ACP Guidelines for Preventing, Treating Pressure Ulcers

Critically ill patients are at high risk of developing pressure ulcers resulting in serious untoward patient and health care system outcomes. Pressure ulcer prevention is therefore an important patient safety priority and establishing a structured approach to pressure ulcer risk assessment to identify patients at risk is a critical first step. The literature was searched using three electronic databases from 2000 to 2011 to identify papers reporting on pressure ulcer risk factors and assessment in adult critical care. The review and appraisal of papers were conducted by two critical care nurses. Papers underwent detailed review if they met inclusion criteria where they identified pressure ulcer assessment scores, scales or risk factors and related to adult critical care patients Seven papers were reviewed. No single assessment tool was sufficiently validated for critically ill patients and seven key critical care risk factors were identified. These risk factors were: mechanical ventilation, impaired circulation, dialysis, long surgery, low protein and too unstable to turn. The tool Critical Care Pressure Ulcer Assessment Tool made Easy (CALCULATE) was developed utilizing the risk factors from the literature and expert critical care nursing consensus decision-making. In the absence of current consensus, valid assessment scales and limited evidence for the most appropriate pressure ulcer assessment for critically ill patients, this assessment tool offers an easy, appropriate alternative for critically ill patients than existing tools primarily validated for acute care wards. 'CALCULATE' offers an important contribution towards the advancement and development of critical care pressure ulcer risk assessment. Future research is needed to further enhance and inform pressure ulcer risk assessment of the critically ill patients. The identification of critical care risk factors may be an indicative method of assessing pressure ulcer risk in the critically ill patients.

1. Co-chaired this panel 2. University of Washington, Seattle, WA 3. University of Texas Medical Branch Galveston, Galveston, TX 4. Sinai Hospital, Baltimore, MD 5. Johns Hopkins Medical Institutions, Baltimore, MD 6. University of Southern Denmark, Odense University Hospital, Odense, Denmark 7. University of South Florida, Tampa, FL 8. University of Virginia Health System, Charlottesville, VA 9. St. Louis Medical Center, St. Louis, MO, and 10. University of San Francisco, San Francisco, CA

Review objective The objective of this review is to establish whether using the Braden subscale mobility assessment is comparable to using the full Braden assessment scale. The specific review questions to be addressed are: 1. What preventive pressure ulcer nursing interventions are initiated based on assessment of mobility impairment alone or in comparison with the full Braden risk assessment scale? 2. What is the effect of using mobility assessment alone on incidence of hospital acquired pressure ulcers? Inclusion criteria Types of participants This review will consider studies that include adult patients, 18 years and older, in acute care setting who are at risk of developing pressure ulcers. At risk patients are those identified using Braden risk assessment scale as ‘at risk’, ‘moderate risk’, ‘high risk; and ‘very high risk’ for developing pressure ulcer6, 9 or the sub scale for impaired mobility as ‘completely immobile’, ‘very limited’ and ‘slightly limited’. Studies involving children only and studies conducted in the emergency department only or in the operating room only will be excluded from the review as they are not consistent with the review objective. Types of intervention(s)/Phenomena of interest This review will consider studies that include pressure ulcer risk identified using assessment of the subscale mobility impairment compared with full Braden scale assessment where available. Types of outcomes This review will consider the following primary outcome measures: • Whether patients in either study arm are more or less likely to receive appropriate preventative interventions, including, but not limited to protective mattresses, creams and skin barriers, vitamin supplements, patient positioning etc • Incidence of hospital acquired pressure ulcers Secondary outcome measures: • Reliability of mobility assessment ± Braden assessment • Frequency of assessment

It is uncertain whether foam dressings are more clinically effective, more acceptable to users, or more cost effective compared to alternative dressings in treating pressure ulcers. It was difficult to make accurate comparisons between foam dressings and other dressings due to the lack of data on reduction of wound size, complete wound healing, treatment costs, or insufficient time-frames. Quality of life and patient (or carer) acceptability/satisfaction associated with foam dressings were not systematically measured in any of the included studies. We assessed the certainty of the evidence in the included trials as low to very low. Clinicians need to carefully consider the lack of robust evidence in relation to the clinical and cost-effectiveness of foam dressings for treating pressure ulcers when making treatment decisions, particularly when considering the wound management properties that may be offered by each dressing type and the care context.

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. 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. 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). 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). 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).

