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Treatment of Pressure Ulcers Guideline Panel. Treatment of Pressure Ulcers. Rockville (MD): Agency for Health Care Policy and Research (AHCPR); 1994 Dec. (AHCPR Clinical Practice Guidelines, No. 15.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Treatment of Pressure Ulcers

Treatment of Pressure Ulcers.

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Executive Summary

Background

Pressure ulcers can be a common and costly problem in acute care, nursing home, and home care populations. For example, the incidence (new cases appearing within a specified period of time) of pressure ulcers in acute care facilities has ranged from 2.7 to 29.5 percent. Prevalence (a cross-sectional count of the number of cases at a specified point in time) in this setting has varied between 3.5 and 29.5 percent. Several populations may be at even higher risk, including quadriplegic patients (60-percent prevalence), elderly patients admitted for femoral fracture (66-percent incidence), and critical care patients (33-percent incidence and 41-percent prevalence). Studies conducted in skilled care facilities and nursing homes have indicated prevalence rates ranging between 2.4 and 23 percent. In a recent 1-year study of 326 home health care patients, the incidence of pressure ulcers was 4.3 percent and the prevalence was 12.9 percent.

In economic terms, the reported cost of pressure ulcer treatment can vary greatly. Miller and Delozier estimated that the total national cost of pressure ulcer treatment exceeds $1.335 billion. Implementation of the recommendations of this guideline is estimated to reduce the cost of pressure ulcer treatment by 3 percent or $40 million.

The panel anticipates that its earlier guideline, Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, No. 3, will stimulate the development of effective prevention programs, thereby reducing the incidence of pressure ulcers. Unfortunately, not all pressure ulcers will be prevented and those that do develop may become chronic. There-fore, this pressure ulcer treatment guideline offers recommendations for the effective treatment of pressure ulcers in adults. At the clinician's discretion, the recommendations in this guideline may also be applied to children, but not to neonates.

Definitions

A pressure ulcer is any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed. Stage I pressure ulcers are defined as nonblanchable erythema of intact skin. (Although Stage I pressure ulcers are not the focus of this treatment guideline, their appearance should prompt greater vigilance in implementing preventive strategies.) Stage II is defined as partial thickness skin loss involving epidermis, dermis, or both. Stage III is characterized by full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage IV pressure ulcers show full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

When assessing a pressure ulcer, one should consider the following limitations in the preceding definitions: (1) It may be difficult to detect Stage I pressure ulcers in darkly pigmented skin; (2) when eschar is present, accurate staging is not possible until the eschar has been removed; and (3) pressure ulcers under casts, orthopedic devices, and support stockings are difficult to assess and require extra diligence.

Guideline Development

To develop this guideline, AHCPR convened a multidisciplinary private-sector panel of physicians, nurses, an occupational therapist, a biomedical engineer, and a consumer representative. In developing the scientific base to support guideline recommendations, the panel conducted an extensive review of the literature on pressure ulcers in adults, heard public testimony at an open forum, examined information obtained from consultants, and submitted several guideline drafts for peer and pilot review.

The panel considered a broad range of interventions including accurate, ongoing assessment of the patient and the ulcer; management of pressure, friction, and shear through the use of specific positioning techniques and support surfaces; care of the ulcer, including debridement, cleansing, dressings, and selected adjunctive therapies; measures to control bacterial colonization and treat infection; operative repair of the ulcers; patient and caregiver education; and quality improvement programs. The scientific evidence, benefits, and harms associated with each intervention were examined using established criteria to rate the strength of evidence. The intent of the panel was to recommend those interventions that were supported by at least one controlled trial. In reality, many well-established clinical practices have never been investigated experimentally. The strength-of-evidence rating printed after the panel recommendations cues the reader to the level of support associated with each recommendation. The known harms of each intervention were carefully identified, and interventions were recommended only if the benefits clearly outweighed potential harms.

