Joyce Black, PhD, RN, CWCN
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Requests for Single Reprints: Joyce Black, PhD, RN, CWCN, University of Nebraska Medical Center, College of Nursing, Omaha Division, Room 5031, 985330 Nebraska Medical Center, Omaha, NE 68198-5330.
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William V. Padula Ph.D. M.S., Heidi M. Wald M.D. M.S.P.H, David O. Meltzer M.D. Ph.D.
WVP: Fellow, Department of Medicine, University of Chicago, Chicago, IL; HMW: Associate Professor, School of Medicine, University of Colorado, Aurora, CO; DOM: Professor of Medicine and Chief, Section
March 26, 2015
In Reply: Pressure Ulcer Prevention and Management
TO THE EDITOR: Black provides a useful perspective about the current state of scientific inquiry among nurses in the treatment and prevention of pressure ulcers (PrUs).(1) The field of wound care is stymied by lacking research funding, making it difficult to move out of its “infancy,” and could benefit from additional investment in methodical research to support evidence-based practices (EBPs). The National Institute of Nursing Research (NINR) is the primary institute of the National Institutes of Health (NIH) to fund research related to PrU prevention given that it is a nursing issue. The NINR Strategic Plan, last updated 2011, prioritizes research on the use of “technology for better wound care.”(2) The report by Qaseem et al. recommends the use of new bed technologies in wound care, but additionally notes the importance of risk-stratification with a predictively valid instrument such as the Braden Scale despite “weak” evidence.(3) NINR should update its strategic plan to emphasize the importance of synergizing these instruments with new technologies and improving validity.Second, funding is scarce to support research in wound care. NINR has the smallest budget of all NIH institutes at $136 million.(4) Commercial industry could do more to supplement wound care research. Of the ten leading manufacturers of products for evidence-based practices (e.g. underpads, dressings, beds, and creams), only three are affiliated with foundations to support wound care research (http://www.prnewswire.com/news-releases/the-top-20-companies-in-the-advanced-wound-care-market-2013-2023-225784351.html). In contrast, the pharmaceutical industry appears more involved since 11 of the 12 leading pharmaceutical manufacturers (http://fortune.com/fortune500/) belong to the PhRMA Foundation.(5)Ultimately, the field has an opportunity to move quickly beyond reliance on costly clinical trials and time-consuming descriptive studies with the evolution of electronic health records (EHRs). EHRs provide accessibility to data that can be used to develop population-specific, predictive algorithms of patient risk, and strategically implement evidence-based practices in the hospital or home-health setting.REFERENCES1. Black J. Pressure Ulcer Prevention and Management: A Dire Need for Good Science. Ann Intern Med 2015;162:387-882. The National Institute of Nursing Research (NINR), Strategic Plan 2011. https://www.ninr.nih.gov/sites/www.ninr.nih.gov/files/ninr-strategic-plan-2011.pdf. Accessed March 18, 2015. 3. Qaseem A, Mir TP, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-694. National Institute of Health (NIH), Office of Budget, Bethesda, MD. http://officeofbudget.od.nih.gov/. Accessed March 18, 2015.5. Pharmaceutical Research & Manufacturers of America (PhRMA), Washington, DC. http://www.phrma.org/. Accessed March 18, 2015.
Joyce Black, PhD, RN. CWCN
University of Nebraska Medical Center
April 28, 2015
The annual number of cases of pressure ulcers in the US is difficult to discern due to variances in reporting. The National Pressure Ulcer Advisory Panel estimates that 4-7% of hospitalized patients develop pressure ulcers. The estimate of incidence is higher in long term care, recently up to 14% 1. These numbers likely reach over 400,000 cases yearly. While this large number emphasizes the significance of pressure ulcers, it also equals the total number of new cases of breast cancer (232,000) and lung cancer (221,000) combined! Given the increasing number of elders, the shortage of nurses and increasingly fragmented care, these numbers will not likely go down. Yet, as Dr. Padula points out the research money to study pressure ulcers is sorely lacking and there are no national foundations, or public efforts at fund raising like is seen with cancer. Sadly, public awareness of pressure ulcers often occurs at the bedside and in courtrooms where they are labeled as medical errors or never events. Now that CMS has made hospital acquired pressure ulcers a quality measure, more hospitals are tracking these wounds. But that work only goes on internally within the facility with little to no externalization or published research. Tracking pressure ulcers via the Centers for Disease Control would aid in the appreciation of the magnitude of the problem and drive money into the adequately powered studies of how to reduce the risk, prevent ulcers, get them to heal quickly and maintain these efforts over time. 3
1. Pressure Ulcers: Prevalence, Incidence and Implications for the Future. National Pressure Ulcer Advisory Panel, 2012. B. Pieper, Ed, Washington, DC
2. Cancer Facts and Figures, 2015. American Cancer Society
3. Padula WV, Mishra MK, Makic MB, Sullivan PW Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011 Apr;49(4):385-92. doi: 10.1097/MLR.0b013e31820292b3.
Joyce Black. Pressure Ulcer Prevention and Management: A Dire Need for Good Science. Ann Intern Med. 2015;162:387–388. doi: 10.7326/M15-0190
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Published: Ann Intern Med. 2015;162(5):387-388.
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