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Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of PhysiciansRisk Assessment and Prevention of Pressure Ulcers FREE

Amir Qaseem, MD, PhD, MHA; Tanveer P. Mir, MD; Melissa Starkey, PhD; Thomas D. Denberg, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians*
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* This paper, written by Amir Qaseem, MD, PhD, MHA; Tanveer P. Mir, MD; Melissa Starkey, PhD; and Thomas D. Denberg, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians. Individuals who served on the Clinical Guidelines Committee from initiation of the project until its approval were Thomas D. Denberg, MD, PhD (Chair); Michael J. Barry, MD; Molly Cooke, MD; Paul Dallas, MD; Nick Fitterman, MD; Mary Ann Forciea, MD; Russell P. Harris, MD, MPH; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schünemann, MD, PhD; J. Sanford Schwartz, MD; Paul Shekelle, MD, PhD; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 26 July 2014.


From the American College of Physicians, Philadelphia, Pennsylvania; New York University Clinical Cancer Center, New York, New York; and Carilion Clinic, Roanoke, Virginia.

Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.

Acknowledgment: The authors thank Dr. Roger Chou for updating the evidence from the original systematic review for the development of this guideline.

Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.

Disclosures: Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1567. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.

Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, aqaseem@acponline.org.

Current Author Addresses: Drs. Qaseem and Starkey: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Dr. Mir: New York University Clinical Cancer Center, 160 East 34th Street, New York, NY 10016.

Dr. Denberg: Carilion Clinic, PO Box 13727, Roanoke, VA 24036.

Author Contributions: Conception and design: A. Qaseem, T.P. Mir.

Analysis and interpretation of the data: A. Qaseem, M. Starkey, T.D. Denberg.

Drafting of the article: A. Qaseem, T.P. Mir, M. Starkey, T.D. Denberg.

Critical revision of the article for important intellectual content: A. Qaseem, M. Starkey, T.D. Denberg.

Final approval of the article: A. Qaseem, T.P. Mir, T.D. Denberg.

Statistical expertise: A. Qaseem.

Administrative, technical, or logistic support: A. Qaseem, M. Starkey, T.D. Denberg.

Collection and assembly of data: A. Qaseem, M. Starkey.


Ann Intern Med. 2015;162(5):359-369. doi:10.7326/M14-1567
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Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations based on the comparative effectiveness of risk assessment scales and preventive interventions for pressure ulcers.

Methods: This guideline is based on published literature on this topic that was identified by using MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists. Searches were limited to English-language publications. The outcomes evaluated for this guideline include pressure ulcer incidence and severity, resource use, diagnostic accuracy, measures of risk, and harms. This guideline grades the quality of evidence and strength of recommendations by using ACP's clinical practice guidelines grading system. The target audience for this guideline includes all clinicians, and the target patient population is patients at risk for pressure ulcers.

Recommendation 1: ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. (Grade: weak recommendation, low-quality evidence)

Recommendation 2: ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence)

Recommendation 3: ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: weak recommendation, moderate-quality evidence)


Pressure ulcers are defined as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure alone or in combination with shear (1). They commonly occur in patients with limited mobility, such as those in hospitals or long-term care settings. It is estimated that up to 3 million adults in the United States are affected by pressure ulcers (2). The prevalence in the United States is estimated to range from 0.4% to 38% in acute care hospitals, 2% to 24% in long-term care nursing facilities, and 0% to 17% in home care settings (24). Between 1990 and 2001, pressure ulcers were reported as a cause of death in nearly 115 000 persons and were listed as the underlying cause of death in more than 21 000 (5). The estimated cost of treating each case of pressure ulcers ranges from $37 800 to $70 000, and up to $11 billion is spent annually in the United States to treat pressure ulcers (2, 67). A growing industry has developed to market various products for pressure ulcer prevention.

Risk factors for pressure ulcers include older age; black race or Hispanic ethnicity; lower body weight; cognitive impairment; physical impairments; and other comorbid conditions that affect soft tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition (811). Various risk assessment instruments have been developed, including the Braden, Cubbin and Jackson, Norton, Ramstadius, and Waterlow scales.