Target Audience

The Clinical Practice Guideline recommendations are intended for clinicians who examine and treat persons who have pressure ulcers. Therefore, the guideline will be of interest to family physicians, internists, geriatricians, physiatrists, nurses and nurse practitioners, enterostomal therapists, infection control officers, physical and occupational therapists, psychological support staff, and dietitians in acute care, long-term care, rehabilitative, geriatric, and home settings. In addition, the recommendations may be useful to health care administrators, policy analysts, regulatory agencies, and third-party payers. Because patients and families are integral to the management team in all settings and during all phases of treatment, they should be apprised of the benefits and harms of available treatment options. Treatments should be consistent with patient goals, values, and personal preferences. Recommendations are applicable to patients seeking palliative as well as restorative care.

Guideline Recommendations

This pressure ulcer treatment guideline provides specific recommendations in six areas described subsequently in detail.

  • Assessment.
  • Managing tissue loads.
  • Ulcer care.
  • Managing bacterial colonization and infection.
  • Operative repair.
  • Education and quality improvement.

Assessment

The assessment of an individual with a pressure ulcer is the basis for planning treatment, evaluating treatment effects, and communicating with other caregivers. Initially, the clinician should determine the location, stage, and size of the pressure ulcer and whether sinus tracts, undermining, tunneling, exudate, necrotic tissue, granulation tissue, and epithelialization are present. Pressure ulcers should be assessed at least once a week, but deterioration either in the patient's overall condition or in the pressure ulcer itself mandates more immediate reassessment as well as a reevaluation of the treatment plan. Clinicians can reasonably expect a clean pressure ulcer with adequate innervation and blood supply to show evidence of healing within 2 to 4 weeks. Failure to do so should prompt a reevaluation of the plan of care, an evaluation of adherence to the plan, and a possible modification of the plan.

In developing a pressure ulcer treatment plan, the clinician should assess not only the pressure ulcer but also the entire person. Such an assessment should include (1) a complete history and physical examination, (2) the identification of complications and comorbid conditions, (3) a nutritional assessment, (4) an assessment of pain, (5) a psychosocial assessment, and (6) an evaluation of the individual's risks for additional pressure ulcers.

The history and physical examination will help the clinician understand the patient's overall physical and psychosocial health. Special attention should be directed to identification and management of illnesses that might impede healing, such as peripheral vascular disease, diabetes mellitus, immune deficiencies, collagen vascular diseases, malignancies, psychosis, and depression. Complications known to be associated with pressure ulcers should be identified and treated early. Possible complications include amyloidosis, endocarditis, heterotopic bone formation, maggot infestation, meningitis, perineal-urethral fistula, pseudoaneurysm, septic arthritis, sinus tract or abscess, squamous cell carcinoma in the ulcer, systemic effects of topical treatments (e.g., iodine toxicity), osteomyelitis, bacteremia, sepsis, and advancing cellulitis.

Nutritional assessment and management are essential to any successful pressure ulcer treatment program. A patient with pressure ulcers should undergo a nutritional assessment, with nutritional status reassessed periodically according to the patient's condition. The panel recommends the 1991 Nutrition Screening Manual as a guide for nutritional assessment. The stage of an existing pressure ulcer has been found to correlate with the severity of nutritional deficits, especially low dietary protein intake and hypo-albuminemia. In addition, studies have demonstrated an association between malnutrition and the development of new pressure ulcers. Risk factors for malnutrition include the inability to take food by mouth or a history of an involuntary change in weight. For individuals at risk for malnutrition, an abbreviated nutritional assessment should be conducted at least every 3 months. Clinicians should encourage dietary intake and supplementation in pressure ulcer patients who are malnourished. If dietary intake remains inadequate, nutritional support (such as tube feeding) should be provided if this is consistent with the goals of care. Approximately 30 to 35 calories/kg/day and 1.25 to 1.50 grams of protein/kg/day are recommended to place the patient in positive nitrogen balance. If deficiencies are demonstrated or suspected, vitamin and mineral supplements should be given. Caregivers should ensure an adequate dietary intake to the extent compatible with the patient's wishes.

Although research related to the assessment of pressure ulcer pain is surprisingly scarce, the panel recommends that clinicians routinely assess for pain, recognizing that pain may be intensified during dressing changes and debridement. Pain should be managed by eliminating or controlling its source and providing analgesia. Further research needs to be conducted to identify the most effective methods of assessing and managing pain associated with pressure ulcers.

