Recommendations for research

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

1 Debridement

What is the effect of enzymatic debridement of non-viable tissue compared with sharp debridement on the rate of healing of pressure ulcers in adults?

Why this is important

Debridement of dead tissue is vital as its presence can delay healing and encourage infection. Although autolytic debridement via natural processes (supported by use of an appropriate dressing) is considered to be adequate for the majority of pressure ulcers, other methods, including mechanical, enzymatic, sharp debridement and larval therapy are available.

There is limited high quality evidence on whether removal of dead tissue via sharp (carried out at the bedside) or enzymatic debridement produces the best outcomes. Use of enzymatic debridement in the UK is limited and the availability of these agents is variable, however, it is used in other countries. Additionally, there is some evidence that it may be slower than sharp debridement and result in the removal of viable tissue.

Identifying the best method of debridement may have significant benefits, including reducing the length of time people with pressure ulcers need to stay in hospital.

2 Negative pressure wound therapy

Does negative pressure wound therapy (with appropriate dressing) improve the healing of pressure ulcers, compared with the use of dressing alone in adults with pressure ulcers?

Why this is important

Negative pressure wound therapy is used for a variety of wounds, including pressure ulcers. It aims to assist healing, reduce the surface area of a wound and remove wound exudate. Negative pressure wound therapy creates a suction force which helps drain the wound and promote wound healing. There is evidence to suggest some benefit in the use of negative pressure wound therapy in other wound areas (for example, surgical wounds) but there is limited evidence to support its use for pressure ulcers.

Negative pressure wound therapy is used variably across the NHS and many trusts have purchased or hired negative pressure wound therapy pumps. There would be benefits to patients and the NHS in establishing whether negative pressure wound therapy improves the healing of pressure ulcers.

3 Risk assessment in neonates, infants, children and young people

Which pressure ulcer tools are most effective for predicting pressure ulcer risk in children?

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 a predicting risk in the population of interest.

4 Pressure redistributing devices

Dopressure redistributing devices reduce the development of pressure ulcers for those who are at risk of developing a pressure ulcer?

Why this is important

Pressure redistributing devices are widely accepted methods of trying to prevent the development of pressure areas for people assessed as being at risk. These devices include different types of mattresses, overlays, cushions and seating. They may work by reducing or redistributing pressure, friction or shearing forces. There is limited evidence on the effectiveness of these devices and much of the evidence has been funded by industry. The cost of pressure redistributing devices can vary significantly and there is limited evidence on whether more sophisticated devices (for example, alternating pressure devices) provide any additional benefit compared to more basic devices such as high-specification foam mattresses.

There is also limited evidence on whether different at-risk sites benefit from using different pressure redistributing devices. For example, a pressure redistributing device used for pressure relief on one site could cause pressure on another site. Further research is needed to identify what devices are beneficial for specific at-risk sites for all age groups.

5 Repositioning

When repositioning a person who is at risk of developing a pressure ulcer, what is the most effective position – and optimum frequency of repositioning – to prevent a pressure ulcer developing?

Why this is important

It is generally accepted that repositioning people who are at risk of developing a pressure ulcer can prevent one developing by removing pressure from the at-risk site. Identifying the most effective position – and the optimum frequency of repositioning – will minimise discomfort and maximise pressure ulcer prevention.

There is limited evidence on the most efficient position and frequency of repositioning for all age groups. Many studies include people who are on pressure redistributing surfaces, so it is unclear whether prevention is because of the support surface or the repositioning. A randomised study of different frequencies and positions on a standard support surface (for example, a high-specification foam mattress) is needed.

  • National Institute for Health and Care Excellence (NICE)