Within this document we shall refer to ’patients’, which includes residents, service users or clients.

The scope of this guideline will include all areas where care is delivered across health and social care services including Care at Home and Care Homes.

A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and/or a combination of these. Pressure ulcers usually occur over a bony prominence but may also be related to a medical device or other object¹.

The cost of treating a pressure ulcer in the UK equates to an estimated £5 billion per year². Anyone can develop a pressure ulcer however they are more common in high-risk groups such as people who are acutely ill, those who cannot independently reposition themselves or are malnourished. Other groups that may be affected include people with spinal injury and the elderly².

Pressure ulcers are considered to be mainly avoidable with effective care, therefore prevention should be considered for every person being cared for within health and social care setting².

This pressure ulcer prevention and management reference guide will ensure practitioners assess and manage patients’ risk of developing pressure ulcers through the provision of evidence-based care using a structured, consistent approach.

This guideline gives reference to many resources throughout which should assist practitioners in managing wounds. Not all wounds have to be referred for assessment, however if referral is required, please see ‘Guidance Notes for Referral’ document (appendix 1). If a foot wound, please refer to Podiatry service for ongoing advice and management. If possible, referral to Tissue Viability is required, please see ‘Guidance Notes for Referral’ document (appendix 1).Where  there is deterioration or non-healing of an individual’s pressure ulcer while in a care home, it is recommended that the tissue viability referral pathway (appendix 12) is followed to support with review, assessment, treatment and management including reporting of adverse care.

This guideline should be read in conjunction with Healthcare Improvement Scotland’s (HIS) Prevention and Management of Pressure Ulcers Standards³ which are also supported by the care inspectorate. All practitioners caring for patients at risk of developing pressure ulcers should complete the NES LearnPro module: Prevention and Management of Pressure Ulcers. Senior nurses/team managers require to support practitioners to achieve this and maintain training records for their staff.

HIS pressure ulcer standards also state: “Pressure ulcers which are graded 2 or above should be reported using a local recording system. These are reviewed to identify learning and any actions are noted and implemented” ³.

Within NHS Ayrshire and Arran it is policy that all acquired pressure ulcers grade 2,3,4, suspected deep Tissue injury, ungradable and mucosal pressure ulcers are reported via DATIX to allow investigation into circumstances. Grade 3 or above should have a more robust investigation carried out as part of root cause analysis of event. Duty of Candour will also usually apply⁴. A pressure ulcer investigation tool should be utilised to aid this process and can be accessed on AthenA and DATIX. 

For private and local authority areas where there is no access to DATIX, it is recommended that there is enhanced communication and reporting of acquired pressure ulcers with the area the individual is being transferred to. The care home manager should contact the discharge setting to clarify if a DATIX has been submitted.

All health and social care staff are responsible for adhering to the guideline and breaches in the care should be reported to the person in charge and their line manager.

Promoting mobility continues to be everyone’s responsibility.

Pressure ulcer development is a highly complex series of events with many risk factors which can vary from person to person. Risk factors can be intrinsic or extrinsic.

Risk assessment

A comprehensive skin assessment must be carried out as part of every risk assessment to assess for any alterations to the condition of the skin. Formal risk assessment should be also be used in conjunction with clinical judgement.

• A preliminary pressure ulcer risk assessment (PPURA) (Appendix 2) can be carried out, which would be repeated daily if patient deemed to be ‘not at risk’.
• If patient is ‘at risk’ a formal risk assessment is carried out using the Adapted Waterlow Risk Assessment Tool (Appendix 3) or other recognised risk assessment tool. (all adult in patients wards within Ayrshire and Arran use Waterlow).
• Paediatric formal risk assessment is carried out using the Adapted Glamorgan Pressure Ulcer Risk Assessment Scale for paediatrics (Appendix 4).

Initial risk assessment

All settings must undertake a formal risk assessment to help identify specific issues, allowing all interventions to prevent pressure ulcers to be addressed⁶. Formal risk assessment should take place within 6 hours of admission or transfer. This includes time spent in the Accident & Emergency Department. However, if the person is acutely ill assessment should be carried out sooner.

