Series 5, chronic wounds; part 4g. Pressure ulcers: support surfaces (mattresses)

Wound Healing Society 2015 update on guidelines for pressure ulcers.

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

British Journal of Healthcare AssistantsVol. 14, No. 6 ClinicalSeries 5, Part 4c. Pressure ulcers—prevention and SSKINMenna Lloyd JonesMenna Lloyd JonesConsultant Editor, BJHCASearch for more papers by this authorMenna Lloyd JonesPublished Online:14 Jun 2020https://doi.org/10.12968/bjha.2020.14.6.289AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries. Quick reference guide. 2019. https://www.epuap.org/pu-guidelines/ (accessed 15 May 2020) Google ScholarHealth in Wales. Transforming care. 2009. http://www.wales.nhs.uk/news/13623 (accessed 15 May 2020) Google ScholarCommunity Health Council. UK eyes on ABM SKIN success. Swansea Bay Community Health Council. 2010. http://www.wales.nhs.uk/sitesplus/902/news/14061 (accessed 15 May 2020) Google ScholarKottner J, Blak J, Call E, Gefen E, Santamaria N. Microclimate: a critical review in the context of pressure ulcer prevention. Clin Biomech (Bristol, Avon). 2018 Nov;59:62–70. doi: https://doi.org/10.1016/j.clinbiomech.2018.09.010. Epub 2018 Sep 5 Crossref, Google ScholarMitchell M. Adult pressure area care: preventing pressure ulcers. Br J Nurs. 2018 Oct 4;27(18):1050–1052. doi: https://doi.org/10.12968/bjon.2018.27.18.1050 Link, Google ScholarNational Institute for Health and Care Excellence. Clinical Guidelines (CG179). Pressure ulcers: prevention and management. 2014. https://www.nice.org.uk/guidance/cg179 (accessed 15 May 2020) Google ScholarWhitlock J, Rowlands S, Ellis G, Evans A. Using the SKIN Bundle to prevent pressure ulcers. 2011. https://www.nursingtimes.net/clinical-archive/tissue-viability/using-the-skin-bundle-to-prevent-pressure-ulcers-03-09-2011/ (accessed 15 May 2020) Google ScholarWounds UK. Best Practice Statement. Maintaining skin integrity. 2018. https://www.wounds-uk.com/resources/details/maintaining-skin-integrity (accessed 15 May 2020) Google Scholar FiguresReferencesRelatedDetailsCited bySeries 5, chronic wounds, part 4e. Pressure ulcers: moisture lesionsMenna Lloyd Jones5 September 2020 | British Journal of Healthcare Assistants, Vol. 14, No. 8 2 June 2020Volume 14Issue 6ISSN (print): 1753-1586ISSN (online): 2052-4420 Metrics History Published online 14 June 2020 Published in print 2 June 2020 Information© MA Healthcare LimitedPDF download

