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Pressure Ulcer Prevention and Management: A Dire Need for Good SciencePressure Ulcer Prevention and Management FREE

Joyce Black, PhD, RN, CWCN
[+] Article, Author, and Disclosure Information

From University of Nebraska Medical Center, Omaha, Nebraska.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0190.

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.


Ann Intern Med. 2015;162(5):387-388. doi:10.7326/M15-0190
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The science underpinning pressure ulcer prevention and treatment is in its infancy. Much of the published research on pressure ulcers has been underpowered and has focused on early signs of healing rather than more definitive outcomes. As a result, the 2014 international clinical practice guideline on pressure ulcer prevention and treatment includes only 77 statements with evidence to support them, whereas the remaining 498 statements are based on expert opinion (1). This issue includes clinical practice guidelines developed by the American College of Physicians (ACP) on the prevention and treatment of pressure ulcers (23). These guidelines are based on systematic reviews prepared by an Evidence-based Practice Center funded by the Agency for Healthcare Research and Quality that evaluated evidence on the effectiveness of interventions to prevent and treat pressure ulcers (45). Unlike the international guideline, the ACP guidelines contain only recommendations supported by evidence. This raises issues about the helpfulness of the recommendations at the bedside, where treatment decisions must sometimes be made in the absence of good evidence.

The ACP guidance reflects that risk assessment tools for pressure ulcers are imperfect predictors of risk. Pressure ulcers typically develop in patients with limited ability to participate in their own care. Therefore, application of the principles that are used to predict risk for other conditions, such as cancer, is problematic. First, patients with pressure ulcers often cannot participate in decisions about whether to have risk assessment. Second, the low sensitivity and specificity of pressure ulcer risk assessment are expected because risk can change within minutes (for example, from anesthesia or sedation). These varying risks are not captured unless the risk assessment tool is completed contemporaneously with changes in patient condition. Further, tools to assess pressure ulcer risk are often used in populations that differ from those in which they were developed. The Braden Scale, the most commonly used tool in the United States, was initially developed for long-term care residents. When applied in acute care settings, it was found to predict pressure ulcers poorly for surgical patients or those with highly acute illness (6). A recent meta-analysis showed 3 variables that predict pressure ulcers in all patients: immobility, perfusion, and prior skin injury (7). At the bedside, other risk factors, such as age and race, become part of the clinical judgment used to predict risk. When used appropriately, the Braden Scale can be a useful screening tool, but clinical judgment should also be used to guide decisions about care.

That the ACP did not consider levels of risk in the recommendations on support surfaces is disappointing. The older studies cited by the ACP compared foam mattresses with a “standard hospital bed,” which was seldom described and may have included spring mattresses. Therefore, static foam mattresses seemed to be better surfaces—but better than what? Evidence supports the use of reactive surfaces, such as foam mattresses, for prevention in low-risk patients who can be moved from side to side (1). The ACP does not recommend more expensive support surfaces for prevention, and although this is generally reasonable, the expert opinion from the international guideline recommended that very-high-risk patients who cannot be moved be placed on active support surfaces, such as alternating-air or low–air-loss surfaces (1). Although advanced support surfaces are more costly than foam surfaces, the cost–benefit ratio may favor their use in selected high-risk patients.

The ACP guideline panel also found insufficient evidence to support a recommendation for oral nutritional supplementation as a means of pressure ulcer prevention. Yet, a 2005 meta-analysis concluded that oral supplementation with 400 to 500 calories daily for 4 to 72 weeks was associated with a 25% reduction in pressure ulcer rates (8).

Because pressure ulcers are largely preventable, pressure ulcer prevention programs have become a safety initiative for many health care systems. The ACP guideline notes that risk assessment is often part of these bundled care practices and that multicomponent interventions can improve patient outcomes. The success of these programs in reducing pressure ulcer incidence is believed to be attributable to their engagement of leadership and administration, involvement of direct care providers, continuous education of staff, and sustained audits and feedback (9).

Although pressure ulcer prevention focuses on reduction of pressure on body sites of at-risk patients, pressure ulcer management is based on 3 principles: removing the offending agent (pressure), protecting the wound from contamination, and promoting healing through nutrition. It is useful to review how the new ACP guideline reflects these principles and why the evidence that the ACP would require to make more definitive recommendations is lacking.