Community patients should have a formal risk assessment carried out at the first community visit. However, some community patients only require minimal visits and the clinician’s clinical judgement may indicate that a formal risk assessment is not required. The rationale for not formally risk assessing the patient should be documented.

Key things to remember when undertaking the risk assessment include:

Reassessment of risk

Formal reassessment of adult patients (Waterlow Risk Assessment) should be undertaken according to their identified risk as follows:-

<10 Low risk           Reassess weekly or if condition changes
10+ At risk              Reassess twice weekly or if condition changes
15+ High risk           Reassess on alternate days
20+ Very high risk    Assess daily.

Within long term care areas such as care of the older person, if the Waterlow score remains unchanged for a period of 2 weeks and the probability of change is small, the Waterlow assessment can be carried out a minimum of once a month unless there is a change in the patient’s condition, either improvement or deterioration.

Reassessment should also take place on transfer to another ward/care setting, if there is a change in condition or sign of skin deterioration¹. This should occur within 6 hours.

In community settings, formal reassessment should be undertaken as above at each district nurse visit, as per clinical judgement.

Paediatric patients should be reassessed daily or every time there is a significant change in their condition.
If unable to examine skin, reason should be documented in the notes³.

Individual elements of risk assessment

Consideration should be given to both intrinsic and extrinsic factors such as relevant co-morbidities, neurological conditions, mobility issues, nutritional status, posture, level of consciousness, sensory impairment, previous pressure damage, pain, psychological factors, social factors, and cognition, medication and continence issues⁸.

• Examination of all of the skin must be carried out as part of the risk assessment process
  and initial findings recorded as baseline information from which to identify any changes.
• Skin must be examined both visually and using palpation by a practitioner who has been trained in pressure ulcer prevention⁹. This may be carried out by non-registered practitioners, however, the responsibility for the assessment, care planning and evaluation remains with the registered practitioners. Having responsibility for the planning of care for patients, registered practitioners should inspect the skin of their patients at least once during their shift.
• Delegation of tasks to non-registered practitioners must be in accordance with the Nursing and Midwifery Council (NMC) Code of Conduct¹⁰.
• Skin should be examined at opportune times such as assisting with personal hygiene.
• In adults particular attention should be paid to vulnerable areas like the sacrum and bony prominences such as trochanters, ischial tuberosity’s and heels. These areas are more commonly where pressure ulceration can occur¹¹.
• If medical devices in situ, check skin under and around these at least twice daily to ensure no pressure damage has occurred¹.
• In children particular attention should be paid to the occiput, ears and neck, which are the more common sites of pressure ulcer development, closely followed by sacrum and heels¹.
• Device related pressure ulcers can occur as a result of devices used. This is often for a variety of diagnostic or therapeutic reason and deemed essential for care⁶. Care must be taken to monitor and minimise damage from devices where able.
• Elderly people have reduced elasticity and often drier skin therefore will be more prone to skin damage ⁸.

Reassessment

• Reassessment of skin should take place regularly, documenting findings.
• If any changes such as redness (erythema) or discolouration occur, a plan of care must be put in place or current plan updated to reduce the risk of deterioration. Any areas of erythema should be further examined.

• Darker skin may be difficult to assess visually. There may or may not be discolouration. The first signs of damage may be a change in temperature or skin consistency. It may feel warmer or cooler and may feel firmer or spongier. Findings from skin examination must be documented. If changes are noted, the action taken should be documented.
• Skin which is dry or exposed to excessive moisture increases the risk of pressure ulcer development. The reasons for the changes should be assessed and managed as dry skin or excessively hydrated skin is more vulnerable to the effects of pressure, friction and shearing forces¹².
• Healthy skin is slightly acidic (pH 4-6.8) which helps protect against colonisation of bacteria and reduces the risk of infection. When urine and faeces come in contact with the skin, the pH alters and the skin becomes more susceptible to injury¹².
• Skin damage which is assessed to be caused by moisture or incontinence, should be clearly documented as excoriation and not graded as a pressure ulcer.
• The level of damage found should be recorded using the Excoriation and Moisture Related Damage Tool (see Appendix 7). Continence problems must be fully assessed and effectively managed to minimise the impact on the skin.

