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Dressing Materials for the Treatment of Pressure Ulcers in Patients in Long-Term Care Facilities: A Review of the Comparative Clinical Effectiveness and Guidelines

Rapid Response Report: Summary with Critical Appraisal

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Pressure ulcers are regions of localized damage to the skin and underlying tissues that usually develop over bony prominences. They occur as a result of uninterrupted pressure exerted on the skin, soft tissues, muscle, and bone leading to the development of localized ischemia, followed by a cascade of processes resulting in necrosis. Areas of the body commonly predisposed to pressure ulcers include heels, hip, elbows, shoulders, back of the head, knees, thighs, and toes. Ulcer severity is assessed in a variety of ways, but the US National Pressure Ulcer Advisory Panel (NPUAP) staging system is the most commonly used. The NPUAP system includes a four-stage categorization, representing progressive severity from intact skin with non-blanchable redness of localized area in Stage I, to full thickness tissue loss with exposed bone in Stage IV.

People with impaired mobility (e.g., stroke or spinal cord injury patients) are most vulnerable to pressure ulcers. Conditions such as poor nutrition, poor sensation, urinary and fecal incontinence, and poor overall physical and mental health are predisposing factors to pressure ulcer formation. The incidence of pressure ulcers vary according to settings, with a range of 2.2 to 23.9 percent in long-term nursing facilities. Prevalence of pressure ulcers is used as an indicator of quality for long-term care facilities, and progression of pressure ulcers in hospitalized patients is often considered an avoidable complication representing failure of inpatient management. Higher prevalence is reported for the elderly, the acutely ill, and those who have sustained spinal cord injuries. In Canada, pressure ulcer prevalence is reported to range between 5.0% in the hospital setting and up to 30% for spinal cord injured patients in the community.

Three fundamental approaches that may be employed sequentially in pressure ulcer wound care are reduction or elimination of underlying contributing conditions such as modifying support surfaces and providing nutritional support; provision of local wound care, including but not limited to wound dressing and topical applications to promote healing; and surgical repair of the ulcer, where appropriate. Pressure ulcer wound care modalities are influenced by clinical practice guidelines and local practice patterns, patient-related issues such as comorbidities and nutritional status, and the stage and features of the wound. Though complete healing with the restoration of functional integrity of skin to highest extent possible is the goal of therapy in most cases, the goal of therapy may be palliative for certain patients such as the terminally ill, focusing on reducing discomfort and/or deterioration of the pressure ulcer.

In a systematic review involving 14,000 patients from 45 health care institutions to determine the prevalence of pressure ulcers in health care settings across Canada, the median prevalence of pressure ulcers in Canada, regardless of health care settings, is reported to be 26%. A study in Ontario, Canada showed that pressure ulcers increase the risk of mortality among geriatric patients by as much as 400%, increase the frequency and duration of hospitalization, and decrease the quality of life of affected patients. It is a source of significant economic burden, estimated to cost approximately $9,000 (Cdn) per patient per month in the community setting. In the United States, it is estimated that total annual cost of treatment of pressure ulcers is $11 billion with treatment cost per case ranging between $37,800 and $70,000.

Dressings are an integral part of proper pressure ulcer wound care. They protect ulcers from trauma and contamination, and promote healing by absorbing exudate to prevent maceration while providing moisture balance to prevent desiccation which can hinder epithelial cell migration. A wide variety of dressings are available; including many with various combinations of properties such as wound bed preparation (debridement), antimicrobial activity, and moisture control. The purpose of this review is to provide information on comparative effectiveness of currently used dressing products to help inform management policy on stage 3 and 4 pressure ulcer.

Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.

Links: This report may contain links to other information available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners’ own terms and conditions.

Copyright © 2013 Canadian Agency for Drugs and Technologies in Health.

Copyright: This report contains CADTH copyright material and may contain material in which a third party owns copyright. This report may be used for the purposes of research or private study only. It may not be copied, posted on a web site, redistributed by email or stored on an electronic system without the prior written permission of CADTH or applicable copyright owner.

Except where otherwise noted, this work is distributed under the terms of a Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International licence (CC BY-NC-ND), a copy of which is available at http://creativecommons.org/licenses/by-nc-nd/4.0/

PMID: 24716257


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