NIHR Signal A new tool may help identify more patients at risk of developing pressure ulcers

Published on 22 December 2015

This was an NIHR-funded study to develop and evaluate a new tool for assessing pressure ulcer risk, called PURPOSE-T. The tool, developed as part of a five year NIHR research programme, is used by following a manual and assesses eight risk factors: mobility; skin; previous pressure ulcer; sensory perception; perfusion (blood flow); nutrition; moisture; and diabetes. Field testing by nurses showed very good agreement between tests and between assessors. This tool, drawing on new research, has many advantages over the various current assessment tools, which show numerous inconsistencies. PURPOSE-T is already being used by early adopter Trusts and could help to reduce the incidence of pressure ulcers.

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Why was this study needed?

Pressure ulcers are areas of damaged skin and tissue, caused when an area of skin is placed under pressure. Typically they occur in a person confined to bed or a chair by an illness, and so are sometimes called bedsores or pressure sores. They can lead to extended hospital stays and reduced quality of life. There are an estimated 180,000 new cases each year in the NHS, with an annual cost for prevention and treatment of between £1.4 and £2.1 billion.

There are over 40 pressure ulcer risk assessment scales available. They vary in how they were developed – for example, informed by literature review, expert opinion or adaptation of an existing scale – and are inconsistent in their coverage of risk factors. Many were developed thirty to forty years ago. It is therefore timely to re-examine which risk factors should be considered in pressure ulcer risk assessment, and how these should be assessed.

The NIHR funded this work to develop and test an up-to-date pressure ulcer risk assessment tool – called the “Pressure Ulcer Risk Primary or Secondary Evaluation Tool”, abbreviated to “PURPOSE-T”.

What did this study do?

The development and testing of the tool comprised five phases: 1) a systematic review, 2) a consensus study, 3) the development of a conceptual framework and theoretical cause pathway, 4) design and pre-testing of the tool and 5) clinical evaluation.

The systematic review identified and clustered pressure ulcer risk factors into domains. The consensus process then used the review of risk factors to develop draft assessment indicators for the development of the tool. In step three, the development of a conceptual framework and theoretical cause pathway helped the team to further understand direct and indirect causal factors for pressure ulcer development. The first draft of the PURPOSE-T tool was built on evidence from steps 1, 2 and 3. Initial pre-testing of the tool was conducted over three sessions and focussed on improving usability. Finally, clinical evaluation of the tool was through field testing of 230 patients by both expert and community or ward-based nurses.

This was a very thorough process to design, test and evaluate a risk assessment tool. The findings should be considered reliable.

What did it find?

  • The systematic review identified 15 risk factor domains, three of which were classified as “primary” domains. They were: 1) mobility and activity, 2) skin and pressure ulcer status and 3) perfusion – the delivery of blood through capillaries – with diabetes a notable risk factor in this domain.
  • PROSPECT-T assesses pressure ulcer risk across eight risk factors: mobility; skin (examination of 13 sites); previous pressure ulcer; sensory perception; perfusion; nutrition; moisture; diabetes.
  • Clinical evaluation field testing of PROSPECT-T showed very good test–retest agreement for the tool and agreement between different users, with percentage agreement ranging from 79.1% to 94.2%.
  • PURPOSE-T was found to have a number of advantages compared to other risk assessment tools, including: 1) A screening stage for all patients allows rapid identification of those obviously not at risk, which may save time in clinical practice; 2) interventions are suggested in response to specific risk factors; 3) pain – recognised to be a key predicator of pressure ulcer development ­– has been incorporated as a risk factor; 4) primary and secondary prevention are distinct, so patients with an existing pressure ulcer or ulcer scarring are allocated to a secondary prevention pathway.

What does current guidance say on this issue?

The 2014 NICE guideline on pressure ulcers recommends that all adults admitted to hospitals, or those with a risk factor receiving NHS care in community settings (for example, poor mobility or cognitive impairment), should have their risk of developing a pressure ulcer assessed. Ideally a validated scale should be used to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale).

NHS England state that all pressure ulcers should be recognised as patient safety incidents and reported through the National Reporting and Learning System (NRLS) for the purposes of national learning.