Quality Indicators for Assessing Care of Vulnerable Elders16 October 2001Quality Indicators for Prevention and Management of Pressure Ulcers in Vulnerable EldersFREEBarbara M. Bates-Jensen, PhD, RN, CWOCNBarbara M. Bates-Jensen, PhD, RN, CWOCNFrom University of California, Los Angeles, Los Angeles, California; and the Borun Center for Gerontological Research, Los Angeles, California.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-135-8_Part_2-200110161-00014 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Pressure ulcers can lead to pain, disfigurement, and slow recovery from comorbid conditions. They interfere with activities of daily living, predispose to osteomyelitis and septicemia (1), and are strongly associated with longer hospital stays and mortality. Frailty and chronic illness, both common among older adults, predispose to pressure ulcers (1–3).The prevalence of pressure ulcers is 10% to 14% among hospitalized patients of all ages (4, 5) and up to 24% among patients in nursing homes (2). One goal of Healthy People 2010 is to reduce the prevalence of pressure ulcers in nursing home patients by 50% (6). Prevention and treatment of pressure ulcers are an important aspect of care for vulnerable elders. This paper presents quality indicators for the prevention and care of pressure ulcers among vulnerable elders and the evidence supporting these indicators.MethodsThe methods for developing these quality indicators, including literature review and expert panel consideration, are described in detail in another paper in this issue (7). For pressure ulcers, the structured literature review identified 177 titles, from which abstracts and articles that were relevant to this report were identified. Fifteen potential quality indicators were proposed on the basis of the literature and the author's expertise and files from previous reviews of the subject (8, 9).ResultsOf the 15 potential quality indicators, 10 were judged to be valid by the expert panel and 1 additional indicator was created by the panel (see the quality indicators). One indicator was merged with an accepted indicator, and 4 were not accepted. The literature supporting each of the indicators judged to be valid by the expert panel process is reviewed below.Quality Indicators 1 and 2: Pressure Ulcer PreventionRisk AssessmentIF a vulnerable elder is admitted to an intensive care unit or a medical or surgical unit of a hospital and cannot reposition himself or herself or has limited ability to do so, THEN risk assessment for pressure ulcers should be done on admission BECAUSE risk assessment can predict pressure ulcer formation in such high-risk groups and forms the basis for intervention.Positioning Needs and Pressure ReductionIF a vulnerable elder is identified as at risk for pressure ulcer development or a pressure ulcer risk assessment score indicates that the person is at risk, THEN a preventive intervention addressing repositioning needs and pressure reduction (or management of tissue loads) must be instituted within 12 hours BECAUSE reduction or elimination of risk factors can prevent pressure ulcer formation.Supporting Evidence. Several cohort and prospective studies and various expert groups provide evidence supporting timely risk assessment. Braden and Bergstrom (10) studied the predictive validity of risk assessment for pressure ulcers in 102 newly admitted nursing home residents. Using the Braden Scale (Figure) with a cutoff score of 18, they demonstrated that the sensitivity, specificity, positive predictive value, and negative predictive value of the admission assessment for subsequent development of pressure ulcers were 75%, 59%, 41%, and 86%, respectively. Of the 28 residents who developed pressure ulcers, the ulcer developed within about 2 weeks after admission in 71%, and all ulcers developed less than 4 weeks after admission (10).Figure. The Braden Scale for predicting risk for pressure ulcers. Download figure Download PowerPoint A multisite cohort study of 843 patients who were followed for 4 weeks found that the Braden Scale was predictive of pressure ulcer development in tertiary care centers, Veterans Affairs medical centers, and skilled nursing facilities (11). As part of the study, prescription of preventive interventions for turning and pressure reduction were evaluated in all three health care settings. Regardless of setting, turning schedules and pressure reduction were prescribed less frequently (7.7% and 34%) for patients at no risk or low risk (Braden Scale scores ≥ 16) than for patients at moderate or high risk (Braden Scale scores ≤ 15; 51% and 69%) (12). In another prospective cohort study of 200 newly admitted nursing home residents, the best predictor of all stages of pressure ulcer formation was Braden Scale score (13). Other investigators also found an association between preventive interventions and Braden Scale scores, in particular the subscale scores for mobility, friction, and shear (14). Prevention interventions are ordered and seem to be used more frequently for people with high-risk Braden Scale scores. However, data showing the effectiveness of the interventions themselves are lacking. Various expert groups, including the National Pressure Ulcer Advisory Panel (NPUAP) (15), the Agency for Health Care Policy and Research (AHCPR) Panel for Prevention and Prediction of Pressure Ulcers (2), and the American Medical Directors Association (AMDA) (3) recommend performing risk assessment in persons who cannot reposition themselves or have limited ability to do so.Quality Indicator 3: Pressure Ulcer PreventionNutritionIF a vulnerable elder is identified as at risk for pressure ulcer development and has malnutrition (involuntary weight loss of ≥ 10% over 1 year or low albumin or prealbumin levels), THEN nutritional intervention or dietary consultation should be instituted BECAUSE poor diet, particularly low dietary protein intake, is an independent predictor of pressure ulcer development.Supporting Evidence. Studies have shown a relationship between risk factors for malnutrition, such as involuntary weight loss, anorexia, gastrointestinal illnesses, cancer, low caloric intake, and low albumin level and pressure ulcer formation; some studies have found a relationship between ulcer severity and severity of malnutrition (16–18). Furthermore, several studies have shown associations between low serum albumin level and the presence (19, 20), severity (17, 18), and healing (21, 22) of pressure ulcers. Other measures of nutritional status, such as body weight, have been shown to correlate with presence (19, 20) and severity (17) of pressure ulcers. Although no direct evidence shows that adequate nutrition will prevent ulcers, these studies provide indirect evidence that prevention of malnutrition will reduce risk for pressure ulcer formation.Quality Indicator 4Pressure Ulcer EvaluationIF a vulnerable elder presents with a pressure ulcer, THEN the pressure ulcer should be assessed for location, depth and stage, size, and presence of necrotic tissue BECAUSE baseline assessment guides interventions, provides data for later comparison to evaluate healing, and can help predict time to healing.Supporting Evidence. No controlled trials of assessment of pressure ulcers have been done, and some experts believe that such studies may be impractical or irrelevant [23]. Several sets of guidelines support formal assessment of pressure ulcers, with documentation of findings, and focus on wound characteristics as a useful method for evaluating and documenting healing. The NPUAP suggested that 1) assessment should include multiple characteristics; 2) pressure ulcer staging is useful for diagnostic purposes only; and 3) size and stage are insufficient measures of healing and, although important, should be used in conjunction with assessment of other wound characteristics (24). Others have also acknowledged the role of assessment in planning and evaluating therapy (3, 25, 26).Observational data support these consensus statements and suggest that many wound characteristics are important predictors of healing or determinants of interventions.Wound Depth and StagePressure ulcers are commonly classified according to staging systems based on the depth of tissue destruction. Stage 1 lesions are least severe, and stage 4 are most severe. Staging systems are best used to diagnose wound severity and show a relationship to healing outcomes, but they do not facilitate monitoring of healing over time (2, 24, 26, 27). Full-thickness wounds (stage 3 and stage 4) generally take longer to heal than partial-thickness wounds (stage 2) (28). A prospective study showed that stage 2 pressure ulcers were 5.2 times more likely to heal than stage 4 pressure ulcers (29). Several other prospective studies also found that wound depth was a predictor of healing and time to healing (21, 30). Two retrospective studies demonstrated that wound depth was related to healing characteristics (31) and that change in depth was related to healing time (8), yet both studies found that initial wound depth did not correlate with healing.SizeSeveral studies have demonstrated a relationship between wound surface area and time to complete healing. In a prospective study to determine progress of healing within specific time frames, van Rijswijk (32) examined the characteristics of full-thickness pressure ulcers in 119 patients (48 of whom had full-thickness ulcers) who were seen in diverse settings. Healing was measured by using surface area tracings, with follow-up of 15 months. Mean reduction in wound surface area for ulcers that healed versus those that did not was significant at 2 weeks (45% vs. −3%) and at 4 weeks (77% vs. 18%). In a secondary analysis of full-thickness pressure ulcers, only 25% healed completely within 50 days, but three quarters had 50% reduction in surface area within 39 days (33). Ulcers with a surface area decrease of at least 39% after 2 weeks healed more quickly than those with a lesser decrease in surface area (median time to healing, 53 vs. 70 days). Retrospective studies also support the relationship between early reduction in surface area and shorter time to healing (8, 31).Presence of Necrotic TissueWound bed characteristics determine treatment options (8, 34). Several studies have shown that replacement of necrotic tissue with granulation and epithelial tissue is indicative of healing (32), and the presence of necrotic tissue at baseline is associated with slower healing (35).Other Characteristics and Assessment ToolsResults of studies of other wound characteristics, such as exudate and undermining, in relation to healing time have been inconclusive (8, 21, 33–36). Nonetheless, assessment is recommended because it can guide treatment (8).Use of a standardized instrument or tool for assessment and documentation of pressure ulcers, such as the Pressure Sore Status Tool (37) or the Pressure Ulcer Scale for Healing (36), is suggested, but no study has examined the effect of standardized evaluation and documentation on pressure ulcer outcomes.Quality Indicators 5 and 6Management of Full-Thickness Pressure UlcersIF a vulnerable elder presents with a clean full-thickness pressure ulcer and has no improvement after 4 weeks of treatment, THEN the appropriateness of the treatment plan and the presence of cellulitis or osteomyelitis should be assessed BECAUSE clean full-thickness pressure ulcers should show evidence of healing or improvement within 4 weeks and lack of improvement should stimulate a change in approach.Management of Partial-Thickness Pressure UlcersIF a vulnerable elder presents with a partial-thickness pressure ulcer and has no improvement after 2 weeks of treatment, THEN the appropriateness of the treatment plan should be assessed BECAUSE partial-thickness pressure ulcers should show evidence of healing or improvement within 2 weeks and lack of improvement should stimulate a change in approach.Supporting Evidence. No direct evidence indicates that reassessment of nonhealing ulcers will improve outcomes. However, it is logical that reassessment is a necessary first step to identify causes of and, hence, treat nonhealing ulcers.These two quality indicators are supported by evidence on rate of healing and healing outcomes from several studies. A randomized, controlled trial involving 85 patients found that up to 42% of stage 2 ulcers healed within 30 days and 75% healed within 60 days, whereas only 17% of stage 3 and 4 ulcers healed within 60 days (30). Similar outcomes were noted in a prospective cohort study of 89 nursing home residents with stage 2 or greater pressure ulcers. After 6 weeks of follow-up, 65% of stage 2 ulcers, 14% of stage 3 ulcers, and no stage 4 ulcers healed (29). In Brandeis and colleagues' (28) cohort study of 1626 patients with a stage 2 or greater pressure ulcer who were admitted to 1 of 51 nursing, up to 54% of stage 2 ulcers healed in 3 months and 74% healed in 6 months (28). Healing rates for stage 3 and 4 ulcers were slower; 31% and 23% healed in 3 months and 59% and 33% healed in 6 months, respectively. Data from a randomized, controlled trial (35) indicated much faster healing times for stage 2 ulcers and provide primary support for the 2-week time frame for the partial-thickness quality indicator: The median healing time was 9 to 11 days, and three quarters of the ulcers healed within 14 to 26 days, depending on topical treatment.In a retrospective study of 143 pressure ulcers, change in surface area at 1 week was a strong predictor of time to 50% healing. The median time to 50% healing among ulcers at all stages that had decreased surface area within 1 week was 21 to 26 days; in contrast, wounds with no change in surface area reached 50% healing in a median of 34 days (8), and an increase in surface area at 1 week was predictive of nonhealing.Reported mean or median times to healing are 8.7 to 38 days (22, 30, 35) for partial-thickness stage 2 ulcers; full-thickness stage 3 or 4 ulcers will heal after 8 to 10 weeks of therapy in 10% to 40% of patients (28, 32). Some investigators have shown that the percentage reduction in surface area after 1, 2, or 4 weeks of treatment is predictive of time to healing (8, 33). The basis for the 4-week timeframe in the full-thickness quality indicator is primarily supported by van Rijswijk and Polansky's study of full-thickness pressure ulcers and percentage reduction in surface area as predictors of time to healing (33).Quality Indicator 7Pressure Ulcer DebridementIF a vulnerable elder presents with a full-thickness sacral or trochanteric pressure ulcer covered with necrotic debris or eschar, THEN debridement by using sharp, mechanical, enzymatic, or autolytic procedures should be done within 3 days of diagnosis BECAUSE dead tissue is a physical obstacle to healing tissue and provides a medium for bacterial invasion and proliferation, which places the patient at high risk for wound infection.Supporting Evidence. Wound debridement can be performed by using sharp, mechanical, enzymatic, or autolytic methods. Sharp debridement involves use of a scalpel, scissors, or other sharp instrument to remove nonviable tissue. One multicenter trial of the effects of a topical growth factor versus placebo on wound healing in 118 patients noted incidentally that sharp debridement was positively associated with healing of diabetic ulcers (38). In this study, all patients received sharp debridement initially and then as needed throughout 20 weeks of follow up. In post hoc analysis, centers that used sharp debridement more frequently (debridement at up to 87% of visits) produced better healing rates (up to 83%) than did centers that used sharp debridement less often (debridement at 15% to 43% of visits; up to 64% healed). Sharp debridement can be safely performed in a fairly aggressive manner at the bedside in a sequential fashion (daily or every other day) by various health care providers. Attention to patient comfort is recommended (systemic or topical analgesia), and some have suggested benefits to combining bedside sequential sharp debridement with other forms of debridement to maximize response (39).Mechanical debridement involves the use of wet-to-dry dressings, whirlpool, or lavage or wound irrigation. The AHCPR panel recommended cautious use of mechanical wet-to-dry dressings for debridement because removal of dressing may cause trauma to new granulation and epithelial tissue. Because debridement with wet-to-dry dressings is painful, the AHCPR panel recommends pain management, such as administration of a systemic analgesic before dressing removal (25). Coarsely woven gauze or cotton sponges appear to be more effective than finer materials in mechanical debridement (40).Enzymatic debridement involves applying a concentrated, commercially prepared enzyme to the surface of the necrotic tissue, with the expectation that it will aggressively degrade necrosis by digesting devitalized tissue. A randomized, controlled trial of enzymatic debridement for necrotic wounds reported a mean time of 8 days to debride stage 4 pressure ulcers with an amorphous hydrogel dressing and a mean time of 12 days for debridement with an enzymatic preparation containing streptokinase and streptodornase (41). These times did not differ significantly, suggesting that an agent with enzyme activity was unnecessary.Autolytic debridement is use of the body's own mechanisms to remove nonviable tissue. Maintaining a moist wound environment allows collection of fluid at the wound site, which allows enzymes within the wound to digest necrotic tissue. Autolytic debridement, which typically involves adequate wound cleansing to wash out partially degraded nonviable tissue, is more effective than wet-to-dry gauze dressings because it removes only necrotic tissue and therefore protects healthy tissues (42–44). Mulder and colleagues (42) evaluated 16 patients in a randomized, controlled trial of a hypertonic hydrogel versus wet-to-dry gauze for wound debridement (the hypertonicity of the gel assists with autolytic debridement by pulling fluid into the area through osmotic forces) (42). The results suggested that the hydrogel could safely facilitate removal of dry adherent eschar from wounds. Other investigators also have found amorphous hydrogels to be effective in removing necrotic debris from wounds (43–45).Quality Indicator 8Pressure Ulcer Management: CleansingIF a vulnerable elder has a stage 2 or greater pressure ulcer, THEN a topical antiseptic should not be used on the wound BECAUSE topical antiseptics may harm the healthy wound bed.Supporting Evidence. No controlled trials have examined the effectiveness or safety of wound cleansing. Contraindications to the use of antiseptic and antimicrobial solutions for cleansing clean pressure ulcers are based on several laboratory studies (46–49). Two studies tested antimicrobial wound cleansers and solutions for toxicity to polymorphonuclear leukocytes. Results showed that even serial dilutions of the products diminished the viability and function of polymorphonuclear leukocytes; in contrast, nonantimicrobial solutions did not cause substantial toxicity to polymorphonuclear leukocytes (46, 47). On the basis of early animal model studies (48, 49), the AHCPR guidelines recommend normal saline as the preferred cleanser because it is noncytotoxic (25).Quality Indicators 9 and 10Pressure Ulcer Debridement for Systemic InfectionIF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis, confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN the ulcer should be debrided of necrotic tissue within 12 hours BECAUSE debridement will reduce dead tissue that provides a medium for bacterial invasion and may lead to systemic infection.Pressure Ulcer Culture for Systemic InfectionIF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis, confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN a tissue biopsy or needle aspiration sample should be obtained and sent for culture and sensitivity testing within 12 hours BECAUSE high bacterial burdens inhibit wound healing and may lead to systemic infection, and needle aspiration or tissue biopsy is the best indicator of bacterial invasion into tissue.Supporting Evidence. Wound infection extends the inflammatory phase of healing, delays collagen synthesis, retards epithelialization, and causes more injury to the tissues because the bacteria produce toxic by-products and compete with fibroblasts and other cells for limited amounts of oxygen and nutrients (50, 51).Signs and symptoms of systemic infection may be due to spread from a full-thickness pressure ulcer. To treat the infection, the source of the infection must be identified; impediments to healing must be removed; and, if possible, the organism causing the infection must be identified. Standard swab cultures do not aid in diagnosis of infection in pressure ulcers because they detect only surface contaminants and not the organism that caused the tissue infection (52). The AHCPR pressure ulcer treatment guidelines recommend wound culture of a tissue biopsy or needle aspiration sample when infection is suspected (25). This procedure may be impractical at some centers, and the NPUAP supports use of a specialized swab technique to culture pressure ulcer wound beds (24, 53). The recommended method of quantitative swab culture involves cleansing the wound with solution that contains no antiseptic. The end of a sterile cotton-tipped applicator is rotated in a 1-cm2 area of the wound for 5 seconds (53, 54) with enough pressure to cause tissue fluid to be absorbed in the cotton tip of the swab. The swab tip is inserted in the tube containing transport media and is sent to the laboratory. Swab culture was not included in the indicator because of the difficulty in distinguishing technique from the medical record.Tissue biopsy is removal of a piece of tissue by using a scalpel or a punch biopsy instrument. The area may be treated with topical anesthetic or injected with local anesthetic. The biopsy is pressure is to the area to and the tissue is sent to the laboratory. aspiration involves of a needle to a with of in the through to the is by the to the The needle is and at for two to The is to the the needle is and and the is sent to the the of systemic infection, the full-thickness ulcer should be treated to decrease the that it is a source of bacterial This is particularly for wounds with that are generally or with necrotic For such ulcers, healing time is because tissue may be Debridement of the with to of or removes dead tissue that provides a medium for bacterial growth and Because systemic infection is debridement of the wound bed should be done within 12 Indicator a vulnerable elder presents with a clean full-thickness or a partial-thickness pressure ulcer, THEN a moist environment should be with topical dressings BECAUSE wounds heal better in a moist Evidence. Several investigators have a moist environment with dry dressings for wound healing. have noted faster healing with moist wound dressings than with wet-to-dry saline gauze dressings (22, The AHCPR guidelines on pressure ulcer treatment which are supported by the American Medical Directors Association (3) and NPUAP also the use of moist dressings over dry an increase in pressure ulcer the of the AHCPR guidelines on pressure ulcers, quality indicators are supported by substantial a literature and with a expert panel 11 valid quality indicators for pressure ulcers were identified. These indicators pressure ulcer care from prevention and assessment to topical Although they are not they provide a baseline for measures that may between quality and Pressure Pressure Ulcers in Prediction and of Health and Health Agency for Health Care Policy and AHCPR Pressure American Medical Directors A study of pressure ulcer prevalence and in care Wound National prevalence pressure ulcer a on Wound The for Quality Wound for 30 October Healthy People of Health and Assessing care of vulnerable methods for developing quality A quantitative analysis of wound characteristics as early predictors of healing in Los University of California, Los Pressure and Wound A for and Braden Bergstrom validity of the Braden Scale for pressure risk in a nursing home Bergstrom Braden pressure ulcer a multisite study of the predictive validity of the Braden Bergstrom Braden study of of pressure ulcers and the relationship between risk characteristics, and prescription of preventive Bergstrom Braden A prospective study of pressure risk among A comparison of patient risk for pressure ulcer development with nursing use of preventive on Pressure Ulcer National Pressure Ulcer Advisory at The role of nutrition in prevention and healing of pressure ulcers. in the of pressure and nutritional Pressure among hospitalized factors for pressure A comparison of and beds or therapy for pressure A pressure healing with van Rijswijk Braden Pressure ulcer patient and wound an AHCPR Wound of National Pressure Ulcer Advisory Wound