Prevention strategies for pressure ulcers begin with identification of high-risk persons. Many interventions designed to prevent pressure ulcers and reduce friction and shear are available, and categories include various support surfaces (such as mattresses, integrated bed systems, overlays, and cushions), repositioning, nutritional supplementation, skin care (for example, dressing and management of incontinence), and topical creams (Table 1). Studies have suggested that prevention of hospital-acquired pressure ulcers is more effective than standard care (12). Although this guideline focuses on a comparative effectiveness review of individual interventions, we understand that care teams often implement multicomponent interventions or bundled approaches to preventing pressure ulcers and that pressure ulcer care involves physicians, nurses, and other members of the care team.

Table Jump PlaceholderTable 1. Pressure Ulcer Preventive Interventions 

The purpose of this American College of Physicians (ACP) guideline is to present the available evidence on the comparative effectiveness of various risk assessment instruments and benefits and harms of strategies to prevent pressure ulcers. The target audience for this guideline is all clinicians, including physicians, nurses, dieticians, and physical therapists. The target patient population comprises all adults at risk for pressure ulcers. For recommendations on the treatment of pressure ulcers, please refer to the accompanying ACP guideline (13).

This guideline is based on a systematic evidence review (14), an update of the literature (Supplement), and an evidence report sponsored by the Agency for Healthcare Research and Quality (AHRQ) (17) that addressed the following key questions:

1. Is the use of risk assessment tools effective in reducing the incidence or severity of pressure ulcers, and how does effectiveness vary according to setting and patient characteristics?

2. How do various risk assessment tools compare with one another in their ability to predict the incidence of pressure ulcers?

3. In patients at increased risk for pressure ulcers, what is the effectiveness and comparative effectiveness of preventive interventions in reducing the incidence or severity of pressure ulcers, and how does effectiveness vary according to assessed risk level, setting, or patient characteristics?

4. What are the harms of interventions for preventing pressure ulcers? Do harms differ according to the type of intervention, setting, or patient characteristics?

We searched MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists to identify trials published in English. The outcomes evaluated for this guideline include pressure ulcer incidence and severity; resource use (including duration of hospital stay or cost); diagnostic accuracy (sensitivity, specificity, and positive and negative likelihood ratios); measures of risk (hazard ratios, odds ratios, and relative risks); discrimination (area under the receiver-operating characteristic curve); and harms, such as dermatologic reactions, discomfort, and infection.

We also supplemented the AHRQ evidence review with another systematic evidence review of multicomponent strategies for preventing pressure ulcers that examined the importance of contextual aspects of programs that aim to reduce facility-acquired pressure ulcers (16). This review included implementation studies (from 2000 to September 2012) of multicomponent initiatives to prevent pressure ulcers in adults in U.S. acute and long-term care settings. Studies were limited to those that reported pressure ulcer rates at least 6 months after implementation of the intervention.

Further details about the methods and inclusion and exclusion criteria applied in the evidence review are available in the full AHRQ report (15) and the Supplement. This guideline rates the quality of evidence and strength of recommendations by using ACP's guideline grading system (Table 2). Details of the ACP guideline development process can be found in ACP's methods paper (17).

Table Jump PlaceholderTable 2. The American College of Physicians' Guideline Grading System 

Low-quality evidence from 1 good-quality study showed no difference among the Waterlow scale, the Ramstadius tool (an unvalidated combination risk assessment and intervention protocol), and nurses' clinical judgment alone in reducing the risk for pressure ulcers or length of stay in patients (18). A recent Cochrane review supported this conclusion, citing lack of evidence to conclusively show a difference between the risk assessment tools and clinical judgment in reducing pressure ulcer incidence (19). No study evaluated the effectiveness of risk assessment tools across care settings or patient subgroups.

Moderate-quality evidence showed that the Braden, Cubbin and Jackson, Norton, and Waterlow scales had low sensitivity and specificity to identify patients at risk for pressure ulcers. In addition, moderate-quality evidence showed that diagnostic accuracy did not differ substantially among the scales (15). Low-quality evidence showed no clear differences in diagnostic accuracy of the Braden scale according to patient characteristics or settings, with lower optimal cutoffs for surgical or acute care patients. Moderate-quality evidence showed no clear differences in diagnostic accuracy of the Braden scale according to baseline pressure ulcer risk. Although the Cubbin and Jackson scale was initially developed for patients in intensive care units, low-quality evidence showed that it had a similar diagnostic accuracy to the Braden and Waterlow scales in this setting (2021). Tables 3 and 4 provide descriptions of the scales as well as sensitivities and specificities; more details are available in the full evidence report (15).

