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

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

March 26, 2015

In Reply: Risk Assessment and Prevention of Pressure Ulcers

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.

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

April 2, 2015

In Reply: Risk Assessment

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.

Todd J. Kowalski, MD, Michelle L. Tilson, CWOCN, Sonya A. Brickner, CWOCN, CFCN

Gundersen Health System

April 9, 2015

In Reply: Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians

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]

Amir Qaseem, MD, PhD, Mary Ann Forciea, MD, Linda Humphrey, MD, MPH

ACP, Univeristy of Pennsylvania, Oregon Health and Science University

August 12, 2015

Author's Response

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