Continence

• Regular review of continence management should be undertaken and documented as any changes in a person’s continence can be a contributing factor in pressure ulcer development.
• Continence assessment and management must be effective to minimise risk of skin damage.
• Advice should be sought from the Continence Nurse Advisor when required.

Nutrition

• Poor nutrition is known to be a risk factor for the development of pressure ulcers as well as cause of delayed healing in existing pressure ulcers¹³.
• It is important to complete regular nutritional screening and make prompt referral for full assessment by a dietician where indicated¹³.
• Recognising poor nutrition by nutritional screening and assessment, support and regular monitoring will help to reduce the risk of developing wounds and optimise outcome.
• Patients who are underweight have lost the protective cushioning effect of fat stores and, if immobile, have an increased risk of pressure ulcer development from skin compression over bony areas.
• Obese individuals are also at risk from malnutrition as may be deficient in various micronutrients¹⁴.
• Patients with wounds should have an assessment of their nutritional status and where required provided with supplements¹⁵.
• Dehydration is also a major risk factor for the development of pressure sores as the skin becomes inelastic, fragile and more susceptible to shear and frictional forces and thus more at risk of pressure damage¹⁴.

Mobility

• Reduced mobility is one of the major risk factors for pressure ulcer development.
• Reduced mobility may be a chronic problem or a transient problem. For example, a transient reduction in mobility may be attributed to the post-operative period when pain is the contributing factor or pregnant women in labour when circumstances reduce mobility. The use of sedation or restraint can also be attributed to transient reduction¹. However, many people have chronic co-morbidities which reduce mobility, for example, people who have had a stroke or spinal injury.
• Every patient who has reduced mobility should have their skin inspected and examined regularly to determine the effect of the pressure on the skin and ensure early detection of skin changes resulting from the pressure.

Sensory impairment

A significant risk of pressure ulcer development exists for people who have a reduced ability to feel sensation. Failing to reposition will increase their risk of a pressure ulcer developing. For example:-

• People with diabetes who have neuropathy of their feet have a higher risk of heel and malleolar pressure ulcers.
• People who have paraplegia and cannot feel sensations when sitting or lying may be unaware of discomfort relating to the length of time they have been in the same position.
• Those who are able to participate in their care should be provided with education to ensure they understand the risks of pressure ulcer development. Discussions around what interventions they can take (i.e. repositioning, good skin care) should occur⁵.

Moving and handling

• All people who are not independently mobile require an assessment to ensure safe moving and handling practices for patients and practitioners are used.
• If it has been identified a person requires a sliding sheet when being repositioned to ensure their safety, this must be used every time. This will minimise the friction and shearing effects on the skin and tissues.
• If moving and handling aids have been used, these should not be left under the patient after the episode of repositioning.
• Further advice should be sought from Moving and Handling Advisor, if required.

Repositioning

• Repositioning is important in preventing complications of immobility including pneumonia, contractures of joints and urinary tract infections¹⁶.
• Several members of the multi-disciplinary team may be involved in repositioning of the person. Advice and assessment should be sought from physiotherapy, occupational therapy and moving and handling, where appropriate.
• Skin inspection should be carried out and documented at each episode of repositioning.
• Correct positioning should minimise pressure, friction and shear and although the optimum interval for repositioning has not been identified, it is widely agreed that regular repositioning of people unable to do so independently is one of the main strategies undertaken to prevent pressure ulceration¹⁷. This should be individualised to each person on the basis of skin inspection².
• Ideally a person should not be repositioned onto a red area to allow the skin time to recover.
• Repositioning people in bed should include the use of 30^o tilt¹, as well as using careful positioning of pillows to separate bony prominences, for example on the legs and feet.
• Every time a patient requires to be moved in bed a sliding sheet must be used.
• The repositioning regime should be documented and, where required, a skin inspection and repositioning chart or SSKIN bundle should be initiated.
• People who are independent should be educated as to the importance of repositioning and encouraged to move regularly.