Table Jump PlaceholderTable 3. Descriptions of Commonly Used Pressure Ulcer Risk Assessment Tools 
Table Jump PlaceholderTable 4. Evidence for Pressure Ulcer Risk Assessment Tools 
Effectiveness and Comparative Effectiveness of Preventive Interventions to Reduce the Incidence or Severity of Pressure Ulcers

Many interventions were studied by only 1 trial each, and pooling of studies was not practical because of methodological limitations and clinical diversity of the studies. Table 5 summarizes the evidence for the various preventive interventions. Static (moderate-quality evidence) (5559) and alternating-air (low-quality evidence) (7476) mattresses or overlays reduced pressure ulcer incidence compared with standard hospital mattresses. Evidence was mixed or showed no statistically significant difference for comparisons of other support surfaces (6169, 7183). Low-quality evidence showed no difference in risk for pressure ulcers or mixed results for heel supports or boots (8485), different wheelchair cushions (8689), nutritional supplementation (9095), various dressings (101102), intraoperative warming (103), and various repositioning intervals (low- to moderate-quality evidence) (96100, 108109). Low-quality evidence showed that a skin cream containing fatty acid and a skin cleanser other than soap decreased risk for pressure ulcers (60, 110111).

Table Jump PlaceholderTable 5. Evidence for Interventions to Reduce Incidence and Severity of Pressure Ulcers 
Harms of Interventions to Prevent Pressure Ulcers

A total of 16 trials reported harms for interventions to prevent pressure ulcers. Although details on specific harms were sparse, no serious treatment-related harms were reported. In summary, evidence was insufficient to determine how harms of preventive interventions vary according to the type of intervention, care setting, or patient characteristics.

Mattresses, Overlays, and Other Support Systems

Low-quality evidence from 9 studies of support surfaces reported harms. Heat-related discomfort was reported in 3 trials of sheepskin overlays, which also led to withdrawals (5657, 60). One trial reported differences in pain and sleep disturbances between different dynamic mattresses (110). A study comparing a multicell pulsating dynamic mattress with a static gel overlay found no differences in risk for adverse events (111). One study reported no increased risk for adverse events with the Heelift Suspension Boot (DM Systems) compared with standard care (84). One study reported an increased risk for withdrawal due to discomfort with the Jay cushion compared with standard wheelchair cushions (88).

Nutritional Supplementation

Low-quality evidence from 1 study reported that tube feeds were poorly tolerated (54% removed within 1 week and 67% removed within 2 weeks) (93).

Repositioning

Low-quality evidence from 2 studies reported increased nonadherence due to intolerability of repositioning at a 30-degree tilt position compared with standard positioning (108109).

Dressings

Low-quality evidence from 1 study showed that application of the Remois Pad (Alcare) resulted in pruritus in 1 patient out of 37 total (112).

Creams, Lotions, and Cleansers

Low-quality evidence from 3 studies reported harms for lotions or creams. Two studies reported 1 case each of a wet sore or rash, and 1 study showed no differences in rash between various creams studied (106, 113114).

Low-quality evidence from 1 study showed no difference in incident stage 2 to 4 ulcers between a multicomponent electronic clinical decision-support system or provision of guidelines (1.8% vs. 2.1%; relative risk, 0.85 [95% CI, 0.23 to 3.10]) (107). Evidence from 1 poor-quality study showed that immediate implementation of musical cues was associated with lower risk for incident ulcers in nursing home residents (6.0% vs. 9.4%; relative risk, 0.64 [CI, 0.45 to 0.90]) (115).

Multicomponent interventions are increasingly becoming the standard of care for prevention of pressure ulcers. Bundling care practices and organizing a team approach to care have been shown to be effective at improving patient outcomes.