This cross-sectional survey set out to delineate risk, prevalence and prevention of pressure ulcers in a university hospital, a general hospital and a nursing home in Sweden. It also looked at the differences in risk factors and preventive strategies between patients with and without pressure ulcers. The one-day survey followed the methodology developed by the European Pressure Ulcer Advisory Panel (EPUAP). It was conducted on Tuesday 5 February 2002. Each patient was visited by two registered nurses, their skin was inspected and any pressure ulcer classified according to the EPUAP grading system. A total of 695 patients were included: 612 from the university hospital, 38 from the general hospital and 45 from the nursing home. The prevalence of pressure ulcers was 23.9% (university hospital), 13.2% (general hospital) and 20.0% (nursing home). Most (60-66%) of the pressure ulcers in the hospitals were assessed as grade I. Only half of the patients at risk or with pressure ulcers were placed on a pressure-reducing mattress and a third of these patients had a plan for repositioning. Significant variables associated with pressure ulcers were old age, geriatric care, low Braden score and incontinence. Prevalence of pressure ulcers was higher than expected. Results relating to both prevalence of pressure ulcers (grade I excluded) and the preventive care given to patients at risk or with pressure ulcers accord with those of a larger Dutch study. Attention must focus on the appropriate risk-assessment skills, highlighting grade I as pressure damage, and the use of appropriate preventive strategies, based on the level of risk.