Respositioning when seated

• Soft tissues become compressed between seating and bony prominences and if unrelieved can result in tissue damage¹⁷. This occurs due to body weight distribution over a smaller surface area resulting in higher pressure and reduced blood flow to the tissues^18,19.
• Best practice deems that people at risk should not be positioned in a seat for more than 2 hours without some form of repositioning and those who are acutely ill are returned to bed for no less than one hour². However the person who is up to sit should have the frequency for repositioning determined using skin inspection to guide the intervals.

Wheelchair and static chair users

Education of people who are long term wheelchair or static chair users is vital to ensure regular repositioning. They should, where possible, reposition every 15 to 30 minutes ²⁰. In the absence of carers/staff, independent people should also be taught to inspect their skin on a regular basis and report any damage to staff, who should assess the skin further.

Each area of the organisation has a variety of equipment that will be used as part of prevention strategies including:

• electric bed frames
• mattresses
• cushions
• chairs
• moving and handling aids
• heel protectors/offloading devices.

It is the responsibility of all practitioners using this equipment to know what is available and how to safely use the equipment they can access.

Practitioners must be aware of the equipment available to ensure they meet clinical need and make best use of the available, limited resources.

Electric bed frames

Electric bed frames can be used to reposition patients. If possible, raise the knee break before raising the backrest to minimise the effect of the backrest pushing the patient towards the foot of the bed. This will reduce friction and shear.

Mattresses

Anyone assessed as being at risk of pressure ulcer development should, at a minimum, be cared for on a pressure redistributing foam mattress. Conventional foam mattresses do not provide adequate protection for those unable to reposition themselves⁶.

In hospital sites:

• Practitioners must be aware of the standard mattress in use in their area and when they are appropriate to use as most beds have pressure reducing foam mattresses as standard.
• Many of the standard mattresses are appropriate for people who are independently mobile when in bed or can reposition with minimal assistance including those with a high or very high risk of pressure ulcer development.
• If a specialist mattress is required, the decision should form part of a comprehensive assessment and the rationale for the selection and date of implementation should be documented.
• The continued need for specialist mattresses should be reviewed on a regular basis to ensure the mattress in use meets the patient’s needs.
• When the need for a specialist mattress is no longer present, the mattress should be replaced with a pressure reducing foam mattress.

In the community:

• Patients should not be cared for on a basic divan mattress if at risk.
• Information regarding the mattresses available from the Community Equipment Store can be found on Athena.

In a care home:

• Short term loan (max of 6 weeks) of pressure relieving mattresses are available on request via the District Nursing Team to give time for purchase of the required equipment by the Care Home (COSLA reference)

Further information on selecting a specialist mattress can be found in the Mattress Selection Guide (Appendix 8)

Cushions

• There are a variety of patient chairs within hospitals. Many of the chairs have integrated high risk pressure reducing foam cushions.
• All practitioners using pressure redistributing cushions should be aware of the type available in their areas so an appropriate selection can be made for at risk patients.
• At risk patients who are seated out of bed require a pressure reducing cushion¹. Cushions may be static or alternating and selection should be based on a full assessment of the patient, equipment and environment. Cushion type and rationale for choice should be documented. 

Chairs

• Seating is often seen as part of a person’s therapeutic treatment; therefore it is important in the recovery process. However, the risk when seated should not be underestimated¹⁹.
• When seated the surface area in contact with the seat is smaller than when in lying on a mattress, therefore the risk of developing a pressure ulcer increases²¹.
• Chairs should be selected, where possible, to ensure they are the correct height, depth and width and allow the feet to be placed flat on the floor. This minimises pressure, friction and shear thereby reducing the risk to the person. However this may be a challenge in the community setting.
• Advice on seating should be sought, if required, from other members of the multi-disciplinary team such as physiotherapy or occupational therapy.

Moving and handling aids

Moving and handling aids should be used to minimise the risk to both patients and practitioners and must be used each time the patient is moved or repositioned.