A psychosocial assessment should be carried out to determine whether the patient comprehends the treatment program and is motivated to adhere to it. This assessment also provides the clinician an excellent opportunity to understand the values, lifestyle, psychosocial needs, and goals of the individual, family, and caregiver and thus collaboratively set treatment goals and arrange interventions that meet the unique needs of the individual. The resources available to individuals being treated at home should also be noted.

Individuals with existing pressure ulcers may be at risk for developing additional ulcers. Risk factors should be identified and modified as part of the treatment regimen (see guideline entitled Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, No. 3).

Managing Tissue Loads

The goal of tissue load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer(s). Specific interventions are designed to decrease the magnitude of pressure, friction, and shear and to provide levels of moisture and temperature that support tissue health and growth. These goals can be met through vigilant use of proper positioning techniques and support surfaces, whether the individual is in bed or sitting in a chair.

While in Bed

Individuals who are in bed should not be positioned on the pressure ulcer(s). If the ulcer is on a circumscribed area such as the heel or the back of the head, positioning devices should be used to raise the ulcer off the support surface. Avoid using donut-type (ring) devices. A written repositioning schedule should be developed and implemented to protect uninvolved areas. The following preventive strategies will benefit patients considered to be at risk for developing additional pressure ulcers:

  • Avoid positioning immobile individuals directly on their trochanters.
  • Use positioning devices to relieve all pressure from the heels and to prevent direct contact between bony prominences.
  • Prevent shear injury by maintaining the head of the bed at the lowest level of elevation and for the shortest period of time that is consistent with medical conditions and other restrictions.

For a more detailed description of these strategies, see the guideline entitled Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, No. 3.

A variety of support surfaces can be used to create an environment conducive to healing; however, there is no compelling evidence that one support surface consistently performs better than all others under all circumstances. Support surfaces should be selected with the following performance characteristics in mind: Increased support area, low moisture retention, reduced heat accumulation, shear reduction, pressure reduction, dynamic (versus static) properties, and cost per day. The panel suggests that clinicians consider the following specific recommendations when selecting support surfaces:

  • Use pressure-reducing surfaces for individuals at risk for additional ulcers.
  • Use a static support surface if the individual can assume a variety of positions without bearing weight on the pressure ulcer and without "bottoming out." To determine if a patient has bottomed out, the caregiver should place his or her outstretched hand (palm up) under the mattress overlay below the existing pressure ulcer or that part of the body at risk for ulcer formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient has bottomed out.
  • Use a dynamic support surface if the individual is unable to assume a variety of positions without weight bearing on a pressure ulcer, bottoms out on a static support surface, or does not show evidence of healing.
  • A low-air-loss or air-fluidized bed may be indicated if a patient has large Stage III or IV pressure ulcers on multiple turning surfaces.
  • The drying effect of a low-air-loss or air-fluidized support surface may help prevent additional ulcers when excess moisture on intact skin is identified as a risk factor.

While Sitting

Interface pressure may be particularly high over sitting surfaces. When a pressure ulcer has formed on such a surface, the individual should avoid sitting. If pressure on the ulcer can be totally relieved, the person can sit for a limited time. Proper postural alignment, distribution of weight, balance, stability, and continuous pressure relief are important positioning considerations for the sitting individual. A written plan for the use of positioning devices should be developed and implemented. An individually prescribed seat cushion should be used and donut-type devices should be avoided. Sitting individuals should be repositioned at least every hour and should shift their weight every 15 minutes if possible. If hourly repositioning is not feasible, the individual should be returned to bed.

Ulcer Care

Care of the pressure ulcer itself involves debridement of necrotic tissue, cleansing of the wound at initial examination and at each dressing change, and using a dressing that keeps the ulcer bed continuously moist but the surrounding intact skin dry. Secondarily, adjunctive therapies can be considered.

Debridement

Any necrotic tissue observed during the initial (or subsequent) assessment of the wound should be debrided from the ulcer, if this intervention is consistent with overall patient goals. Because several methods of debridement are available, the clinician should select the method most appropriate to the patient's condition and goals. Regardless of the method selected, the need to assess and control pain should be considered.