Wound Literature Review 2010

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

Journal of Wound CareVol. 24, No. 5 CorrespondenceLettersCatherine A. Sharp, Richard J. White, Jan Kottner, Emily HaeslerCatherine A. SharpSearch for more papers by this author, Richard J. WhiteSearch for more papers by this author, Jan KottnerSearch for more papers by this author, Emily HaeslerSearch for more papers by this authorCatherine A. Sharp; Richard J. White; Jan Kottner; Emily HaeslerPublished Online:13 May 2015https://doi.org/10.12968/jowc.2015.24.5.237AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References 1 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014. Google Scholar2 Kosiak, M. Etiology and pathology of ischemic ulcers Etiology and pathology of ischemic ulcers. Archives of Physical Medicine and Rehabilitation 1959; 40: 2, 62–69. Medline, Google Scholar3 Gefen, A. How Much Time Does it Take to Get a Pressure Ulcer? Integrated Evidence from Human, Animal, and In Vitro Studies Ostomy Wound Manage. 2008; 54: 10, 26–35. Google Scholar4 Stojadinovic, O., Minkiewicz, J., Sawaya, A. et al.. Deep tissue injury in development of pressure ulcers: a decrease of inflammasome activation and changes in human skin morphology in response to aging and mechanical load. PLoS One 2013 8: 8, e69223. Crossref, Medline, Google Scholar5 Saver, J.L., Smith, E.E., Fonarow, G.C. et al.. The “Golden Hour” and Acute Brain Ischemia: Presenting Features and Lytic Therapy in >30 000 Patients Arriving Within 60 Minutes of Stroke Onset. Stroke; a journal of cerebral circulation. 2010; 41: 7, 1431–1439. Crossref, Medline, Google Scholar6 Sharp, C.A., McLaws, M.L. Estimating the risk of pressure ulcer development: is it truly evidence based? Int Wound J 2006; 3: 4, 344–353. Crossref, Medline, Google Scholar1 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. Google Scholar2 Oomens, C.W., Bader, D.L., Loerakker, S., Baaijens F. Pressure induced deep tissue injury explained. Ann Biomed Eng. 2015; 43(2):297–305. Crossref, Medline, Google Scholar3 Coleman, S., Nixon, J., Keen, J. et al. A new pressure ulcer conceptual framework. J Adv Nurs. 2014; 70: 10, 2222–2234. Crossref, Medline, Google Scholar4 Moore Z.E., Cowman, S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev 2014 5; 2: CD006471. Google Scholar5 Gillespie, B.M., Chaboyer, W.P., McInnes, E. et al.. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst Rev 2014 3; 4: CD009958. Google Scholar6 Moore, Z.E., Cowman, S. Repositioning for treating pressure ulcers. Cochrane Database Syst Rev 2015 Jan 5; 1: CD006898. Medline, Google Scholar7 Jaeschke, R., Guyatt, G., H., Dellinger, P. et al.. Use of GRADE grid to reach decisions on clinical practice guidelines when consensus is elusive. BMJ 2008; 337: 7665. Crossref, Google Scholar8 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. Google Scholar FiguresReferencesRelatedDetailsCited byTwo-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse?22 January 2019 | Journal of Bioethical Inquiry, Vol. 16, No. 1Supplementing the Braden scale for pressure ulcer risk among medical inpatients: the contribution of self-reported symptoms and standard laboratory tests20 October 2016 | Journal of Clinical Nursing, Vol. 26, No. 1-2 2 May 2015Volume 24Issue 5ISSN (print): 0969-0700ISSN (online): 2052-2916 Metrics History Published online 13 May 2015 Published in print 2 May 2015 Information© MA Healthcare LimitedPDF download

Animportant focus in critical care units is maintaining circulatory, respiratory, and renal function. Care of critically ill patients also requires interventions that are designed to prevent pressure ulcers, an all-too-common complication of immobility, inadequate nutrition, and illnesses or medications that affect blood flow and perfusion. Pressure injuries may be avoidable when consistent attention is given to assessment, nutrition, and appropriate positioning within appropriate time frames. At least 10 published guidelines for the prevention and treatment of pressure ulcers can be found on the National Guidelines Clearinghouse Web site (www.guideline.gov). A planned repositioning schedule tailored to each individual patient is recommended in all pressure ulcer prevention guidelines. Recently, the National Pressure Ulcer Advisory Panel, in collaboration with the European Pressure Ulcer Advisory Panel, announced updated guidelines for prevention and treatment of pressure ulcers. Each guideline recommendation is supported by a rigorous review of the literature and a strength-of-evidence rating. The goals in progressive mobility programs, specifically prevention of complications associated with immobility, are aligned with recommended interventions for pressure ulcer prevention. Techniques for progressive mobility can be combined with repositioning techniques recommended for prevention of pressure ulcers.

Basics Are Best in Dealing With Pressure Ulcers

To quantify pressure ulcer (PU) prevalence and to describe and identify the PU risk factors in acute hospital wards. A descriptive quantitative study was performed in 13 wards in a central hospital in Finland. The study included PU risk evaluation using the Braden risk assessment method, and full skin and medical assessment of consenting adult patients. Patients in paediatric, maternity and psychiatric wards, and in the intensive care unit were excluded. Patient's PUs were examined on the ward, and evaluated and classified using the international European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (EPUAP/NPUAP) Pressure Ulcer Classification System. Demographic data, the Braden risk assessment scale, skin assessment, and the location and severity of PUs were also recorded. A sample of 229 inpatients was examined for signs of PUs on one day in 2013. The overall PU prevalence was 8.7% (20 patients). Of those assessed as 'at risk of developing PUs', four patients (1.7%) were considered at 'very high risk', 39 patients (17.0%) at 'high risk', and 60 patients (26.2%) with a 'moderate risk'. The patient's age and length of treatment period were associated with PU risk, while only length of treatment period was associated with PU prevalence. Older patients had a higher risk of PUs than younger ones. The longer the hospital stay, the higher the PU risk was. In addition, patients with a long hospital stay more often had a PU. According to the study, PUs occur with significant frequency in acute hospital wards. It is important to carry out PU prevention actions among all patient groups, but risk increases among older patients and those who, for any reason, stay in hospital for a longer period of time.