Heel protectors

• The surface area of the heel is covered by a small volume of subcutaneous tissue which can be exposed to high mechanical load in individuals on bedrest¹.
• Patients deemed to be ‘high risk’ (i.e. known peripheral vascular disease, diabetes, neuropathy, immobile or with a current foot ulcer) should have foot protection put in place (see Appendix 9).
• The use of pillows placed under the calf to keep the heels free of the support surface can also be effective, however, careful placement of the pillows and frequent inspection of the area is required. The pillows should be placed along the length of the calf avoiding pressure to the popliteal space and Achilles tendon¹. The knee should be flexed at 5-10 degrees in order to reduce the risk of deep vein thrombosis¹⁹.

Theatre/recovery

• People undergoing procedures in theatre have an increased risk of pressure ulceration¹. This is, in part, due to the duration of surgery, increased episodes of hypotension, low core temperature during surgery and reduced mobility post-operatively.
• To reduce the risk of pressure ulcer development all operating tables should have pressure redistributing surfaces and measures should be in place to avoid hypothermia.
• The anaesthetic nurse/practitioner, during the peri-operative period, has the responsibility for identifying risk factors and implementing appropriate positioning and repositioning ²². This should also include skin inspection.
• Appropriate aids should be used to position the patient during surgery and where possible, the heels should have the pressure off loaded, in such a way as to avoid pressure on the Achilles tendon by distributing the weight along the calf.
• Skin assessment, pre-operatively, should be documented to give a baseline from which to measure any changes.
• Subsequent skin inspection should be documented and actions taken should any changes be noted.
• Peri operative risks and any identified skin changes should be recorded and communicated to the continuing care area to ensure effective pressure relieving strategies continue²².

Palliative care

For patients who are in the last few days of life, care will be focused on comfort and quality of life. As patients experience organ failure, the skin too can fail and healing of wounds will be unrealistic¹. However, every effort should be made to prevent pressure ulceration occurrence using appropriate interventions. This will be dependent on the condition of the patient and individual circumstances including patient and family choice to maintain comfort and dignity. Decisions regarding care should be following consultation with the multi-disciplinary team¹.

Admission, discharge and transfer of at-risk patients

Practitioners responsible for the care of an at-risk patient who is admitted to, discharged from or transferred between care settings, must ensure the area receiving the patient is aware of any changes to the clinical condition or condition of the skin as well as interventions required to meet the patient needs. This requires to be communicated timeously to ensure equipment and services are available prior to the patient being moved. Ensure the condition of the skin is documented on admission, discharge and transfer of the patient.

Transport

• Consideration must be given to patients who are at risk of pressure ulcer development or have existing pressure ulcers when using patient transport.
• To minimise the risk of deterioration, Scottish Ambulance Service must be made aware of the patient’s risk or, if they have existing pressure damage. This should be communicated when staff are arranging transport to minimise transport time.
• If the patient has been on an alternating mattress, a clinical decision has to be made as to the method of transfer whether seated or lying.
• The surfaces in ambulances may not have the same pressure reduction properties currently used by the patient therefore the patient’s risk of pressure ulcer development increases.

Holistic assessment should include the patient’s health and wellbeing needs, assessment and grade of pressure ulcer and consider which equipment and support will be required². This should all be documented in the patient’s personalised care plan which should be reviewed regularly, updated with any relevant changes and adapted as required.

Wound assessment

A Wound Assessment Chart should be completed for each wound. A thorough wound assessment should include the following:

• Correct grading using the Scottish Adaptation of the European Pressure Ulcer Advisory Panel (EPUAP) Classification Tool. Measurements should be recorded including depth and undermining or tunnelling.
• Position of ulcer - It is important to identify location on body and clearly document this.
• Identification of tissue type-see Scottish Wound Assessment and Action Guide (SWAAG) available on AthenA or in care home resource folder.
• Level of exudate - in order to select most appropriate dressings to manage.
• Presence of infection - a wound containing slough or necrotic tissue will contain bacteria⁶. It is important to correctly identify signs/symptoms of infection, in order to ensure correct management and selection of appropriate antimicrobial products.
• Surrounding skin status - to ensure dressing products are managing exudate levels and minimising peri wound skin damage.
• Assessment of pain - in order to adequately manage patient’s pain, it is important to understand the type and cause of pain and treat appropriately⁶.

Cleansing

Cleansing is the process by which a wound is washed to remove dressing materials, microorganisms and debris and should only be performed where clinically indicated¹.