Sharp debridement is the most rapid method and may be the most appropriate technique for removing areas of thick, adherent eschar and devitalized tissue in extensive ulcers. When there are signs of advancing cellulitis or sepsis, rapid debridement is imperative, and sharp debridement is the method of choice. Small ulcers may be debrided at the bedside, whereas more extensive ulcers are debrided in the operating room or in special procedures rooms. Sterile instruments should be used, and a clean, dry dressing should be applied for 8 to 24 hours if sharp debridement is associated with bleeding; after 8 to 24 hours, a moist dressing may be resumed. Those who perform sharp debridement should have demonstrated the necessary clinical skills and must meet licensing requirements.

Mechanical debridement includes the use of wet-to-dry dressings at prescribed intervals (usually every 4 to 6 hours), hydrotherapy, wound irrigation, and dextranomers. Wet-to-dry dressings adhere to eschar, removing the eschar when the dry dressing is removed. Because this method tends to be painful and nonselective, adequate analgesia should be provided before dressings are removed, and the clinician should avoid placing a dry dressing over granulating tissue. Hydrotherapy and wound irrigation are useful for softening and mechanically removing eschar and debris. Dextranomers are beads placed in an ulcer bed to absorb exudate, bacteria, and other debris.

Enzymatic debridement is often used in long-term care facilities and in home care. This method of debridement should be considered when the individual cannot tolerate surgery and when the ulcer does not appear to be infected. Infected ulcers should be debrided more rapidly. Enzymatic debridement is accomplished by applying topical debriding agents to devitalized tissue on the wound's surface. Collagenase, a biologic licensed by the Food and Drug Administration (FDA), is an example of such a product. A clean moist dressing should be applied over the ulcer after enzyme application.

Autolytic debridement is accomplished by placing a synthetic dressing over the ulcer and allowing the eschar to self-digest through the action of enzymes normally present in the wound fluid. Although slower than other methods, autolytic debridement may be appropriate for patients who cannot tolerate other methods and are not likely to develop infections. Autolytic debridement is contraindicated in infected ulcers.

Clinicians may elect not to debride heel ulcers that have a dry eschar and no edema, erythema, fluctuance, or drainage. However, these wounds should be assessed daily for complications that might require debridement.

Wound Cleansing

Ulcer wounds should be cleansed initially and at each dressing change. The process of cleansing a wound involves selecting both a wound-cleansing solution and a mechanical means of delivering that solution to the wound. Saline irrigation is a safe and appropriate cleansing method for most pressure ulcers. Antiseptic agents (e.g., povidone iodine, iodophor, sodium hypochlorite solution [Dakin's® solution], hydrogen peroxide, acetic acid) and skin cleansers are toxic to wound tissue and should not be used. Commercial wound cleansers that do not contain harmful chemicals may be used at the clinician's discretion. To avoid traumatizing the wound, the clinician should apply a minimum amount of mechanical force when cleansing with gauze, cloth, or sponges. Irrigation pressures ranging from 4 to 15 pounds per square inch (psi) are safe and effective. For pressure ulcers that contain thick exudate, slough, or necrotic tissue, whirlpool treatment should be considered, but for clean wounds this is not appropriate.

Dressings

Clinicians should select a dressing that will keep the ulcer bed continuously moist while allowing the surrounding intact skin to remain dry. The dressing should control exudate without desiccating the ulcer bed. Caregiver time is a valid consideration when one is selecting a dressing. Although film and hydrocolloid dressings are more expensive than moist saline gauze, the added expense may be offset by savings in caregiver time. Wound dead spaces can be eliminated by loosely filling cavities with dressing materials; overpacking should be avoided. Dressings near the anus are less likely to remain intact and should be carefully monitored.

Adjunctive Therapies

The panel examined the roles of several adjunctive therapies in supporting pressure ulcer healing. These therapies include electrotherapy; hyperbaric oxygen; infrared, ultraviolet, and low-energy laser irradiation; ultrasound; miscellaneous topical agents (including cytokine growth factors); and systemic drugs other than antibiotics. Although many of these therapies hold promise for the future, electrical stimulation is the only adjunctive therapy with sufficient supporting evidence to warrant recommendation at this time. The panel recommends that a course of electrical stimulation be considered for Stage III and IV pressure ulcers that do not respond to conventional therapy.