Pressure Ulcer Content in Undergraduate Programs

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations based on the comparative effectiveness of treatments of pressure ulcers. This guideline is based on published literature on this topic that was identified by using MEDLINE, EMBASE, CINAHL, EBM Reviews, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, and the Health Technology Assessment database through February 2014. Searches were limited to English-language publications. The outcomes evaluated for this guideline include complete wound healing, wound size (surface area, volume, and depth) reduction, pain, prevention of sepsis, prevention of osteomyelitis, recurrence rate, and harms of treatment (including but not limited to pain, dermatologic complications, bleeding, and infection). 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 with pressure ulcers. ACP recommends that clinicians use protein or amino acid supplementation in patients with pressure ulcers to reduce wound size. (Grade: weak recommendation, low-quality evidence). ACP recommends that clinicians use hydrocolloid or foam dressings in patients with pressure ulcers to reduce wound size. (Grade: weak recommendation, low-quality evidence). ACP recommends that clinicians use electrical stimulation as adjunctive therapy in patients with pressure ulcers to accelerate wound healing. (Grade: weak recommendation, moderate-quality evidence).

Guidelines are documents systematically prepared to support medical experts and patients for making appropriate judgments in particular clinical situations. The Japanese Society of Pressure Ulcers (JSPU) published the Guidelines for the Prevention and Management of Pressure Ulcers in February 2009, which has undergone revisions leading to the publishing of the fourth edition in 2015. Their guideline was not intended solely for physicians, but for nurses, nutritionists, pharmacists, physical therapists, occupational therapists and other health-care professionals; it emphasized the prevention and care over the treatment. On the other hand, the present guideline, “Guidelines for the diagnosis and treatment of pressure ulcers”, placed more emphasis on the treatment. Both guidelines shared the same goal: systematically presenting evidence-based recommendations to support clinical decisions in the prevention, care and treatment of pressure ulcers, serving as a tool for improving the quality of diagnosis and treatment of pressure ulcer patients, and improving the care for pressure ulcers in Japan as a whole. The Wound, Pressure Ulcer and Burn Guidelines Drafting Committee (Table 1) was composed of members delegated by the Board of Directors of the Japanese Dermatological Association. The committee meetings were held gathering or through email since October 2008, and has drafted the guidelines for wounds in general, and other five related guidelines, including this guideline, by taking into consideration the opinions of the Scientific Committee, the Guideline Committee, and the Board of Directors of the Japanese Dermatological Association. The present guidelines reflect the current standards for diagnosis and treatment of pressure ulcers in Japan. However, the factors that a physician should take into consideration during diagnosis and treatment of a pressure ulcer are more diverse than those of other wounds; the patient's underlying disease, the situation of a care-providing facility, the patient's home and the locoregional conditions in which the patient resides should be considered. It is unlikely that the optimized treatment for an individual patient is in absolute agreement with these guidelines. Any deviation from these guidelines should not be the basis for citation in lawsuits or legal disputes. Chairperson: Hironobu IHN (Professor, Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University) Vice-chairperson: Takao TACHIBANA (General Manger, Department of Dermatology, Osaka Red Cross Hospital) Yuji INOUE (Director, Suizenji Dermatology Clinic) Sakae KANEKO (Associate Professor, Department of Dermatology, Shimane University Faculty of Medicine) Hiroyuki KANOH (Associate Professor, Department of Dermatology, Graduate School of Medicine, Gifu University) Yoichi SHINTANI (Director, Shintani Dermatology Clinic) Jun TSUJITA (Chair, Department of Dermatology, Social Insurance Inatsuki Hospital, Fukuoka Prefecture Social Insurance Hospital Association) Minoru HASEGAWA (Assistant Professor, Department of Dermatology, Faculty of Medical Sciences, University of Fukui) Hideki FUJITA (Associate Professor, Department of Dermatology, School of Medicine, Nihon University) Sei-ichiro MOTEGI (Lecturer, Department of Dermatology, Graduate School of Medicine, Gunma University) Andres LE PAVOUX (Director, Ichige Dermatology Clinic) Zenzo ISOGAI (Chief Physician, Division of Dermatology and Connective Tissue Medicine, Department of Advanced Medicine, National Center for Geriatrics and Gerontology) Ryokichi IRISAWA (Research Associate, Department of Dermatology, Tokyo Medical University) Masaki OTSUKA (Assistant Director, Division of Dermatology, Shizuoka Cancer Center) Takafumi KADONO (Associate Professor, Department of Dermatology, St. Marianna University School of Medicine) Monji KOGA (Lecturer, Department of Dermatology, Fuculty of Medicine, Fukuoka University) Kuninori HIROSAKI (Chief Physician, Department of Dermatology, Hokkaido Medical Care Center) Hiroshi FUJIWARA (Specially-Appointed Professor, Niigata University Medical and Dental Hospital; Chair, Department of Dermatology, Uonuma Institute of Community Medicine) Masatoshi ABE (Assistant Director, Sapporo Dermatology Clinic) Ryuta IKEGAMI (Chair, Department of Dermatology, JCHO Osaka Hospital) Taiki ISEI (Chair, Department of Dermatology, Osaka National Hospital) Hiroshi KATO (Lecturer, Department of Geriatric and Environmental Dermatology, Graduate School of Medical Sciences, Nagoya City University) Eiichi SAKURAI (Assistant Director, Sakurai Dermatology Clinic) Hideaki TANIZAKI (Lecturer, Department of Dermatology, Osaka Medical College) Takeshi NAKANISHI (Specially-Appointed Associate Professor, Department of Dermatology, Shiga University of Medical Science) Koma MATSUO (Director, Nakano Dermatology Clinic) Osamu YAMASAKI (Lecturer, Department of Dermatology, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University) Jun ASAI (Lecturer, Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine) Yoshihide ASANO (Associate Professor, Department of Dermatology, Faculty of Medicine, University of Tokyo) Takayuki ISHII (Chief Physician, Division of Dermatology, Toyama Prefectural Central Hospital) Yohei IWATA (Associate Professor, Department of Dermatology, Fujita Health University School of Medicine) Tamihiro KAWAKAMI (Associate Professor, Department of Dermatology, St. Marianna University School of Medicine) Masanari KODERA (Chair, Department of Dermatology, JCHO Chukyo Hospital) Manabu FUJIMOTO (Professor, Department of Dermatology, Faculty of Medicine, University of Tsukuba) Takaaki ITO (Lecturer, Department of Dermatology, Hyogo College of Medicine) Ryuichi KUKINO (Director, Kukino Dermatology Clinic) Yasuko SARAYAMA (Assistant Chair, Department of Dermatology, Kobe Rosai Hospital) Miki TANIOKA (Director, Tanioka Dermatology Clinic) Takeo MAEKAWA (Associate Professor, Department of Dermatology, Jichi Medical University) Hiroshi YATSUSHIRO (Chief Physician, Department of Dermatology, Fukui-ken Saiseikai Hospital) Masahiro AMANO (Professor, Department of Dermatology, Faculty of Medicine, University of Miyazaki) Yoichi OMOTO (Chief Physician, Department of Dermatology, Yokkaichi Municipal Hospital) Masakazu KAWAGUCHI (Associate Professor, Department of Dermatology, Yamagata University Faculty of Medicine) Keisuke SAKAI (Chair, Department of Dermatology, Minamata City General Hospital and Medical Center) Naotaka DOI (Research Associate, Department of Dermatology, Wakayama Medical University) Akira HASHIMOTO (Research Associate, Department of Dermatology, Tohoku University Graduate School of Medicine) Masahiro HAYASHI (Lecturer, Department of Dermatology, Yamagata University Faculty of Medicine) Naoki MADOKORO (Chair, Department of Dermatology, MAZDA Hospital) Yuichiro YOSHINO (Chair, Department of Dermatology, Japanese Red Cross Kumamoto Hospital) All expenses required for drafting these guidelines have been borne by the Japanese Dermatological Association, and no aid or financial support has been provided by specific organizations, enterprises or pharmaceutical companies. Furthermore, in the case that a committee member (Table 1) participating in the drafting of these guidelines was involved in the development of a specific, relevant drug, that member abstained from determining to what degree the item in question was recommended. Aside from that, each committee member has no conflict of interest to disclose in the drafting of these guidelines. Databases search: The key word search in Medline, PubMed, Japanese Medical Abstracts Society and Cochrane Database of Systematic Reviews, as well as the personal references of the committee members, were performed. Search period: The studies published between January 1980 and December 2013 were reviewed. More recent publications were also considered, if appropriate. Adoption criteria: Priority was placed on systematic reviews of randomized controlled trials (RCT) and on individual RCT. If they were not available, cohort studies and case–control studies were adopted. Case series studies were also used as references. Basic research studies were not considered as evidence in recommendation. The criteria adopted in the “Guidelines for the diagnosis and treatment of malignant tumors” described below, published by the Japanese Dermatological Association, were used as a reference for the classification of the evidence levels. Evidence level classification: The Minds Handbook for Clinical Practice Guideline Development 2014 was referenced for the recommendation levels. Classification of recommendation levels and descriptions: Recommendation levels: If the recommendation levels could not be determined, recommendation level “none” may be given. The recommendations appear with the strength of evidence (defined as A, B, C and D) and the recommendation level as in the following examples: Before the publication of these guidelines, those of annual progress in drafting were presented in the Annual Meetings of the Japanese Dermatological Association from 2012 to 2015, to solicit opinions from the association members in order to make necessary revisions. The present guidelines are scheduled to be updated in the next 3 or 5 years. However, if a partial update becomes necessary, it will be presented on the website of the Japanese Dermatological Association. Pressure ulcer: External force applied to the body reduces or blocks blood flow in the soft tissue between the bone and the skin surface. If this state continues for a certain period, the tissue sustains irreversible ischemic damage and develops into a pressure ulcer. Topical agents: Drugs that are applied through the skin or directly to skin lesions for localized treatment. They are prepared by compounding various drugs with a base. Dressing materials: Modern wound-dressing materials for creating a wet environment for wounds. Conventional sterilized gauze is excluded. Wound-dressing materials: Wound-dressing materials can be broadly divided into dressing materials (modern dressing materials) and medical materials such as gauze (classic dressing materials). The former are medical materials that provide conditions optimal for wound healing by maintaining a moist environment, and must be used selectively depending on the state of the wound and the amount of exudate. Gauze allows drying of the wound and cannot maintain a moist environment if exudate volume is insufficient. Medical materials other than conventional gauze that provide an optimal environment for wound healing by covering the wound and maintaining moisture may also be called wound-dressing materials or dressing materials. Occlusive dressing: All dressing methods used to avoid drying of wounds for moist wound healing are called occlusive dressings. This is a collective term for dressings using modern wound-dressing materials other than conventional gauze dressing. Wet-to-dry dressing: Dressing aimed at debridement performed by applying gauze saturated with physiological saline to the wound, and once the gauze has dried, non-selective removing of foreign material and necrotic tissue adhering to it occurs when it is changed. Surgical treatments: Surgery, surgical debridement and invasive treatments of subcutaneous pockets. Physical therapy: Treatment performed by applying stimulation to the body using physical means, which include physical energy such as heat, water, light, ultrashort waves, electricity, ultrasound, vibration, pressure and traction. Thermotherapy, cryotherapy, hydrotherapy, phototherapy, ultrashort wave therapy, electric stimulation therapy, ultrasound therapy, negative-pressure therapy, high-pressure oxygen therapy and traction therapy are variations of physical therapies. These are performed to mitigate pain, promote wound healing and