What are the implications?

The PURPOSE-T risk assessment tool uses a manual and is intended for use by qualified nurses. It has already been implemented in early adopter Trusts, both acute and community, and the authors state that it is ready for wider implementation across the NHS.

The development of PURPOSE-T was exemplary, based on a systematic review of the risk factor evidence, and involved international and interdisciplinary experts, in partnership with service users. The tool offers a number of advantages over current assessment procedures..

Further and ongoing evaluation of PURPOSE-T is needed. Reliability of the tool across different patient populations needs to be assessed, as well as the impact the tool has on decision-making and pressure ulcer incidence in practice. The authors of the study hope that the development of an electronic version of PURPOSE-T will facilitate continued refinement of the tool. They are also keen that a lay version of the tool is developed, so that patients and carers can use it for self-assessment. Use of the tool in the NHS will allow a larger dataset to test how well it predicts pressure ulcers developing in routine care.

Citation

Nixon J, Nelson EA, Rutherford C, et al. Pressure UlceR Programme Of reSEarch (PURPOSE): using mixed methods (systematic reviews, prospective cohort, case study, consensus and psychometrics) to identify patient and organisational risk, develop a risk assessment tool and patient-reported outcome Quality of Life and Health Utility measures. Programme Grants Appl Res. 2015;3(6).

This project was funded by the National Institute for Health Research Programme Grants for Applied Research programme (Grant Reference Number RP-PG-0407-10056).

Bibliography

NHS England. Serious Incident Framework 2015/16- frequently asked questions. London: NHS England; 2015.

NHS Improving Quality. Pressure ulcers. Leeds: NHS England; 2015.

NICE. Pressure ulcers: prevention and management. CG179. London: National Institute for Health and Care Excellence; 2014.

Why was this study needed?

Pressure ulcers are areas of damaged skin and tissue, caused when an area of skin is placed under pressure. Typically they occur in a person confined to bed or a chair by an illness, and so are sometimes called bedsores or pressure sores. They can lead to extended hospital stays and reduced quality of life. There are an estimated 180,000 new cases each year in the NHS, with an annual cost for prevention and treatment of between £1.4 and £2.1 billion.

There are over 40 pressure ulcer risk assessment scales available. They vary in how they were developed – for example, informed by literature review, expert opinion or adaptation of an existing scale – and are inconsistent in their coverage of risk factors. Many were developed thirty to forty years ago. It is therefore timely to re-examine which risk factors should be considered in pressure ulcer risk assessment, and how these should be assessed.

The NIHR funded this work to develop and test an up-to-date pressure ulcer risk assessment tool – called the “Pressure Ulcer Risk Primary or Secondary Evaluation Tool”, abbreviated to “PURPOSE-T”.

What did this study do?

The development and testing of the tool comprised five phases: 1) a systematic review, 2) a consensus study, 3) the development of a conceptual framework and theoretical cause pathway, 4) design and pre-testing of the tool and 5) clinical evaluation.

The systematic review identified and clustered pressure ulcer risk factors into domains. The consensus process then used the review of risk factors to develop draft assessment indicators for the development of the tool. In step three, the development of a conceptual framework and theoretical cause pathway helped the team to further understand direct and indirect causal factors for pressure ulcer development. The first draft of the PURPOSE-T tool was built on evidence from steps 1, 2 and 3. Initial pre-testing of the tool was conducted over three sessions and focussed on improving usability. Finally, clinical evaluation of the tool was through field testing of 230 patients by both expert and community or ward-based nurses.

This was a very thorough process to design, test and evaluate a risk assessment tool. The findings should be considered reliable.

What did it find?