Benefits

Moderate-quality evidence from a review of 26 implementation studies showed that multicomponent interventions can improve skin care and reduce pressure ulcer rates in both acute and long-term care settings (16). The review found that key components of successful interventions include simplification and standardization of pressure ulcer–specific interventions and documentation, involvement of multidisciplinary teams and leadership (including ostomy, continence, and other nurses and personnel), designated skin champions who educate staff about skin care and ulcer prevention, ongoing staff education (including team meetings and motivational campaigns), and sustained audit and feedback (including weekly prevalence reports, formal and informal feedback, and all-facility meetings) (16). Successful interventions also incorporated evidence-based guidelines into their practices.

Harms

The systematic review found no harms reported for the multicomponent strategies that were used to prevent pressure ulcers (16).

Costs

The systematic review identified 4 studies (116120) that reported significant cost savings with the multicomponent approach. In 2008, a 2-hospital system (548 beds in Naples, Florida) estimated annual cost savings of approximately $11.5 million as a result of statistically significant reductions in pressure ulcer prevalence (118).

Low-quality evidence showed that risk assessment tools (the Waterlow and Ramstadius scales) were equivalent to clinical judgment alone for reducing pressure ulcer incidence. Evidence on the diagnostic accuracy of the commonly used risk assessment instruments showed that these tools can help in the identification of patients who are at an increased risk for pressure ulcers, although the sensitivities and specificities were low. Diagnostic accuracy did not differ substantially among the various risk assessment instruments, and studies of direct comparisons were limited.

Most of the evidence on preventive interventions came from studies assessing support surfaces. Moderate-quality evidence showed that advanced static mattresses and overlays were associated with a lower risk for pressure ulcers compared with standard mattresses in higher-risk patients. Evidence on other preventive interventions, including nutritional supplementation, lotions, cleansers, and dressings, was limited and inconclusive because most were assessed by few studies.

Little evidence was available on harms of preventive interventions, although no serious harms were reported. Evidence was also insufficient to draw a conclusion about harms based on the type of intervention, care setting, or patient characteristics.

All of the preventive interventions reviewed in this guideline were assessed individually, but they can be bundled to provide optimum care. Evidence shows that multicomponent strategies can improve clinical outcomes. Key components of successful implementation efforts include simplification and standardization of pressure ulcer–specific interventions and documentation, involvement of multidisciplinary teams and leadership, designated skin champions, ongoing staff education, and sustained audit and feedback. The Figure summarizes the recommendations and clinical considerations.

Grahic Jump Location
Figure.

Summary of the American College of Physicians guideline on risk assessment and prevention of pressure ulcers.

Grahic Jump Location

Recommendation 1: ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. (Grade: weak recommendation, low-quality evidence)

Risk assessment is often part of bundled care and multicomponent interventions for preventing pressure ulcers. Risk factors for pressure ulcers include older age; black race or Hispanic ethnicity; lower body weight; cognitive impairment; physical impairments; and other comorbid conditions that affect soft tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition. Clinicians should make individualized decisions based on risk assessment on whether to use a single or multicomponent intervention to prevent pressure ulcers in patients.

The current evidence does not conclusively show a difference between clinical judgment and risk assessment scales in reducing pressure ulcer incidence. However, tools may be especially useful for clinicians without expert gestalt. Moderate-quality evidence showed that the Braden, Cubbin and Jackson, Norton, and Waterlow scales can predict which patients are more likely to develop a pressure ulcer, and all of these instruments have low sensitivity and specificity. In addition, moderate-quality evidence showed that the diagnostic accuracies of the scales do not differ substantially. No study evaluated the effectiveness of risk assessment tools across care settings or patient subgroups.

Recommendation 2: ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence)

Moderate-quality evidence showed that the use of advanced static mattresses or overlays was associated with a lower risk for pressure ulcers compared with standard hospital mattresses, and no brand was shown to be superior. Advanced static mattresses and overlays are also less expensive than alternating-air or low–air-loss mattresses and can be used as part of a multicomponent approach to pressure ulcer prevention.