‘Routine’ cleansing of acute wounds is discouraged whereas cleansing of chronic wounds is standard practice to remove debris, slough and reduce biofilms²³. Please refer to wound cleaning pathway for further guidance on cleansing of wounds. (appendix 11).

Debridement

Debridement is defined as:
'The removal of dead, non-viable tissue, infected or foreign material from the wound bed and surrounding skin’²⁴.

Assess the need to debride and ensure consideration given to the amount of necrotic tissue, grade and size of wound, patient tolerance and co morbidities⁸.

The most appropriate method of debridement should be selected based on the individual, the wound bed and the clinical setting¹.

Methods of debridement

• Autolytic-occurs naturally and is the body’s natural process of softening and removing devitalised tissue. Wound products are often used to speed up this process.
• Sharp-can be either surgical by a surgeon under theatre conditions, or conservative sharp performed by a skilled practitioner at the bedside. Both methods involve the practitioner removing dead or devitalised tissue with a scalpel, blade or scissors. Surgical debridement would extend into viable tissue, conservative would not.
• Biosurgical-larval/maggot debridement therapy - involves the use of green bottle fly larvae bred under sterile laboratory conditions. Larvae secrete enzymes which breakdown dead/devitalised tissue and come bagged or loose for application ²⁵.
• Hydrosurgery - uses high pressure water irrigation to debride and cleanse wounds.

Pain

• Pain due to pressure ulcers can be caused by: pressure, shear and friction, damaged nerve endings, inflammation and/or infection, procedures or treatments or muscle spasms¹.
• Pain is very subjective and varies in how severe it is depending on the individual, their past experiences and emotions⁸ and patients can experience anxiety with the experience/fear of pain.
• It is important to assess patient’s pain and manage this appropriately whether this is acute or chronic pain.

Managing infection and biofilms

• Wounds should be continually assessed at each dressing change and staff pick up and act on any significant changes.
• Do not routinely swab wounds. Where indicated swab wound if clinical signs of infection present.
• Microorganisms can be located on all skin surfaces. As soon as skin is broken, it will quickly become contaminated and colonised by bacteria¹. Despite this, wounds can progress and heal normally. However, if the bacterial levels multiply and cause either local, spreading or systemic infection, this requires to be acted upon.
• Biofilms are often present on wounds and can prevent them from healing. Biofilms are a thin, slimy film of bacteria which adhere to wound surfaces¹.
• Systemic antibiotics are only required where there are signs of bacteraemia, sepsis, advancing cellulitis or osteomyelitis¹. They should be reserved for treatment of serious bacterial infections, specific to micro-organism and given for shortest duration possible²⁶.
• Routine use of antimicrobials is not recommended in the management of pressure ulcers, but where clinically indicated⁸. (Please refer to appendix 10 for guidance on identifying infection and when to use antimicrobial products).

Dressing selection

• A dressing should be selected which promotes a warm, moist wound healing environment⁸ and should address and manage exudate levels appropriately. Exudate which leaks onto peri wound skin can cause maceration and excoriation, leading to skin deterioration, increased pain and discomfort²³.
• There are many dressing with various functions and staff should be aware of what these are before use as well as contraindications. NHS Ayrshire and Arran have a wound product formulary to aid dressing selection and should be adhered to where possible.
• Information on correct selection of wounds products according to tissue type and exudate levels can be found on the Scottish Wound Assessment and Action Guide (SWAAG).

Negative pressure wound therapy

Negative pressure wound therapy:

• A controlled negative pressure system applied topically to wounds. Through application of a filler (usually specialist foam or gauze), covered and sealed with a film then application of a drain attached to a pump, negative pressure is delivered and exudate drained into a canister²⁷.
• Can be used where higher levels of exudate require to be managed or to aid healing of particular wounds.