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

Skin care strategies to prevent pressure ulcer for patients in acute care settings: a systematic review

AMDA is preparing to introduce the long-awaited update of its pressure ulcer guideline. It has been a “daunting but incredibly rewarding task,” to take the 1996 original Pressure Ulcer guideline and the 1999 Pressure Ulcer Therapy Companion, and combine them into the new interdisciplinary clinical practice guideline, stated the American Medical Directors Association.The evidence-based, updated guideline, “Pressure Ulcer Prevention and Management in the Long Term Care Setting,” covers the revised federal regulations on pressure ulcers and updates staging, according to the 2007 National Pressure Ulcer Advisory Panel (www.npuap.org). It also discusses unavoidability; distinguishes pressure ulcers from venous, arterial, diabetic, and ischemic ulcers; and removes practices that were experientially based.In addition, there will be a session at the AMDA Annual Symposium on March 7, 2008, entitled “An Update on the Clinical Practice Guideline for Pressure Ulcers in the LTC Setting,” to update the essential components of the prevention and management of pressure ulcers in LTC institutions. Most important, it will cover updates that have occurred since publication of the last guidelines. A second session, “Advanced Technology in Wound Care: An Evidence-Based Review for Treatment of Nonhealing Ulcers,” will be presented the same day.In the meantime, resources on pressure ulcer detection and treatment can be found on the Clinical Corner dedicated to the topic at www.amda.com/tools/clinical/pressureulcers.cfm.Ms. Vance is the director of clinical affairs at the American Medical Directors Association. AMDA is preparing to introduce the long-awaited update of its pressure ulcer guideline. It has been a “daunting but incredibly rewarding task,” to take the 1996 original Pressure Ulcer guideline and the 1999 Pressure Ulcer Therapy Companion, and combine them into the new interdisciplinary clinical practice guideline, stated the American Medical Directors Association. The evidence-based, updated guideline, “Pressure Ulcer Prevention and Management in the Long Term Care Setting,” covers the revised federal regulations on pressure ulcers and updates staging, according to the 2007 National Pressure Ulcer Advisory Panel (www.npuap.org). It also discusses unavoidability; distinguishes pressure ulcers from venous, arterial, diabetic, and ischemic ulcers; and removes practices that were experientially based. In addition, there will be a session at the AMDA Annual Symposium on March 7, 2008, entitled “An Update on the Clinical Practice Guideline for Pressure Ulcers in the LTC Setting,” to update the essential components of the prevention and management of pressure ulcers in LTC institutions. Most important, it will cover updates that have occurred since publication of the last guidelines. A second session, “Advanced Technology in Wound Care: An Evidence-Based Review for Treatment of Nonhealing Ulcers,” will be presented the same day. In the meantime, resources on pressure ulcer detection and treatment can be found on the Clinical Corner dedicated to the topic at www.amda.com/tools/clinical/pressureulcers.cfm. Ms. Vance is the director of clinical affairs at the American Medical Directors Association.

<p>Although great strides have been made to tackle hospital-acquired pressure ulcers (HAPUs), there is a need for greater recognition of device-related pressure ulcers (DRPUs), including their causes, management and prevention. This consensus statement, an updated second edition, aims to continue raising awareness of these largely preventable injuries and, crucially, to stimulate action. DRPUs are relatively common and account for a growing proportion of HAPUs. Updated information on the incidence of DRPUs is described in chapter 1. Although it is recognised that DRPUs increase the financial burden of healthcare, there is little formal analysis of their economic impact. This needs to be addressed; robust evidence on the burden of DRPUs and the value that can be released by adopting prevention strategies is needed to help drive action. Our understanding of the pathophysiology of DRPUs has improved significantly over the past few years; this is described in chapter 2. One crucial difference between PUs and DRPUs is that body-weight forces are less significant in DRPUs, with the force being exerted from a device that is typically strapped or taped onto the body. Devices and their securement may generate high stress concentrations in tissues, leading to cell and tissue-damage pathways associated with sustained deformation. As more evidence is published on DRPUs, recurring themes are emerging, as outlined in chapter 3: The most vulnerable patients are bearing the brunt of DRPUs; paediatric and neonatal patients, and all those needing critical care are particularly susceptible. During the COVID-19 pandemic, a new high-risk population (people with severe COVID-19 infection) emerged. They are at increased risk of DRPUs because of their need for prolonged ventilatory support, especially when 'proning' Devices associated with DRPUs are often used to perform essential, life-saving functions. They include continuous positive airway pressure (CPAP) masks or endotracheal tubes. Minimising their use is clearly not an option, so practice innovation is needed Although the most common locations for DRPUs are the face, ears, lower legs and heels, any location where a device comes into close contact with the skin can be at risk. In the same vein, any device, whether needed for a medical purpose or not, has the capacity to cause injury if its use is not properly managed. Vigilance is needed for all patients. What can be done? The importance of routine risk assessment is covered in chapter 4. Although use of a validated risk assessment tool is the vital first step, this will not be enough on its own. Several steps can be taken to ensure the safe use of devices. These are described in chapter 5 and include device repositioning, cushioning with prophylactic dressings and moisture control (only where possible and clinically appropriate). Of key importance is the development of an institutional protocol and champions to ensure all necessary steps are adopted. For any of these changes to be put into practice, awareness of DRPUs needs to increase. A number of proposals are outlined in chapter 6. A change of focus among health professionals and policy makers, along with more investment in education and training, are needed. All patients being managed with a medical device must be considered as at high risk. The pandemic introduced the world to the problem of DRPUs in health professionals caused by the extended wear of personal protective equipment. Health professionals also have a right to expect institutional protocols and provision of devices that protect them from DRPUs. Cutting-edge ideas and technologies that may be available in the future are described in chapter 7. When designing new products, manufacturers of medical devices have a duty of care to investigate the risks of DRPUs associated with their products and mitigate them, wherever possible. Our developing understanding of how the design, structure and materials used in medical devices contribute to DRPUs will help us develop new solutions for tomorrow. The first step is for everyone involved to ask themselves, 'what can I do to help?' There is work to be done-your journey to reduce DRPUs starts here!.</p>

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.

British Journal of Healthcare AssistantsVol. 14, No. 9 ClinicalSeries 5, chronic wounds; part 4f. Pressure ulcers: sitting and pressure ulcer preventionMenna Lloyd JonesMenna Lloyd JonesConsultant Editor, BJHCASearch for more papers by this authorMenna Lloyd JonesPublished Online:12 Oct 2020https://doi.org/10.12968/bjha.2020.14.9.460AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References All Wales Tissue Viability Nurses Forum. All Wales best practice guidelines: seating and pressure ulcers. 2019. Wounds UK. https://www.pmguk.co.uk/data/page_files/Best%20Practice/All%20Wales-Seating%20and%20PUs_FINAL.pdf (accessed 28 September 2020) Google ScholarCollins F. An adequate service? Specialist seating provision in the UK. Journal of Wound Care. 2001; 10(8):333–337 Link, Google ScholarDealey C. Pressure sores: the result of bad nursing? Br J Nurs. 10 December 1992–13 January 1993;1(15):748 Link, Google ScholarNational Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Pressure ulcer prevention and treatment of pressure ulcers: quick reference guide. 2014. http://www.epuap.org/wp-content/uploads/2016/10/quick-reference-guide-digital-npuap-epuap-pppia-jan2016.pdf (accessed 28 September 2020) Google ScholarNational Institute of Health and Care Excellence. Pressure ulcers: prevention and management. 2014. https://www.nice.org.uk/guidance/cg179 (accessed 28 September 2020) Google ScholarStephens M, Bartley CA. Understanding the association between pressure ulcers and sitting in adults, what does it mean for me and my carers? Seating guidelines for people, carers and health & social care professionals. J Tissue Viability. 2018 Feb;27(1):59–73. doi: https://doi.org/10.1016/j.jtv.2017.09.004. Epub 2017 Sep 6 Crossref, Google ScholarStockton L, Gebhardt KS, Clark M. Seating and pressure ulcers: clinical practice guidelines. J Tissue Viability. 2009 Nov;18(4):98–108. doi: https://doi.org/10.1016/j.jtv.2009.09.001. Epub 2009 Oct 22 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 October 2020Volume 14Issue 9ISSN (print): 1753-1586ISSN (online): 2052-4420 Metrics History Published online 12 October 2020 Published in print 2 October 2020 Information© MA Healthcare LimitedPDF download