Recommendation 3: ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: weak recommendation, moderate-quality evidence)

The current evidence does not show a clear benefit for pressure ulcer prevention using alternating-air beds and overlays compared with static mattresses and overlays, and alternating-air beds and overlays are associated with significantly higher costs. Lower-cost support surfaces should be the preferred approach to care.

Evidence is insufficient to compare various preventive interventions, such as different types of repositioning and leg elevations, relative to various kinds of usual care. Creams and lotions, dressings, repositioning, and nutritional support, in any combination, are generally regarded as usual care. Of note, the comparison group in many studies was standard care that often included repositioning, skin care, and/or nutrition. Therefore, any lack of evidence showing benefit relative to the comparison group of usual care does not mean that usual care should be abandoned.

Data on the efficacy of many of the interventions came only from single studies, and further research into comparative effectiveness of pressure ulcer prevention strategies is warranted. In addition, more research is needed on the comparative efficacy of pressure ulcer risk assessment tools and their efficacy compared with clinical judgment.

Prevention of pressure ulcers is the first important step, and advanced static mattresses and overlays were associated with a lower risk for pressure ulcers compared with standard mattresses in higher-risk patients. Many hospitals in the United States use alternating-air and low–air-loss mattresses and overlays despite the lack of evidence showing a potential benefit in the reduction of pressure ulcers in high-risk populations. Using these support systems is expensive and adds unnecessary burden on the health care system. Based on the review of the current evidence, lower-cost support services should be the preferred approach to care.

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Figures

Grahic Jump Location
Figure.

Summary of the American College of Physicians guideline on risk assessment and prevention of pressure ulcers.

Grahic Jump Location

Tables

Table Jump PlaceholderTable 1. Pressure Ulcer Preventive Interventions 
Table Jump PlaceholderTable 2. The American College of Physicians' Guideline Grading System 
Table Jump PlaceholderTable 3. Descriptions of Commonly Used Pressure Ulcer Risk Assessment Tools 
Table Jump PlaceholderTable 4. Evidence for Pressure Ulcer Risk Assessment Tools 
Table Jump PlaceholderTable 5. Evidence for Interventions to Reduce Incidence and Severity of Pressure Ulcers 

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Letters

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In Reply: Risk Assessment and Prevention of Pressure Ulcers
Posted on March 26, 2015
William V. Padula Ph.D. M.S., C. Tod Brindle R.N. M.S.N. C.W.O.C.N, Mary Beth F. Makic Ph.D. R.N.
WVP: Fellow, Department of Medicine, University of Chicago, Chicago, IL; CTB: Wound Ostomy Continence Nurse, Virginia Commonwealth University Health System, Richmond, VA; MBFM: Associate Professor, Co
Conflict of Interest: None Declared
TO THE EDITOR: The ACP guidelines by Qaseem and colleagues effectively summarize the strength of evidence supporting pressure ulcer (PrU) prevention, which is only weak to moderate in most cases.(1) We agree with their recommendation that clinicians should risk-assess all hospitalized patients to identify those at-risk for PrUs.(1) How this first step is implemented is important in order to initiate other components of evidence-based practices (EBPs) as indicated by the Wound, Ostomy and Continence Nurses Society (WOCN) as well as the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA) in the 2014 International Guidelines for PrU prevention.(2,3)

Qaseem et al. reviewed several risk-assessment instruments, including the Braden, Cubbin and Jackson, Norton, Ramstadius and Waterlow scales, and found that the Braden and Norton scales possessed good quality evidence for prognosis of risk.(1) However, these instruments lacked subscales that would differentiate patient risk on the basis of socio-demographics or clinical setting.

In addition, a recent meta-analysis by Garcia-Fernandez and colleagues found that the Braden Scale has the most validation studies and shows high-capacity to predict PrUs.(3) Good predictive capacity was found for the Norton scale as well.(3) In fact, this meta-analysis of four studies with a pooled sample of 1500 patients determined that clinical judgment alone achieved inadequate PrU risk-assessment.