• Employees are reminded that they may have patients/carers who require communication in an alternative format e.g., other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.
• In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.
• Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline; however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance, 2019. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA.
2. Guest, J.F. Ayoub, N. McIlwraith, T. Uchegbu, I. Gerrish, A. Weidlich, D. Vowden, K. & Vowden, P., 2017. Health Economic burden that different wound types impose on the UK’s National Health Service. Int. Wound Journal [online]. 14(2), pp.322-330. [viewed 27 July 2021]. Available from: DOI: 10.1111/iwj.12603.
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20. Moore, Z. & Van Etten, M. 2015. Preventing pressure damage when seating. Wounds UK 11(3), Supp 2. pp 18-23.
21. Stockton, L. Gebhardt, K.S. and Clark, M. 2009. Seating and pressure ulcers: clinical practice guideline. Journal of Tissue Viability 18 (4) 98-108.
22. Putnam, K. 2016. Minimising pressure ulcer risk for surgical patients. AORN Journal [online].103(4),pp 7-9. [viewed 26 July 2021]. Available from: https://doi.org/10.1016/S0001-2092(16)30009-6.
23. Milne, J. 2019. The importance of skin cleansing in wound care. BJN [online]. 28(12), [viewed 8 August 2021]. Available: https://doi.org/10.12968/bjon.2019.28.12.S20.
24. Wounds UK, 2013. Effective debridement in a changing NHS: a UK consensus. Wounds UK. London. Pp 1-13. Available from www.wounds-uk.com.
25. Biomonde, 2021. Larval Debridement Therapy (LDT) Formulary Resource Document [online]. Biomonde. [viewed 21 August 2021]. Available from: http://www.biomonde.com
26. Wounds UK, 2020. Best Practice Statement: Antimicrobial stewardship strategies for wound management. Wounds UK. London pp 1-21.
27. Apelqvist, J. Willy, C., Fagerdahl, A.M. Fraccalvieri, M. Malmsjo, M.Piaggesi, A. Probst, A. and Vowden, P., 2017. Negative Pressure Wound Therapy – overview, challenges and perspectives. J Wound Care [online]. 26(3),Supp 3, S1–S113. [viewed 24 August 2021]. Available from: https://doi.org/10.12968/jowc.2017.26.Sup3.S1.

In order to allow prioritisation of clinical work by the Tissue Viability Service, each patient being referred must have a referral completed before a member of the Tissue Viability Team visits the area or arranges a joint visit with the community/practice nurse. Referrals from consultants and GPs will continue to be accepted in letter format if the referral is non-urgent.

The pager system should only be used for urgent referrals. All other information can be left on the secure answer machine - patient details can be provided.

If the patient is admitted to hospital with a wound, it is important that we ascertain the current treatment plan as this may already be effective and therefore no changes may require to be made. The current care plan can be sent into hospital with the patient or the ward nurse must phone a member of the community team/practice nurse or care home staff to obtain this information.

If verbal advice has been provided over the phone as above by a Tissue Viability nurse please record this advice in patient notes.

If a member of the Tissue Viability Service has not contacted the area within the expected time frame, please follow-up initial referral with a further telephone call. 

We will endeavour to contact the area, and, if appropriate, visit the patient within the intended time frame.

Preliminary pressure ulcer risk assessment (PPURA)

NHS Ayrshire and Arran adapted Waterlow pressure area risk assessment chart

Adapted Glamorgan pressure ulcer risk assessment scale

SSKIN bundle

Scottish adaptation of the European Pressure Ulcer Advisory Panel (EPUAP) pressure ulcer classification tool

Scottish excoriation & moisture related skin damage tool

Mattress selection guide pathway

• Remember pressure redistributing mattress will help but not completely alleviate pressure - patients still require to be repositioned.
• Skin inspection must be carried out at regular intervals - increase frequency if problems identified.
• Assess equipment needs and use of equipment, ensure appropriate to their condition including pressure redistribution cushions, heel protection and sliding sheets.
• SSKIN bundle should be completed accurately and regularly. Where used, ensure mattress information recorded as well as other equipment and ensure in working order.
• Ensure equipment is stepped down when no longer required.

Equipment choice may vary according to hospital. Please see below for examples of each type of mattress. User guides can be located on the Tissue Viability pages on Athena.

Scottish Ropper Ladder for Infected Wounds

Wound cleansing pathway

In the event that the care home team require support they should refer as below: