.
97
EPUAP, NPUAP, PPPIA, “Prevention and
Treatment of Pressure Ulcers: Quick Reference
Guide”,
Thank you for the reference. All
references have been considered and
included where relevant.
Donnelly, J., J. Winder, W.G. Kernohan, and M.
Stevenson, “An RCT to Determine the Effect of a
Heel Elevation Device in Pressure Ulcer
Prevention Post-Hip Fracture,” Journal of
Wound Care. July 2011
McInerney J. Reducing Hospital-Acquired
Pressure Ulcer Prevalence Through a Focused
Prevention Program. Advances in Skin & Wound
Care, 21(2): 75-8, February 2008.
Bales, Isabel, “A Comparison Between the Use
of Intravenous Bags and the Heelift Suspension
Boot to Prevent Pressure Ulcers in Orthopedic
Patients,” Advances in Skin & Wound Care.
March 2012, p. 129
Drennan, Denis, “Why Now is the Time for a
Multidisciplinary Approach to Preventing Heel
Pressure Ulcers”. Kestrel Health Information
White Paper
Fowler E, Scott-Williams S, McGuire JB.,
“Practice recommendations for preventing heel
pressure ulcers.” Ostomy Wound Manage. 2008
Oct;54(10):42-8, 50-2, 54-7
101
Yes please reference the following NHS
Education for Scotland resources applicable to
20
Thank you for the reference. All
references have been considered and
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comments
Response
Pressure Ulcer Prevention
included where relevant.
http://www.nes.scot.nhs.uk/education-andtraining/by-theme-initiative/healthcareassociated-infections/online-short-courses/theprevention-and-management-of-pressureulcers.aspx
http://www.nes.scot.nhs.uk/education-andtraining/by-theme-initiative/healthcareassociated-infections/educationalprogrammes/tissue-viability.aspx
NHS Education for Scotland e-learning
programme on The prevention and
management of Pressure Ulcers and Workbook
have been updated to reflect the new European
guidance (reference below).
The resource “Creating Viable Option Tool”
which informs the educational needs for staff in
health and social care, is currently being
reviewed and we are awaiting comments from
Scottish Social Services Council.
102
EPUAP (2014. Prevention and Treatment of
Pressure Ulcer. National Pressure Ulcer Advisory
Panel, European Pressure Ulcer Advisory Panel
and Pan Pacific Pressure Injury Alliance. Second
edition. London: Cambridge Media.
Thank you for the reference. All
references have been considered and
included where relevant.
104
Appears to be fairly comprehensive covering all
age groups and all locations for those at
risk.Two queries:
Thank you for your comments. The
standards are intended to cover all
people at risk of, or identified with, a
pressure ulcer. We are unable to go
into detail for specific conditions.
1) Will the standard be including Diabetic foot
ulcers as these are not specifically
mentioned under ‘Areas that will not be
covered’ (page 3). Will there be guidance
on how to differentiate between a diabetic
foot ulcer and a pressure ulcer on a diabetic
patient?
105
2) Will the standard address ‘device related’
pressure ulcers as these have been
identified as a problem locally?
21
Thank you for your comment. The
standards cover the assessment,
management and prevention of all
pressure ulcers regardless of how they
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comments
Response
developed.
106
1) NPUAP*, EPUAP*, PPPIA*; Prevention and
Treatment of Pressure Ulcers: Quick Ref Guide.
Emily Haesler (Ed.) Cambridge Media: Osbourne
Park, Western Australia; 2014 – May need to
refer to complete document but this is not
available free it has to purchased via NPUAP or
EPUAP websites.
Thank you for the reference. All
references have been considered and
included where relevant.
*NPUAP – National Pressure Ulcer Advisory
Panel
*EPUAP – European Pressure Ulcer Advisory
Panel
*PPPIA – Pan Pacific Pressure Injury Alliance
2) Wounds UK. Best Practice Statement.
Eliminating pressure ulcers. London: Wounds
UK 2013
3) Wounds UK. Best Practice Statement. Care of
the Older Person’s Skin London: Wounds UK
2012 (Second Edition)
110
Standard approach to the “high risk foot” which
may include long term conditions such as
diabetes , vascular compromised ,rheumatoid,
connective tissue conditions or just frail elderly
Thank you for your comments. The
standards are intended to cover all
people at risk of, or identified with, a
pressure ulcer. We are unable to go
into detail for specific conditions. All
references have been considered and
included where relevant.
117
Identification of Pressure ulcer and Grading.
Thank you for your comment. This is
included within the standards.
119
Standardisation of documentation –including
wound charts and guidance around
photographs of wounds.
Thank you for your comments.
Examples of documentation and best
practice have been provided. These
standards apply to private and
independent healthcare providers also.
Should/could it be made explicit that private
providers of care would be advised to work to
these standards.
122
The EPUAP /NUAP 2014 prevention and
management of pressure ulcers should be
referenced.
22
Thank you for the reference. All
references have been considered and
included where relevant.