While current evidence is inconclusive about the direct association between risk-assessment and PrU reductions, the evidence does support the use of validated PrU risk-assessment tools such as Braden or Norton scales in conjunction with clinical judgement.(2-4) The ACP guidelines should not deter any providers from using these instruments, even those with “expert gestalt.” Staff nurses, for instance, should become comfortable using the best-available structured instruments to carry out risk-assessment. Likewise, those with clinical expertise who are revered by others of less experience should strive to establish a benchmark for best-practices in quality improvement by synergizing their judgment with the strengths of risk-assessment instruments.(5)

Clinical practice guidelines such as these preventive recommendations from the ACP need to align providers with national best-practices and the use of structured instruments even when the science to support their use is continuing to grow and strengthen. As the field of nursing continues to investigate improved population-based risk-assessment instruments as part of EBPs, training providers to use structured instruments as opposed to clinical judgment will make a transition to modern instruments more seamless.

REFERENCES

1. 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):359-69.

2. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

3. Ratliff CR, Tomaselli N. WOCN update on evidence-based guideline for pressure ulcers. J Wound Ostomy Continence Nurs. 2010; 37(5):459-60.

4. Garcia-Fernandez FP, Pancorbo-Hidalgo PL, Agreda JS. Predictive capacity of risk assessment scales and clinical judgement for pressure ulcers: a meta-analysis. J Wound Ostomy Continence Nurs. 2014; 41(1): 24-34.

5. Padula WV, Mishra MK, Makic MB, Valuck RJ. A framework of quality improvement interventions to implement evidence-based practices for pressure ulcer prevention. Adv Skin Wound Care. 2014 Jun; 27(6): 280-284.
In Reply: Risk Assessment
Posted on April 2, 2015
Jill Monfre PhD RN CWOCN, Justin Endo MD
Dr. Endo: Assistant Professor, Department of Dermatology, University of Wisconsin; Dr. Monfre: Clinical Nurse Specialist, University of Wisconsin Hospital and Clinics
Conflict of Interest: None Declared
The American College of Physicians (ACP) has improved physician awareness with their pressure ulcer (PrU) guidelines. We agree with the comments from Padula et al. in response to the ACP guidelines. The collaboratively published guideline by the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) is an excellent, comprehensive and updated reference. (1)
While we await further research, what should our role as internists be in PrU management, and what can the ACP do to help us implement best practice based on limited evidence?
In a study by Cox et al., two-thirds of surveyed physicians believed that their role was important in preventing PrU, but less than half reported feeling adequately trained during residency. (2) Less than 40% ever attended a continuing education program or lecture about PrU. Over 80% of physicians did not understand the purpose of a pressure redistribution mattresses. This survey suggests that physicians might benefit from receiving general background information about PrU in addition to the granular recommendations of published clinical guidelines. We hope that ACP continues to work to fill this practical knowledge gap, which, in turn, might help physicians co-manage PrU and communicate with interdisciplinary wound care teams.

References
1. European Pressure Ulcer Advisory Panel NPUAP, Pan Pacific Pressure Injury Alliance, 2014;Pages. Accessed at Cambridge Media at http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf.
2. Cox J, Roche S, Gandhi N. Critical care physicians: attitudes, beliefs, and knowledge about pressure ulcers. Adv Skin Wound Care. 2013;26(4):168-76.