increase the elasticity of tissues such as muscles and ligaments. “Physical therapy” is used as a general term for all these therapies, and the means for the treatment are conventionally called “physical agents” to avoid confusion. NPUAP pressure ulcer staging system: A classification of depth of pressure ulcers, a staging system proposed by the NPUAP in 1989. Conventionally, pressure ulcers have been classified into stages I, II, III and IV. Recently, however, the category of deep tissue injury (DTI) has been added based on the concept that deep areas may be damaged even without damage to the skin surface. Therefore, according to the new NPUAP pressure ulcer staging system issued in 2007, pressure ulcers are categorized into six stages: (suspected) DTI, stages I, II, III and IV, and unstageable (whether the depth of pressure ulcer is III or IV is impossible to determine). DESIGN: An assessment scale for evaluating the conditions of pressure ulcers introduced by the Japanese Society of Pressure Ulcers in 2002 as an assessment tool consisting of seven items: depth, exudate, size, inflammation/infection, granulation tissue, necrotic tissue and pocket. There are two types: one used for severity classification representing severe and mild using capital and lowercase letters, respectively, and the other for the evaluation of patient progress by quantifying the healing process to allow monitoring. The latter type exists as the 2002 version, and the 2008 revision (DESIGN-R® with the “R” standing for “rating”) was amended to provide a more accurate rating of severity as well as evaluation of the course of pressure ulcers. Deep tissue injury: The term used by the NPUAP in 2005, meaning a pressure ulcer without epidermal loss (stage I) in which there is a suspicion of damage to tissues deeper than subcutaneous tissue. In the NPUAP pressure ulcer staging system for pressure ulcers revised in 2007, “(suspected) deep tissue injury” was added as a new stage. It may be translated as “deep tissue damage” for damage other than pressure ulcers Nutrition support team (NST): The Japan Council for Nutritional Therapy (JCNT) calls nutritional management performed appropriately for individual patients and for the treatment of individual disorders “nutrition support” and defines a team of several professions including a physician, nurse, pharmacist, managerial dietician and clinical laboratory technician as the NST. Erosion: Cutaneous or mucosal loss not extending beyond the basement membrane (dermoepidermal junction, mucosa). Usually heals without leaving a scar. Ulcer: Cutaneous or mucosal loss extending beyond the basement membrane (dermoepidermal junction, mucosa). Usually leaves a scar after the cure. Decompression: Reducing contact pressure similarly to that of pressure reduction. Previously, reducing the pressure to less than 32 mmHg, considered to be the internal pressure of capillaries, was defined as decompression, and to 32 mmHg or above as pressure reduction, but this distinction is not made today. Body pressure-dispersion devices: Devices that reduce the pressure on a unit of body surface area due to contact with a support such as a bed or a chair by widening the contact area or by shifting the area under pressure over time to reduce the pressure at any single site over the long term. Devices used for patients in a recumbent position include special beds, overlay mattresses layered over a bottom mattress, and replacement mattresses to be substituted for conventional mattresses. Devices used for patients in a seated position include cushions placed on chairs and wheelchairs and pads used to adjust the body position. Materials used in body pressure-dispersion devices include air, water, urethane foam, gels and rubber. Wound bed preparation: Management of the wound surface environment to promote wound healing. Specifically, necrotic tissue is removed, bacterial load is reduced, drying of the wound is prevented, excessive exudates are controlled, and pockets and wound edges are treated. TIME: Practical principles of wound bed preparation based on the concept of evaluating factors that prevent wound healing from the viewpoints of tissue (T), infection or inflammation (I), moisture (M) and wound edge (E), and using the results for treatment and management Moist wound healing: Maintaining the wound surface in a moist environment. This retains polynuclear leukocytes, macrophages, enzymes and cell growth factors contained in exudates on the wound surface. Such an environment promotes autolysis and removal of necrotic tissues, and does not interfere with cell migration. Negative-pressure wound therapy (NPWT): A type of physical therapy. The wound is maintained in a closed environment and suction is applied to adjust the negative pressure of 125–150 mmHg. This therapy directly eliminates bacteria and exotoxins in the wound, promotes neovascularization in granulation tissue and alleviates edema. Pocket: A wound cavity larger than a skin defect. The tissue covering a pocket is called the cover wall or cover lid. Undermine. Washing: Removing chemical stimulants, infection sources and foreign bodies from the skin or wound surface using the pressure or lysing effect of a liquid. Washing may be performed using physiological saline, tap water or saline or tap water combined with a surfactant such as soap or detergent in a method known as washing with soap. The effect of washing may be derived from the flow volume or hydraulic pressure. Debridement: A therapeutic action to clean the wound by removing foreign material, necrotic tissue, senescent cells that no longer react to stimulation by promoters of wound healing such as growth factors, as well as foci of bacterial infection, which are often associated with the above. Methods include: (i) autolytic debridement induced by occlusive dressing; (ii) mechanical debridement (e.g. wet-to-dry dressing, high-pressure washing, hydrotherapy and ultrasonic washing); (iii) debridement using proteolytic enzymes; (iv) surgical debridement; and (v) biological debridement using maggots. Critical colonization: Conventionally, the microbial environment of the wound was classified into infected and aseptic states, but the current trend is to understand the two conditions as existing along a continuum (the concept of bacterial balance). Infection of the wound is understood as continuous stages of contamination, colonization and infection, and infection is considered to occur depending on the balance between the bacterial burden on the wound and host resistance. Critical colonization is a stage between colonization and infection when the balance has shifted toward infection and the number of bacteria has increased. Biofilm: Bacteria that have colonized the surface of a foreign body or in necrotic tissue may produce polysaccharides on their body surface. These gradually fuse and form a membrane-like structure, which envelops bacteria. This is called a biofilm. Bacteria wrapped in a biofilm are protected from ordinary antibiotics and leukocytes, and so infection is likely to persist. Seating: A supportive technique for using cushions and the like to provide a safe and comfortable seated position for the patient based on a physical evaluation taking into account the effect of gravity. It particularly refers to helping those patients who cannot sit upright to remain seated. The basic principles for the prevention, care and treatment of pressure ulcers are to avoid compression and shearing forces to the skin and protecting the wound surface. When a pressure ulcer has developed, the principle of treatment is “wound bed preparation” based on the TIME concept in the early, “black” and “yellow” stages. Achieving the good wound bed in “red” and “white” stages, “moist wound healing” will be intended. Note: The TIME concept is an acronym for “tissue” (treatment of non-viable or deficient tissue, that is management of necrotic/inactive tissue), “infection or inflammation” (control of infection or inflammation), “moisture” (correction of moisture imbalance, management of exudate) and “edge of wound” (treatment of non-advancing or undermined epidermal margin, management of the wound edge). Figures 1 and 2 show “the algorithm for diagnosis and treatment of pressure ulcers”, prepared based on the aforementioned concepts. The recommended and proposed treatments covered all the topical agents and dressing materials for injured skin, approved by the Japanese National Health Insurance Program, as well as surgical and physical treatments. While petroleum jerry-based antibiotic-containing ointments were approved for the treatment of erosion and ulcers by the Program, their use on deep pressure ulcers in the chronic phase may lead to the appearance of antibiotic-resistant bacterial strains; thus, the long-term use of those ointments should be avoided. Their use on the acute phase pressure ulcers or the chronic phase shallow ulcers, in expectation of the is including therapy and other not approved by the Japanese National Health Insurance Program, was also in this guideline, the present situation that it is performed at home under the 2 the as well as the level of recommendation and of the recommendation for ulcer or can a stage pressure ulcer be from using the method or the compression method is proposed as an Recommendation compression method The in diagnosis of as well as due to due to by or contact by an electric and chemical due to is Recommendation assessment of are for the assessment of for factors include the for home and the pressure ulcer evaluation presented by the of and Their appropriate use is recommended. Recommendation The use of and so is recommended to the skin and to prevent pressure ulcers. In the of a or the like to bone for the prevention of pressure ulcers is recommended. Recommendation foam, Nutritional support is recommended for the prevention and care of pressure ulcers. of and is recommended. Recommendation Nutritional support The use of a body pressure-dispersion and body position is recommended for the prevention of pressure ulcers their care as the use of a body pressure-dispersion and body position is recommended Recommendation Prevention Care of patients with pressure ulcers is recommended. Recommendation body pressure is proposed for and injury patients with pressure ulcers. Recommendation promote wound with the support team or a in nutritional is recommended for patients with or at of pressure ulcers and in a nutritional Recommendation The use of drugs such as and drugs body pressure-dispersion and dressing materials is proposed as for in pressure ulcers. Recommendation and body pressure-dispersion and dressing materials ulcers, acute treatments other than should be performed for pressure ulcers in the acute If dressing materials are to be used in the acute those that allow of the wound surface such as and are recommended. If topical agents are to be ointments such as and are recommended for protecting the wound and is recommended for use in the acute ointments antibiotics are proposed as an Recommendation and other antibiotics the diagnosis of deep tissue and blood are proposed as an Recommendation of the and course of the with is recommended dressing of the wound surface using dressing materials that allow of the such as a and dressings is recommended. Recommendation of the and course of the with decompression, and dressings pressure for the care of shallow pressure shallow pressure ulcers in the process of the use of is proposed as an Recommendation of the wound maintaining an appropriate moist environment is necessary for the of shallow pressure ulcers the level shallow Therefore, dressing materials often a in treatment. and are recommended. If topical agents are or is recommended for protecting the wound surface. ointments antibiotics and drugs such as and are recommended. Recommendation levels: Dressing materials: Topical agents: or other ointments drugs such as and pressure Treatment of early, “black” and “yellow” stage pressure Wound bed preparation based on the TIME concept Treatment of non-viable or deficient tissue surgical debridement for the removal of necrotic Surgical debridement of necrotic tissue is recommended if the patient's after the evaluation of Recommendation The use of and is recommended for removing necrotic tissue from deep pressure ulcers. necrotic tissue, the use of is recommended. dressing the use of is recommended. evidence is for and so not using it Wet-to-dry dressings also and so not using it Recommendation levels: tissue at a deep pressure ulcer: necrotic of infection or inflammation should infection of pressure ulcers be It is recommended to the of infection by evaluating of the ulcer and skin, the of inflammation of such as results of of the wound surface or the results of and blood Recommendation levels: of such as results of of the wound and blood of antibiotics is recommended not when bacterial from the ulcer surface are but also when of inflammation are in the skin the or when or of the is Recommendation The use of and is recommended for infection of pressure ulcers. there is no evidence for the use of an an it not be used Recommendation levels: dressing material when wound infection is the use