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comments
Response
123
Mention of good nutrition in prevention and
healing perhaps.
Thank you for the reference. All
references have been considered and
included where relevant.
124
Clear clinical criteria should be set for any
potential risk assessments for CYP, do not wish
to mass screen for all admissions as pressure
ulcer rate within this client group is low – need
to have staff engagement – mass screening of
all admissions to unit will not engage staff. For
example – post op children / post POP
applications, non ambulant children, ng / sats
probe placement etc.
Standardisation of documentation and clear
guidance on expectations of photography of
wounds
Thank you for your comment. Standard
3 includes risk assessments for all
people regardless of age or care
setting.
133
Under ‘assessment’ – can the standards clearly
state, with evidence/rationale, that a
recognised tool be used for the initial and ongoing risk assessment of pressure ulcers for
patients, following use of PPURA, if in use?
(Reference Vale of Leven recommendation no.
25). Some health boards have adapted ‘PPURA’
to ‘PURA’ and have discontinued use of any
other recognised multi-factorial validated
assessment tool. (It was understood that PPURA
was an initial short assessment only, and those
patients who were identified as ‘at risk’ would
have a more comprehensive, validated
assessment tool completed?) However, in some
NHS Boards, patients who are identified as
being ‘at risk’ from the locally adapted ‘PURA’
are not having any in-depth assessment carried
out on an individual basis when required, but
instead all patients have a brief ?4 step ‘PURA’
process carried out every day. This does not
seem to target those patients most at risk who
require more in-depth assessment or
demonstrate person-centred care?
Thank you for your comments. Risk
assessment tools have been specifically
referenced and examples provided. The
standards also provide criteria on initial
assessment and full assessment.
138
Governance and reporting structures as well as
the production of an annual report on pressure
ulcers, incidence data, use of incident reporting
(e.g. datix) and shared learning should be
Thank you for your comment. The
standards reference governance and
reporting structures throughout.
130
23
Thank you for your comment.
Documentation has been included
within the standards and reference
made to wound photography with the
person’s permission within Standard 6.
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
ID
Scope engagement comments
Response
included.
143
HIS Standards for complex nutrition (when
published later in 2015)
Thank you for the reference. All
references have been considered and
included where relevant.
150
Also as the new standard is there to prevent
ulcers from happening in the future- you may
want to include a section on what to do in
terms of reporting one that has developed. You
might be covered this under management of
the wound?
Thank you for your comment. This has
been included within the standards.
Overall, it seems to cover everything, my
suggestions may not be relevant to this
document or are covered with the titles you
already mention.
24
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
Management of pressure ulcers
ID
Scope engagement comments
Number
Response
90
It is good to see that care homes, social care
Thank you for your comment.
and community settings are included as primary
care would benefit from similar initiatives to the
ones that SPSP has developed in the acute
setting. It will be helpful to draw on the
information they have gained to develop
standards that will address the specific needs of
people being cared for in a homely setting
134
Will care planning and treatment plans be
covered under ‘management of pressure
ulcers’? It would be useful if the standards are
explicit in terms of what constitutes ‘effective
management’ and also the expected
appropriate documentation which evidences
effective management. (Ref Vale of Leven
no.26, 27)
Thank you for your comments. Care
planning and treatment plans have
been covered throughout the
standards. Criteria and examples have
been provided in relation to
management and documentation.
135
Will access to equipment be included under
‘management’?
Thank you for your comment. The
project group considered this and
agreed that access to equipment is
included within the standards.
4
Ensure that we cover management of pain and
its relation to pressure ulcer development,
children with special needs
Thank you for your comments. Pain
management has been referred to. The
standards apply to all people at risk of
developing pressure ulcers.
63
Another issue I feel should be addressed is
equipment availability. Certainly through my
experience there was a lack of knowledge about
prevention and pressure relief in relation to
appropriate seating. To paint the picture I had
pitting oedema +++ up to my waist and was
chair bound whilst an in patient and the
available seating was to narrow thus causing
further pressure on my inner and outer thighs
as I was ‘squashed’ into the chair.
Thank you for your comments. This has
been included within the standards.
When I suggested using a wider seat there
seemed to be a lack of understanding as to why
this would be appropriate and was told there
were none available. There seems to be a lot of
knowledge and understanding about pressure
25
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
‘bottom up’ and alternating airflow seat
cushions available however limited
thought/knowledge regarding pressure ‘from
the sides’ when assessing a patient for seating
in relation to pressure risk.
108
Prevention & Management to include:
The assessment for, easy access and provision
of pressure relieving devices where appropriate
99
Charge Nurses have asked if these could be
included
•
Use of appropriate dressings if
breakdown in skin occurs
•
Use of barrier creams at all times
•
Use of chart documentation
Thank you for your comment. This has
been included within the standards.
Thank you for your comment. We are
unable to go into the specifics of
treatment. However, the standards
include other relevant guidance in
relation to dressings, creams which can
be made referred to. In terms of chart
documentation, this is mentioned
under examples of evidence under
appropriate standards.