Managing Bacterial Colonization and Infection

All Stage II, III, and IV pressure ulcers are colonized with bacteria. The panel recommends that colonization be minimized through effective wound cleansing and debridement. If purulence or foul odor develops, more frequent cleansing and possibly debridement are required. Swab cultures should not be used, because they detect only surface colonization and have no diagnostic value. When a culture is required, the Centers for Disease Control and Prevention (CDC) recommend obtaining fluid through needle aspiration or obtaining tissue through ulcer biopsy.

In most cases, adequate cleansing and debridement prevent colonization from progressing to clinical infection. However, if a clean ulcer is not healing or continues to have exudate despite optimal care for 2 to 4 weeks, the clinician should consider a 2-week trial of topical antibiotics that are effective against gram-negative, gram-positive, and anaerobic organisms (e.g., silver sulfadiazine, triple antibiotic).

Healing may be impaired if bacterial levels exceed 10 5 organisms per gram of tissue or if the patient has osteomyelitis. If the ulcer does not respond to topical antibiotic therapy, the clinician should obtain quantitative bacterial cultures, preferably by means of tissue biopsy, and evaluate the underlying bone for osteomyelitis. Topical antiseptics should not be used. Systemic antibiotics should be given to patients with bacteremia, sepsis, advancing cellulitis, or osteomyelitis but are not required for local pressure ulcer infections.

Pressure ulcers should be protected from exogenous sources of contamination such as feces. In addition, the following infection control measures should be taken to prevent cross-contamination:

  • Follow body substance isolation (BSI) precautions or an equivalent isolation system that is appropriate to the setting and the patient's condition.
  • Use clean gloves for each patient.
  • When treating multiple ulcers on the same patient, attend to the most contaminated ulcer last (e.g., in the perianal region).
  • Remove gloves and wash hands between patients.
  • Use sterile instruments for debridement.
  • Use clean dressings in hospitals, nursing homes, and skilled care facilities to treat pressure ulcers as long as dressing procedures comply with institutional infection control guidelines and appropriate measures are taken to ensure that dressings remain clean when stored.
  • Use clean dressings in the home setting if dressings are stored appropriately.
  • Follow local regulations to safely dispose of contaminated dressings in the home setting.

Operative Repair

Operative repair should be considered for individuals with clean Stage III or IV pressure ulcers that do not respond to optimal care. Additional research is needed to identify clear criteria for selecting patients most likely to benefit from surgical management. Possible candidates include medically stable patients who are adequately nourished and can tolerate operative blood loss and postoperative immobility. Quality of life, patient preferences, treatment goals, risk of recurrence, and anticipated rehabilitative outcomes should also be considered. Factors that may impair postoperative healing include smoking, spasticity, levels of colonization, incontinence, and urinary tract infection; these should be addressed preoperatively.

Operative procedures include one or more of the following: Direct closure, skin grafting, skin flaps, musculocutaneous flaps, and free flaps. The least traumatic yet most effective method should be selected for ulcer repair. Patients should be counseled on the benefits and harms of the operative techniques appropriate to their circumstances. Prophylactic ischiectomy is not recommended.

Vigilant postoperative followup care is essential to healing. An air-fluidized bed, low-air-loss bed, or Stryker frame should be used for a minimum of 2 weeks postoperatively. Tissue viability at the surgical site should be assessed as clinically indicated. The patient should slowly increase periods of time positioned on the flap to gradually increase tolerance to pressure. As a measure of tolerance, flaps should be monitored to detect pallor or redness that does not resolve after 10 minutes of pressure relief. Patient education and assessment are essential for preventing recurrence.

Education and Quality Improvement

Institutions and health care agencies are responsible for developing and implementing educational programs for patients, families, and caregivers. These programs should translate knowledge about pressure ulcers into effective treatment plans and should cover the entire continuum of care, from prevention through treatments that promote healing and prevent recurrence. Accurate assessment of tissue damage should be emphasized as well as principles of treatment and outcome monitoring. The education program should be an integral part of quality improvement monitoring. In addition, a quality improvement program should be established to facilitate comprehensive, consistent care that can be monitored, evaluated, and changed as conditions warrant.

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