  • The systematic review identified 15 risk factor domains, three of which were classified as “primary” domains. They were: 1) mobility and activity, 2) skin and pressure ulcer status and 3) perfusion – the delivery of blood through capillaries – with diabetes a notable risk factor in this domain.
  • PROSPECT-T assesses pressure ulcer risk across eight risk factors: mobility; skin (examination of 13 sites); previous pressure ulcer; sensory perception; perfusion; nutrition; moisture; diabetes.
  • Clinical evaluation field testing of PROSPECT-T showed very good test–retest agreement for the tool and agreement between different users, with percentage agreement ranging from 79.1% to 94.2%.
  • PURPOSE-T was found to have a number of advantages compared to other risk assessment tools, including: 1) A screening stage for all patients allows rapid identification of those obviously not at risk, which may save time in clinical practice; 2) interventions are suggested in response to specific risk factors; 3) pain – recognised to be a key predicator of pressure ulcer development ­– has been incorporated as a risk factor; 4) primary and secondary prevention are distinct, so patients with an existing pressure ulcer or ulcer scarring are allocated to a secondary prevention pathway.

What does current guidance say on this issue?

The 2014 NICE guideline on pressure ulcers recommends that all adults admitted to hospitals, or those with a risk factor receiving NHS care in community settings (for example, poor mobility or cognitive impairment), should have their risk of developing a pressure ulcer assessed. Ideally a validated scale should be used to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale).

NHS England state that all pressure ulcers should be recognised as patient safety incidents and reported through the National Reporting and Learning System (NRLS) for the purposes of national learning.

What are the implications?

The PURPOSE-T risk assessment tool uses a manual and is intended for use by qualified nurses. It has already been implemented in early adopter Trusts, both acute and community, and the authors state that it is ready for wider implementation across the NHS.

The development of PURPOSE-T was exemplary, based on a systematic review of the risk factor evidence, and involved international and interdisciplinary experts, in partnership with service users. The tool offers a number of advantages over current assessment procedures..

Further and ongoing evaluation of PURPOSE-T is needed. Reliability of the tool across different patient populations needs to be assessed, as well as the impact the tool has on decision-making and pressure ulcer incidence in practice. The authors of the study hope that the development of an electronic version of PURPOSE-T will facilitate continued refinement of the tool. They are also keen that a lay version of the tool is developed, so that patients and carers can use it for self-assessment. Use of the tool in the NHS will allow a larger dataset to test how well it predicts pressure ulcers developing in routine care.

Citation

Nixon J, Nelson EA, Rutherford C, et al. Pressure UlceR Programme Of reSEarch (PURPOSE): using mixed methods (systematic reviews, prospective cohort, case study, consensus and psychometrics) to identify patient and organisational risk, develop a risk assessment tool and patient-reported outcome Quality of Life and Health Utility measures. Programme Grants Appl Res. 2015;3(6).

This project was funded by the National Institute for Health Research Programme Grants for Applied Research programme (Grant Reference Number RP-PG-0407-10056).

Bibliography

NHS England. Serious Incident Framework 2015/16- frequently asked questions. London: NHS England; 2015.

NHS Improving Quality. Pressure ulcers. Leeds: NHS England; 2015.

NICE. Pressure ulcers: prevention and management. CG179. London: National Institute for Health and Care Excellence; 2014.

NIHR Pressure Ulcer Programme

Published on 30 September 2015

Nixon J, Nelson EA, Rutherford C, Coleman S, Muir D, Keen J, McCabe C, Dealey C, Briggs M, Brown S, Collinson M, Hulme CT, Meads DM, McGinnis E, Patterson M, Czoski-Murray C, Pinkney L, Smith IL, Stevenson R, Stubbs N, Wilson L, Brown JM