To measure pressure ulcer quality indicator (QI) scores and to describe the self-reported skin integrity assessment, pressure ulcer risk assessment, and pressure ulcer prevention and treatment practices in long-term care facilities (LTCFs). Retrospective analysis of a large data set and comparative survey. LTCFs in Missouri. Three hundred sixty-two LTCFs participated in the survey. Three hundred twenty-one facilities had pressure ulcer QI scores between April 1 and September 30, 1999. Pressure ulcer QI scores, Pressure Ulcer Prevention & Treatment Practices Survey. The mean+/-standard deviation pressure ulcer QI score was 10.9+/-6.2%, with a risk-adjusted score of 15.7+/-8.9% for high-risk residents and 3.1+/-3.6% for low-risk residents. Minimizing head-of-bed elevation to less than 30 degrees was used by fewer than 20% of facilities. More than 40% of facilities used a risk assessment tool that was not evidence based. Fewer than 13% of facilities used the Agency for Health Care Policy and Research pressure ulcer prevention and treatment guidelines. No relationship was found between the number of prevention strategies (P=.892) or the number of treatment strategies (P=.921) and the pressure ulcer QI scores. Valid and reliable pressure ulcer risk assessment tools are seriously underused. Evidence-based pressure ulcer prevention and treatment guidelines appear to be rarely implemented. This study provides a basis for developing educational and quality improvement programs and future research related to pressure ulcer prevention and treatment in LTCFs.

