Maintaining alignment [with a pillow] may be difficult if the patient moves. In addition, pillows do not prevent plantar flexion contracture or lateral leg and foot rotation.” 1

A stakeholder queried why high-specification foam mattresses were specifically recommended during surgery for adults but not children. Recommendations on support surfaces for children are less specific on settings than the recommendations in adults and therefore cover using a high-specification mattress in surgery. A cross-referral to the NICE guideline on sepsis: recognition, diagnosis and early management will be made from recommendation 1.4.18.A stakeholder wanted to draw attention to limitations of moist wound care. However the current surveillance review identified 2 RCTs showing benefit of moist dressings, which agrees with the guideline recommendation to consider using a dressing that promotes a warm, moist wound healing environment. The primary outcome measures will be (i) incidence of new pressure ulcers at the heel and (ii) resolution of category I heel pressure ulcers. Secondary endpoints will be patient comfort along with patient and staff acceptance of the heel protectors. Ensure that the heels are free of the surface of the bed… Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon.” 3 In one study, implementation of a heel pressure injury prevention protocol that included Prevalon Heel Protector resulted in a 28% decrease in facility- acquired heel pressure injuries over a one-year period. Continued use of the Prevalon Heel Protector over four years coupled with in-depth education, continuous monitoring of compliance, and continual reporting of outcomes to ensure accountability, resulted in a cumulative 72% decrease in heel pressure injuries. 4 A cross-referral to the NICE guideline on nutrition support for adults will be made from recommendation 1.4.5.

A stakeholder noted the EPUAP references in the guideline need updating, which we will do via an editorial amendment. A cross-referral to the NICE guideline on peripheral arterial disease: diagnosis and management will be made from recommendation 1.4.26. Several stakeholders supplied new evidence, however none was suitable for inclusion in the surveillance review for various reasons (unpublished research, unsuitable evidence type, not in scope, outside search dates). Another study published in JWOCN demonstrated a 100% prevention of both heel pressure ulcers and plantar flexion contracture over a seven month period when using the heel protector device. 3 Multiple guidelines recommend the use of a heel protection device that completely offloads the heel to help prevent the development of heel pressure ulcers. 1,2 Prevalon Heel Protectors are the number one brand of heel protection. 3 They offer continuous heel offloading to protect your patients’ heels. START A TRIAL Choose the optimal heel protectorMultiple guidelines recommend the use of a heel protection device that completely offloads the heel to help prevent the development of heel pressure injuries. 1,2 Prevalon ® Heel Protectors are the number one brand of heel protection. 3 They offer continuous heel offloading to protect your patients’ heels. START A TRIAL Choose the optimal heel protector

A cross-referral to the NICE guideline on antimicrobial stewardship: systems and processes for effective antimicrobial medicine use will be made from recommendations 1.4.21, 1.4.22, 1.5.18 and 1.5.19. The following sentence will also be added to the guideline introduction: 'NHS Improvement has also produced a guide to help deliver a consistent approach to defining and measuring pressure ulcers, and helping to understand the level of pressure damage harm in England: Pressure ulcers: revised definition and measurement framework'.Stakeholders asked for the PURPOSE-T risk assessment tool to be added to the guideline. All evidence we have examined for this suggests further study is needed, therefore we will await further evidence before considering it as a recommended tool.