Programme Grants for Applied Research Volume 3 Issue 6 , 2015

Background The Pressure UlceR Programme Of reSEarch (PURPOSE) consisted of two themes. Theme 1 focused on improving our understanding of individuals’ and organisational risk factors and on improving the quality of risk assessments (work packages 1–3) and theme 2 focused on developing patient-reported outcome measures (work packages 4 and 5). Methods The programme comprised 21 individual pieces of work. Pain: (1) multicentre pain prevalence study in acute hospitals, (2) multicentre pain prevalence study in community localities incorporating (3) a comparison of case-finding methods, and (4) multicentre, prospective cohort study. Severe pressure ulcers: (5) retrospective case study, (6) patient involvement workshop with the Pressure Ulcer Research Service User Network for the UK (PURSUN UK) and (7) development of root cause analysis methodology. Risk assessment: (8) systematic review, (9) consensus study, (10) conceptual framework development and theoretical causal pathway, (11) design and pretesting of draft Risk Assessment Framework and (12) field test to assess reliability, validity, data completeness and clinical usability. Quality of life: (13) conceptual framework development (systematic review, patient interviews), (14 and 15) provisional instrument development, with items generated from patient interviews [from (1) above] two systematic reviews and experts, (16) pretesting of the provisional Pressure Ulcer Quality of Life (PU-QOL) instrument using mixed methods, (17) field test 1 including (18) optimal mode of administration substudy and item reduction with testing of scale formation, acceptability, scaling assumptions, reliability and validity, and (19) field test 2 – final psychometric evaluation to test scale targeting, item response categories, item fit, response bias, acceptability, scaling assumptions, reliability and validity. Cost–utility: (20) time trade-off task valuations of health states derived from selected PU-QOL items, and (21) validation of the items selected and psychometric properties of the new Pressure Ulcer Quality of Life Utility Index (PUQOL-UI). Key findings Pain: prevalence studies – hospital and community patients experience both pressure area-related and pressure ulcer pain; pain cohort study – indicates that pain is independently predictive of category 2 (and above) pressure ulcer development. Severe pressure ulcers: these were more likely to develop in contexts in which clinicians failed to listen to patients/carers or recognise/respond to high risk or the presence of an existing pressure ulcer and services were not effectively co-ordinated; service users found the interactive workshop format valuable; including novel components (interviews with patients and carers) in root cause analysis improves the quality of the insights captured. Risk assessment: we developed a Pressure Ulcer Risk Assessment Framework, the PURPOSE-T, incorporating the Minimum Data Set, a screening stage, a full assessment stage, use of colour to support decision-making, and decision pathways that make a clear distinction between patients with an existing pressure ulcer(s) (or scarring from previous ulcers) who require secondary prevention and treatment and those at risk who require primary prevention (http://medhealth.leeds.ac.uk/accesspurposet). Quality of life: the final PU-QOL instrument consists of 10 scales to measure pain, exudate, odour, sleep, vitality, mobility/movement, daily activities, emotional well-being, self-consciousness and appearance, and participation (http://medhealth.leeds.ac.uk/puqol-ques). Cost–utility: seven items were selected from the PU-QOL instrument for inclusion in the PUQOL-UI (http://medhealth.leeds.ac.uk/puqol-ui); secondary study analysis indicated that item selection for the PUQOL-UI was appropriate and that the index was acceptable to patients and had adequate levels of validity. Conclusions The PURPOSE programme has provided important insights for pressure ulcer prevention and treatment and involvement of service users in research and development, with implications for patient and public involvement, clinical practice, quality/safety/health service management and research including replication of the pain risk factor study, work exploring ‘best practice’ settings, the impact of including skin status as an indicator for escalation of preventative interventions, further psychometric evaluation of PU-QOL and PUQOL-UI the measurement of ‘disease attribution.’

The Braden scale was developed in 1987 and looks at the following criteria: sensory perception; moisture; activity; mobility; nutrition; and friction and shear.

The Waterlow score was developed in 1985 and assesses the following areas: build/weight for height; skin type/visual risk areas; sex and age; malnutrition screening tool; continence; and mobility. Additional areas are assessed in special risk patients: tissue malnutrition; nerve damage; major surgery or trauma.

The Norton risk-assessment scale was the first to be developed, in 1962, and considers five domains: physical condition; mental condition; activity; mobility; continence.

Expert commentary

This five year research programme has important implications for pressure ulcer prevention. Critically the researchers demonstrated that severe pressure ulcers were more likely to develop in contexts in which clinicians failed to listen to patients or carers and services were not effectively coordinated. They have developed a Pressure Ulcer Risk Assessment Framework and have used patient and public involvement as a cornerstone of the work. They have also stressed the importance of more high-quality risk factor research in the field, agreement on common standards for the definition of key risk factors and the need to develop and test prediction models. It is relevant to all who are involved with pressure ulcer prevention.

Professor Gerry Stansby, Consultant Vascular Surgeon, Newcastle upon Tyne Hospitals