129
Treatment of pressure ulcers ie bloods,
supplements, prescribed equipment, dressings
and guidance on changing dressings.
Thank you for your comment. The
standards do not go into detail in
relation to specific treatment and
management options.
7
From local SAER specify detailed
communication from hospital to community
nurses on discharge home when patients risk
level had changed due to acute illness
Thank you for your comment. Effective
communication on transfer between
settings is included within the
standards.
8
Include communication with ambulance
services and provision of pressure reducing
surfaces when travelling in patient transport.
Thank you for your comment.
Communication between all staff in
different settings is included.
91
Carer information and communication
Thank you for your comment.
Information and communication with
individuals with pressure ulcers and
their carer is woven throughout the
document.
2
The health technology assessment on
antimicrobial wound dressings for wounds will
be published in October 2015. It includes the
evidence separately for pressure ulcers. It also
includes a patient issues chapter, and results of
a staff survey, which may be of interest.
Thank you for the reference. All
references have been considered and
included where appropriate.
10
Prevention and Treatment of Pressure Ulcers
2014 European pressure ulcer advisory panel,
Thank you for the reference. All
references have been considered and
26
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
37
pan pacific pressure injury alliance and national
pressure ulcer advisory panel
included where appropriate.
In relation to prophylactic dressings:
Thank you for the references. This level
of detail is outwith the remit of the
standards.
Prophylactic dressing application to reduce
pressure ulcer formation in cardiac surgery
patients. Journal of Wound Ostomy and
Continence Nursing 2012; 39(2): 133-142
Brindle, CT., Wegelin, J.A.
Microclimate impact of prophylactic dressings
using in vitro body analog method
Wounds 2013; 25(4):94-103
Call, E., Pedersen, J., Bill, B., Oberg, C.,
Ferguson-Pell, M.
Dressings as an adjunct to pressure ulcer
prevention: consensus panel recommendations
International Wound Journal 2014; doi:
10.1111/iwj.12197
Black, J., Clark, M., Dealey, C., Brindle, C.T.,
Alves, P., Santamaria, N., Call, E.
An estimate of the potential budget impact of
using prophylactic dressings to prevent
hospital-acquired Pus in Australia
Journal of Wound Care 2014; 23(11):583-589
Santamaria, N., Santamaria, H.
56
NPUAP, EPUAP, et al. (2014). Prevention and
treatment of pressure ulcers: clinical practice
guideline. E. Haesler. Osborne Park, Western
Australia, Cambridge Media.
Thank you for the reference. All
references have been considered and
included where relevant.
IHI (2011). How-to Guide: Prevent Pressure
Ulcers. Cambridge, MA: , Institute for
Healthcare Improvement
80
National Pressure Ulcers Advisory Panel
European Pressure ulcer Advisory Panel and
Pan Pacific Pressure Injury Alliance
Prevention and Treatment of Pressure Ulcers:
Quick Reference Guide
Emily Haesler (ED), Cambridge Media: Perth
Australia 2014
National Institute for Clinical Excellence (NICE)
Pressure Ulcer: Prevention & Management of
Pressure Ulcer. (2014)
27
Thank you for the reference. All
references have been considered and
included where relevant.
Prevention and management of pressure ulcers draft standards: scope engagement report – February 2016
102
EPUAP (2014. Prevention and Treatment of
Pressure Ulcer. National Pressure Ulcer Advisory
Panel, European Pressure Ulcer Advisory Panel
and Pan Pacific Pressure Injury Alliance. Second
edition. London: Cambridge Media.
Thank you for the reference. All
references have been considered and
included where relevant.
106
1) NPUAP*, EPUAP*, PPPIA*; Prevention and
Treatment of Pressure Ulcers: Quick Ref Guide.
Emily Haesler (Ed.) Cambridge Media: Osbourne
Park, Western Australia; 2014 – May need to
refer to complete document but this is not
available free it has to purchased via NPUAP or
EPUAP websites.
Thank you for the reference. All
references have been considered and
included where relevant.
*NPUAP – National Pressure Ulcer Advisory
Panel
*EPUAP – European Pressure Ulcer Advisory
Panel
*PPPIA – Pan Pacific Pressure Injury Alliance
2) Wounds UK. Best Practice Statement.
Eliminating pressure ulcers. London: Wounds
UK 2013
3) Wounds UK. Best Practice Statement. Care of
the Older Person’s Skin London: Wounds UK
2012 (Second Edition)
122
The EPUAP /NUAP 2014 prevention and
management of pressure ulcers should be
referenced.
Thank you for the reference. All
references have been considered and
included where relevant.
126
Additional reference based on the adult support
and protection would be the Adult Support and
Protection (Scotland) Act 2007
Thank you for the reference. Adult
support and protection are outwith the
scope of the standards.
153
There is simple guidance in the NHSGG&C
Wound Dressing Formulary on Wound Bed
Preparation and Dressing Choice pathways.
Thank you for the references. This level
of detail is outwith the scope of the
standards.
28
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