The ACP guideline states that there is weak evidence for the effect of various support surfaces on pressure ulcer healing. Restrictions in payment for advanced support surfaces have contributed to the scarcity of observational data on their effectiveness. Generally, a patient qualifies for reimbursement for the use of an advanced support surface when a stage 3 or 4 pressure ulcer is present but no longer qualifies once the ulcer shows signs of healing and is downstaged to stage 2. Although evidence is lacking on the effectiveness of these surfaces, the international guideline provides expert opinion on the appropriate type of support surface for patients with pressure ulcers until better evidence is available. Regardless of the surface used, it is imperative that the patient continue to be turned to relieve pressure on the ulcer. High-quality research is needed to determine which surfaces promote complete and durable closure of pressure ulcers.

The ACP recommendations also highlight the scarcity of definitive data on other interventions to promote wound healing. The guideline statements on hydrocolloid and foam dressings stem from weak, low-quality evidence. Because chronic wounds are contaminated and biofilms exist in them, antiseptic dressings, such as those containing silver, honey, and cadexomer iodine, seem to be justified. The international guideline provides consensus-based advice on these topical treatments (1). Although the ACP recommends electrical stimulation, access to practitioners licensed to perform it can be limited in some settings. The ACP found insufficient evidence to advocate nutritional support to prevent pressure ulcers but recommends protein or amino acid supplementation to reduce the size of existing ulcers. However, it provides no dosing recommendations. The guideline from the Trans Tasman Dietetic Wound Care Group recommends 1.25 to 1.5 g of protein per kilogram of body weight daily for patients with pressure ulcers in whom nutritional risk is moderate or high for a delay in wound healing (10).

Despite the number of cases of pressure ulcers and the potential for life- and limb-threatening harm, practices vary greatly. Evidence is scarce in the science of pressure ulcers, and definitive analysis of benefits and harms of various interventions is difficult because of the limited available studies. Although clinical guidelines can be augmented with expert opinion, a dire need remains in the field of pressure ulcer prevention and treatment for scientists, clinical research, and implementation science.

References

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2014.
 
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; 162:359-69.
 
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; 162:370-9.
 
Chou R, Dana T, Bougatsos C, Blazina I, Starmer AJ, Reitel K, et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Ann Intern Med. 2013; 159:28-38.
CrossRef
 
Smith ME, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, et al. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med. 2013; 159:39-50.
CrossRef
 
He W, Liu P, Chen HL. The Braden Scale cannot be used alone for assessing pressure ulcer risk in surgical patients: a meta-analysis. Ostomy Wound Manage. 2012; 58:34-40.
PubMed
 
Coleman S, Gorecki C, Nelson EA, Closs SJ, Defloor T, Halfens R, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013; 50:974-1003.
PubMed
CrossRef
 
Stratton RJ, Ek AC, Engfer M, Moore Z, Rigby P, Wolfe R, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005; 4:422-50.
PubMed
CrossRef
 
Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013; 158:410-6.
CrossRef
 
Trans Tasman Dietetic Wound Care Group. Evidence based practice guidelines for the nutritional management of adults with pressure injuries. Trans Tasman Dietetic Wound Care Group. 2011.
 

Figures

Tables

References

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2014.
 
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; 162:359-69.
 
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; 162:370-9.
 
Chou R, Dana T, Bougatsos C, Blazina I, Starmer AJ, Reitel K, et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Ann Intern Med. 2013; 159:28-38.
CrossRef
 
Smith ME, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, et al. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med. 2013; 159:39-50.
CrossRef
 
He W, Liu P, Chen HL. The Braden Scale cannot be used alone for assessing pressure ulcer risk in surgical patients: a meta-analysis. Ostomy Wound Manage. 2012; 58:34-40.
PubMed
 
Coleman S, Gorecki C, Nelson EA, Closs SJ, Defloor T, Halfens R, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013; 50:974-1003.
PubMed
CrossRef
 
Stratton RJ, Ek AC, Engfer M, Moore Z, Rigby P, Wolfe R, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005; 4:422-50.
PubMed
CrossRef
 
Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013; 158:410-6.
CrossRef
 
Trans Tasman Dietetic Wound Care Group. Evidence based practice guidelines for the nutritional management of adults with pressure injuries. Trans Tasman Dietetic Wound Care Group. 2011.
 

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In Reply: Pressure Ulcer Prevention and Management
Posted on March 26, 2015
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
Conflict of Interest: None Declared
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.


REFERENCES

1. Black J. Pressure Ulcer Prevention and Management: A Dire Need for Good Science. Ann Intern Med 2015;162:387-88

2. 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):359-69

4. 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.
Author's Response
Posted on April 28, 2015
Joyce Black, PhD, RN. CWCN
University of Nebraska Medical Center
Conflict of Interest: None Declared
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.
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