Pressure ulcers have high prevalence in patients and can be prevented with proper nursing interventions. The aim of this study was to evaluate nurses' knowledge about prevention and treatment of pressure ulcers. The present study was conducted with 111 nurses working in a General hospital in Greece. In this study, nurses had adequate knowledge about prevention and treatment of pressure ulcers. Respondents answered correctly in questions about staging of pressure ulcers (98.2%, 98.2%, 99.1%, 97.3%, 93.7%), the role of changing position in prevention of pressure ulcer (97.3%), the use of foam mattress (85.6%) and stretched sheets (92.8%), the use of antiseptic solution (95.5%, 85.6%), and interventions to reduce pressure on patients' heels (88.3%). A number of participants had adequate level of knowledge in the questions about the role of diet in healing of pressure ulcers (71.2%), products or devices for prevention or treatment of pressure ulcers (61.3%, 36.9%), healing of pressure ulcers (58.6%, 46.8%), prevention of bone pressure ulcers (31.5%), cleaning of a pressure ulcer (52.3%), and the role of low blood pressure as a risk factor for pressure ulcer (55.9%). However, the development of educational programs can help nurses to improve their knowledge about prevention and treatment of pressure ulcers.

Wound Literature Review 2010

Journal of Wound CareVol. 24, No. 4 EducationThe prevention and management of pressure ulcers: summary of updated NICE guidanceL. Cooper, C. Vellodi, G. Stansby, L. AvitalL. Cooper1Department of Plastic Surgery, Royal Free HospitalSearch for more papers by this author, C. Vellodi2Department of Acute Medicine and Medicine for the Elderly, Barnet and Chase Farm Hospitals NHS Trust, LondonSearch for more papers by this author, G. Stansby3Department of Vascular Surgery, Freeman Hospital, Newcastle upon Tyne. On behalf of the Guideline Development GroupSearch for more papers by this author, L. Avital4National Clinical Guideline Centre, Royal College of Physicians London.Search for more papers by this authorL. Cooper; C. Vellodi; G. Stansby; L. AvitalPublished Online:8 Apr 2015https://doi.org/10.12968/jowc.2015.24.4.179AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References 1 Dealey, C., Posnett, J., Walker, A. The cost of pressure ulcers in the United Kingdom. J Wound Care 2012; 21: 6, 261–262. Link, Google Scholar2 Moore, Z., Johanssen, E., Van Etten, M. A review of PU prevalence and incidence across Scandinavia, Iceland and Ireland (Part I). J Wound Care 2013; 22: 7, 364–368 Link, Google Scholar3 Grey, J.E., Harding, K.G., Enoch, S. Pressure Ulcers. Br Med J 2006; 332: 472–425. Crossref, Medline, Google Scholar4 Graves, N., Birrell, F,. Whitby, M. Effect of Pressure Ulcers on Length of Hospital Stay. Infect Control Hosp Epidemiol 2005; 26: 3, 293–297. Crossref, Medline, Google Scholar5 Bennett, G., Dealey, C., Posnett, J. The cost of pressure ulcers in the UK. Age Ageing 2004; 33: 3, 230–235. Crossref, Medline, Google Scholar6 The NHS Outcomes Framework 2014/15, Department of Health 2013. www.gov.uk/government/publications/nhs-outcomes-framework-2014-to-2015 (Accessed June 2014). Google Scholar7 Johansen, E., Moore, Z,. van Etten, M., Strapp, H. Pressure ulcer risk assessment and prevention: what difference does a risk scale make? A comparison between Norway and Ireland. J Wound Care 2014; 23: 7, 369–370. Link, Google Scholar8 Pressure ulcers: prevention and management of pressure ulcers. (2014) National Institute for Health and Care Excellence. www.guidance.nice.org.uk/CG179 (accessed 22/06/2014). Google Scholar9 European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009. www.epuap.org/guidelines/Final_Quick_Treatment.pdf. (accessed 19/1/2015). Google Scholar10 NICE Guidelines Manual. (2012) www.nice.org.uk/article/pmg6/chapter/1%20introduction (accessed 31/10/2014). Google Scholar11 Pressure ulcers overview. NICE Pathways 2014. pathways.nice.org.uk/pathways/pressure-ulcers (accessed 22/06/2014). Google Scholar12 Pressure ulcer prevention, treatment and care. NICE Information for the public 2014. www.publications.nice.org.uk/pressure-ulcer-prevention-treatment-and-care-ifp179 (Accessed June 2014). Google Scholar FiguresReferencesRelatedDetailsCited ByDevelopment of customized support for the prevention of Pressure Ulcer (PU) using multi-materials printingJournal of Physics: Conference Series, Vol. 1969, No. 1Pressure injury prevalence and predictors among older adults in the first 36 hours of hospitalisation8 August 2019 | Journal of Clinical Nursing, Vol. 28, No. 21-22Development and validation of the pressure ulcer management self‐efficacy scale for nurses21 April 2019 | Journal of Clinical Nursing, Vol. 28, No. 17-18Pressure heel ulcers in patients with type 2 diabetes: Is it T.I.M.E. to customise wound bed preparation according to different heel areas?17 April 2018 | International Wound Journal, Vol. 15, No. 5Support surfaces for treating pressure ulcers11 October 2018 | Cochrane Database of Systematic Reviews, Vol. 2018, No. 10References and Further Reading3 September 2018Large‐Scale Hospital Mattress Switch‐Out Leads to Reduction Hospital‐Acquired Pressure Ulcers: Operationalization of a Multidisciplinary Task Force8 March 2018 | Worldviews on Evidence-Based Nursing, Vol. 15, No. 3Pressure injuries in intensive care: What is new?Intensive and Critical Care Nursing, Vol. 45Pressure ulcers in critically ill patients – Preventable by non-sedation? A substudy of the NONSEDA-trialIntensive and Critical Care Nursing, Vol. 44Secondary Assessment of Life-Threatening Conditions of Older Patients9 September 2017Cicatrização de úlceras por pressão com extrato Plenusdermax® de Calendula officinalis L.Revista Brasileira de Enfermagem, Vol. 69, No. 2Spinal cord injury5 March 2016Spinal cord injury5 March 2016 2 April 2015Volume 24Issue 4ISSN (print): 0969-0700ISSN (online): 2052-2916 Metrics History Published online 8 April 2015 Published in print 2 April 2015 Information© MA Healthcare LimitedPDF download

Despite the implementation of prevention strategies, pressure ulcers (PUs) continue to be a challenging health problem for patients (and their carers), clinicians and health-care providers. One area of growing interest is the use of prophylactic dressings (which were originally designed for the treatment of PUs and other wound types) as a component of standard prevention measures. Over the past few years, a large amount of scientific and clinical data relating to this subject has been published in peer-reviewed journals and presented at international meetings and conferences. A substantial proportion of these data relate to one group of dressings: multi-layer foam dressings with Safetac, which are manufactured by Mölnlycke Health Care (Gothenburg, Sweden). This evidence pool has influenced the experts involved in updating the Clinical Practice Guideline, produced by the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance, on the prevention and treatment of PUs. The updated Guideline, published in 2014, recommends that, as part of their PU prevention regimens, clinicians should consider applying prophylactic dressings to bony prominences in anatomical areas that are frequently subjected to friction and shear. A literature review was undertaken to identify clinical data from the entire evidence hierarchy, as well as scientific data from laboratory studies, on the use of multi-layer foam dressings with Safetac in the prevention of pressure ulceration. The MEDLINE (National Library of Medicine, Bethesda, US) and EMBASE (Elsevier B, Amsterdam, Netherlands) bibliographic databases were searched. In addition, abstract books and proceedings documents relating to national and international conferences were scanned in order to identify presentations (i.e. oral, e-posters and posters) of relevance to the review. Clinical and health economic experts have undertaken numerous studies, including randomised controlled trials, to assess the efficacy and cost-effectiveness of using multi-layer foam dressings with Safetac as a component of standard PU prevention strategies. The results of these studies indicate that the application of multi-layer foam dressings containing Safetac can reduce the occurrence of PUs on anatomical locations such as the sacrum and the heel, and underneath medical devices. Scientists have also developed and used laboratory methods to gain a better understanding of how prophylactic dressings work. The results of these studies indicate that the composition of foam dressings containing Safetac (i.e. their multi-layer structure) sets them apart from other dressings due to their ability to mediate the effects of physical forces (i.e. pressure, friction and shear) and control microclimate, all of which contribute to pressure ulceration. The evidence pool clearly indicates that the prophylactic use of multi-layer foam dressings with Safetac as a component of standard prevention measures is beneficial to the clinician, the health-care provider and the patient. It should be noted that the findings outlined in this review may not be transferable to other products as their makeup and components are likely to differ significantly from those of multi-layer foam dressings with Safetac. As the importance of evidence-based practice and the need for cost-effective care continues to grow, clinicians and provider should carefully consider this point when selecting prophylactic dressings for PU prevention.