Why this is important

The debridement of non-viable tissue within a pressure ulcer is thought to help healing occur as quickly as possible, as the presence of dead tissue can delay healing and encourage infection. Autolytic debridement via natural processes, often supported by the use of an appropriate dressing, provided for other purposes, is considered to be adequate for the majority of pressure ulcers and is current standard care. However, many other methods of debriding non-viable tissue are available, including mechanical, enzymatic, surgical and sharp debridement and larval therapy. A pressure ulcer with non-viable tissue may have levels of exudate and odour that are affecting quality of life, therefore it may be desirable to expedite the debridement process to improve this. Expert consensus suggests there may be an association between the presence of non-viable tissue and the probability of wound infection. Where the risk of infection is thought to be present the healthcare professional needs to identify the most appropriate method of debridement for the individual.

There is currently limited high quality evidence available to suggest whether the removal of non-viable tissue via sharp debridement (carried out at the bed side, by an appropriately qualified healthcare professional) or enzymatic debridement, produces the best outcomes and allows for quicker healing of the pressure ulcer. Currently within the UK, the use of enzymatic debridement is limited and the availability of these agents is variable however, it is frequently used in other countries. Additionally, there is some suggestion that the removal of non-viable tissue via enzymatic debridement may be slower than using sharp debridement and that it may result in the removal of otherwise viable tissue.

Identifying the best method of removing non-viable tissue may have significant benefits in terms of patient quality of life, for example, by reducing the length of stay for people in hospital or the about of time spent on bed rest.

Why this is important

Negative pressure wound therapy (NPWT) is used for a variety of wounds, including pressure ulcers, with the intention of assisting healing, reducing the surface area of a wound and the removal of wound exudate. NPWT aims to create a suction force which enables the drainage of wounds and promote wound healing. Although there is evidence to suggest benefit in the use of NPWT in some other wound areas (for example, surgical wounds) there is limited evidence to support the use of NPWT in pressure ulcers.

Despite this, NPWT is used variably across the NHS and many trusts have purchased or hired NPWT pumps. Given this, it is likely that there would be benefits to both patients and the NHS in identifying whether the use of NPWT may be beneficial to improving the healing of pressure ulcers.

Why this is important

Various nutrients have been associated with promoting pressure ulcer repair through their role in collagen formation and development of connective tissue. For example, nutrients such as protein, vitamin C, zinc have historically been considered important because of their role in protein synthesis and collagen formation. Other nutrients are posited as also improving pressure ulcer healing for example, arginine by, among other things, promoting protein synthesis, collagen formation and wound strength; or collagen protein hydolysate by providing increased protein content. There is currently weak, low quality evidence to support the use of nutritional supplements in people who have pressure ulcers, in studies with small sample sizes, lack of blinding and using mixed nutritional supplements. Further evidence would help to identify suitable composition of supplements, which could potentially provide benefit.

Why this is important

Pressure relieving and redistributing devices are widely accepted methods preventing the development of pressure ulcers for patients assessed as being at risk of developing pressure ulcers. These devices include different types of mattresses, overlays, cushions and seating and work by either reducing pressure, friction or shearing forces. There is currently limited evidence (most of which is funded by industry) to identify whether certain features of these devices are beneficial. Furthermore, these devices can vary significantly in cost and it is currently unclear whether the provision of more advance devices, for example, alternating pressure devices, provide any additional benefit compared to static low tech devices such as high specification foam mattresses.

There is also limited evidence to identify whether different at risk sites benefit from different pressure redistributing devices. For example, it has been suggested that some pressure redistributing devices used for pressure relief of other sites can cause further pressure to be inflicted upon the heel and therefore result in an increase in the incidence of pressure ulcer development. Further research is needed to identify what devices are beneficial for specific at-risk sites, including the heel.

Why this is important

It is generally accepted that repositioning individuals, both neonates, infants, children, young people and adults who are at risk of developing a pressure ulcer can prevent the development of a pressure ulcer by redistributing pressure at the at risk site.¹ However, encouraging people who are at risk of developing a pressure ulcer or providing them with help with frequent repositioning can impact substantially upon a patient's comfort, particularly when this is done at night or when repositioning is painful. In addition, this can have substantial cost implications, particularly in terms of staff time. It is therefore important to identify the most efficient position and frequency of repositioning, to minimise discomfort to the patient, ensure that benefits in terms of pressure ulcer prevention are maximised and resources are used efficiently.

There is limited RCT evidence available to suggest the most efficient position and frequency of repositioning in populations of all ages. Of the evidence that is available, many studies include patients who are on pressure redistributing surfaces, meaning that it is unclear whether any benefit in pressure ulcer prevention is provided by the support surface or repositioning intervention. Therefore there is a need for a study to randomise patients to different frequencies and positions of repositioning, whilst receiving a standard support surface for example, a high specification foam mattress.

Why this is important

There are a few published pressure ulcer risk assessment tools for children, but most of these have no evidence of validity, and over half have been developed from adult pressure ulcer risk assessment tools. Of the tools which have validation data, the evidence is mainly poor quality.

When healthcare professionals are choosing a risk assessment tool to use in clinical practice, they should be looking for a tool that has evidence to demonstrate that it is good at predicting risk in the population of interest.