In Reply: Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians
Posted on April 9, 2015
Todd J. Kowalski, MD, Michelle L. Tilson, CWOCN, Sonya A. Brickner, CWOCN, CFCN
Gundersen Health System
Conflict of Interest: None Declared
TO THE EDITOR: The American College of Physicians clinical practice guidelines for prevention, assessment, and treatment of pressure ulcers (1, 2) highlight the dearth of evidence available to guide clinicians and health systems. This is salient because pressure ulcers have been coined “never events.” Since 2008 Centers for Medicare & Medicaid Services (CMS) has withheld reimbursement for treatment of hospital-acquired stage III and IV pressure ulcers, but—in contrast to other disease states for which evidence strongly suggests that better processes yield better outcomes—pressure ulcer rates have not improved (3). Furthermore, 100% of expert voting attendees at a recent National Pressure Ulcer Advisory Panel (NPUAP) consensus conference believe that patient situations may render pressure ulcers unavoidable (4).
More surprising is the tenuous evidence upon which the staging system used for pressure ulcers is based, in particular the NPUAP pressure ulcer stage of “Suspected Deep Tissue Injury (DTI)–depth unknown.” In 2007, the NPUAP added the DTI stage in order to engender more aggressive treatment interventions. At that time not a single published study validated the definition or outlined the prognostic significance of the newly defined entity. Since then, research suggests that < 1% of skin lesions labeled “DTI” by certified wound nurses may progress to stage III ulcers (5). Expert wound diagnosticians attending a 2007 NPUAP consensus conference achieved only 60% accuracy when classifying pressure ulcers and associated dermal lesions using the new definitions. Documentation and diagnosis of DTI is further obscured because no ICD-9 nor ICD-10 codes are specific to DTI. The NPUAP recommends that DTI be coded as “pressure ulcer, unstageable”; however, the Agency for Healthcare Research and Quality considers hospital-acquired unstageable pressure ulcers a Patient Safety Indicator (PSI)—a reflection of quality of care. In turn, PSI data are used by the CMS Value-Based Purchasing program to determine whether to pay or withhold payment for services. Thus, DTI documentation not only conveys uncertain clinical ramifications but also may result in adverse quality and fiscal metrics for hospital systems. Overall, these findings highlight that pressure ulcers ought not be utilized as hospital-based quality measures until evidence-based interventions that yield improved outcomes are available, particularly when public reporting and financial sanctions may be tied to them. We recommend that DTI undergo rigorous study before it is considered a distinct clinical entity and that the condition not be associated with any quality or reimbursement metrics.

Todd J. Kowalski, MD
Michelle L. Tilson, CWOCN
Sonya A. Brickner. CWOCN, CFCN
Gundersen Health System
La Crosse, WI 54601

References
1. 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;162(5):359-69. [PMID: 25732278]
2. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):370-9. [PMID: 25732279]
3. Waters TM, Daniels MJ, Bazzoli GJ, Perencevich E, Dunton N, Staggs VS, et al. Effect of Medicare's nonpayment for hospital-acquired conditions: lessons for future policy. JAMA Intern Med. 2015;175(3):347-54. [PMID: 25559166]
4. Black JM, Edsberg LE, Baharestani MM, Langemo D, Goldberg M, McNichol L, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage. 2011;57(2):24-37. [PMID: 21350270]
5. Sullivan R. A two-year retrospective review of suspected deep tissue injury evolution in adult acute care patients. Ostomy Wound Manage. 2013;59(9):30-9. [PMID: 24018390]


Author's Response
Posted on August 12, 2015
Amir Qaseem, MD, PhD, Mary Ann Forciea, MD, Linda Humphrey, MD, MPH
ACP, Univeristy of Pennsylvania, Oregon Health and Science University
Conflict of Interest: None Declared
As Dr. Padula rightfully pointed out, the evidence is inconclusive to link specific pressure ulcer risk assessment tools with outcomes such as reduced pressure ulcers. We also found insufficient evidence to determine the superiority of any one tool over the others or over clinical gestalt for predicting the development of pressure ulcers. The ACP guideline does not recommend against using pressure ulcer risk assessment tools, nor is the intent to discourage this practice. However, in the absence of evidence, we cannot promote the use of these tools over clinical judgment and leave the decision of risk assessment up to the care provider.

Dr. Kowalski brings up the important point that developing performance measures for many chronic conditions, such as preventing pressure ulcers, is challenging. We agree that performance measures should be based on robust scientific evidence in the areas that shows clinical benefit rather than on statistical data or expert opinion.


Mary Ann Forciea, MD, FACP
University of Pennsylvania Health System, Philadelphia, PA

Linda L. Humphrey, MD, MPH, MACP
Oregon Health and Science University, Portland, OR

Amir Qaseem, MD, PhD, MHA, FACP
American College of Physicians, Philadelphia, PA
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Supplement. Pressure Ulcer Risk Assessment and Prevention: Update to a Comparative Effectiveness Review

Summary for Patients

Risk Assessment and Prevention of Pressure Ulcers

The full report is titled “Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians.” It is in the 3 March 2015 issue of Annals of Internal Medicine (volume 162, pages 359-369). The authors are A. Qaseem, T.P. Mir, M. Starkey, and T.D. Denberg, for the Clinical Guidelines Committee of the American College of Physicians.

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