Best Practices for the Prevention and Treatment of Pressure Ulcers

Best Practices for the
Prevention and Treatment
of Pressure Ulcers
– Ken Dolynchuk, MD, PhD, FRCSC, FACS; David Keast, MD, CCFP; Karen Campbell, RN, MScN, NP; Pam Houghton,
BSc, PT, PhD; Heather Orsted, RN, BN, ET; Gary Sibbald, MD, FRCPC(C); and Angela Atkinson, RN, BN, ET
ABSTRACT
In this article, the Canadian Association of Wound Care puts forward 12 recommendations for best practices in the prevention and
treatment of pressure ulcers that focus on an interdisciplinary
patient-centered approach. These recommendations are a synthesis
of the Agency for Health Care Policy and Research guidelines,
European guidelines, and current literature as interpreted by the
Canadian experience and achieved through a national consensus
panel. The article concludes that best practice guidelines must be
fluid documents that respond to new evidence and experience.
Ostomy/Wound Management 2000;46(11)38–52
T
he practice of wound care has evolved over the past
decade. Technological advances in local wound
care, pressure reduction and relief surfaces, and
adjunctive therapies have revolutionized the prevention and
management of pressure ulcer care. Six years have passed
since the Agency for Health Policy and Research (AHCPR)
published its evidence-based guidelines for pressure ulcer
management in the United States.1 Since then, other guidelines also have been developed in Europe.2,3
A Canadian consensus panel met and presented at a
national forum at the Canadian Association of Wound Care
(CAWC) conference in Toronto, Canada in November
1999.
They reviewed the evidence to date and recommended an
overall approach to pressure ulcer management. This panel
focused on: risk assessment, accurate staging and wound
assessment, early intervention, prevention, and quality-oflife issues relating to pressure ulcers. As a result of this
review, the CAWC developed 12 recommendations of pressure ulcer management forming best clinical practices in
patient care (see Table 1 for a quick reference guide of the
12 recommendations).
Recommendation 1
Complete Patient History and Physical Examination
to Determine General Health and Risk Factors that
May Affect Healing
An organized patient history and physical examination
are essential (see Table 2). Knowledge of cause, duration,
and history of previous ulcers will be helpful in assessing
potential healability. The history and physical should
include co-existing health conditions that may contribute to
the major risk factors for pressure ulceration. Significant
uncontrolled diseases that may impact healing include: cardiac, renal, gastrointestinal, collagen-vascular, neuromuscular, hematological disorders, and anemia. The history should
review medications with special attention to those drugs that
may impair healing (ie, systemic corticosteroids, chemotherapeutic agents, and nonsteroidal anti-inflammatories).
Recent acute illnesses or acute exacerbation of chronic
diseases may cause lethargy, leading to immobility and
increasing the risk of pressure ulcers. For example, a stroke
may significantly alter bed mobility and sensation as well as
lead to nutritional compromise through altered swallowing.
Ideally, all institutionalized (acute, chronic, or long-term
care) patients should be assessed for pressure ulcer risk factors. End-of-life care may be accompanied by nonhealable
Please address correspondence to: Heather Orsted, RN, 320 17th Avenue SW, Calgary, Alberta T2T 5T1, Canada.
38
OstomyWound Management
In this Stage II pressure ulcer, a persistent area of erythema
shows areas of breakdown, exposing the superficial dermis.
An eschar with unknown depth does not allow this ulcer to be
accurately staged.
In this Stage IV pressure ulcer, subcutaneous fat is revealed on
the left side and muscle in the deep part of the right-hand
portion of the ulcer.
The pressure ulcer with undetermined depth, shown here, has
a small opening on the surface, revealing extensive
undermining.
Extensive surgical debridement to attached edges uncovered a
deep Stage IV ulcer to joint capsule.
A calcium alginate rope was used on this pressure ulcer for
hemostasis. Any bleeding vessels require electrocautering or surgical ligation.
November 2000 Vol. 46 Issue 11
39
TABLE 1
QUICK REFERENCE GUIDE TO THE 12
RECOMMENDATIONS FOR BEST PRACTICES
IN THE PREVENTION AND TREATMENT OF
PRESSURE ULCERS
Recommendation 2
Assess and Modify Situations Where
Pressure May Be Increased
It is always important in chronic wounds to
treat the underlying causes, if possible. With
pressure ulcers, understanding and recognizing
sources of pressure and designing a pressure1. Complete patient history and physical examination to determine general health and risk factors that may delay healing.
reduction treatment plan is vital. Many meth2. Assess and modify situations where pressure may be
ods exist to reduce or eliminate pressure.
increased (eg, when seated or lying down).
Turning and positioning to offload areas of
3. Assess and control pain.
increased pressure may be one of the easiest
4. Maximize nutritional status.
ways to prevent a pressure ulcer. The AHCPR
5. Control moisture and incontinence.
Guidelines for Pressure Ulcers in Adults:
6. Maximize activity and mobility, reducing or eliminating friction and shear.
Prediction and Prevention Number #3 recom7. Assess and assist with psychosocial needs and develop a
mends that patients at risk for pressure ulcers
patient-centered plan.
(as determined by a risk assessment tool) be
8. Stage, assess, and treat the wound to provide an optimal
turned and positioned at least every 2 hours,
wound environment (debridement, infection control, moiswith small body movements performed as often
ture balance, biologicals).
as every 15 minutes.1 They encourage the use of
9. Introduce adjunctive modalities if clinically indicated.
10. Consider surgical intervention for deep nonhealing ulcers
positioning aids like wedges and pillows to
(Stage III and IV).
maintain and support the patient in the desired
11. Develop an interdisciplinary team with flexibility to meet the
and comfortable position. In many high-risk
patient’s needs.
patients, repositioning alone is not effective,
12. Educate patient, caregiver, and healthcare professional on the
and the patient may need the benefit of presprevention and treatment of pressure ulcers.
sure-reducing and/or pressure-relieving devices.
More than 100 pressure-reducing devices exist.
Although there is a lack of standard informapressure ulcers where the prime aim of treatment is to allevition on these surfaces, Krouskop and van Rijswijk recomate pain and suffering, prevent infection, and provide a fulmend the following 10 parameters be used as performance
filling quality of life. On the other end of the spectrum,
criteria7:
patients with congenital or acquired loss of sensation have increased risk of pressure ulcers at a
Ostomy/Wound Management 2000;46(11):38–52
young age. Risk assessment tools, such as the
Braden4 or Norton Scales,5 are significant evaluaKEY POINTS
tive tools and should be used and recorded at ini❏ Practice guidelines are never static, infrequently tested for validity,
tial assessment and subsequent periodic examinareliability, or effects on patient outcomes, and always secondary to
tions. However, there is still controversy over the
the overall goal of patient care.
best tool and whether the actual scale of risk pre❏ Last year, the Canadian Association of Wound Care advisory panel
on pressure ulcer management met to review existing pressure ulcer
diction is applicable between settings.6 Therefore,
guidelines from the United States and Europe and compared them to
it is a matter of determining which tool works
more recent research findings.
best with particular staff mix (nursing aide, LPN,
❏ The resultant 12 recommendations for best practice provide food
for thought and may help clinicians modify their own guidelines.
RN) in a specific setting (acute care, home care,
Failure to move is not just an individual patient risk factor for the
❏
long-term care). The absolute value of the risk
development of pressure ulcers, nor is it the only one.Viewing cliniscore may be less important than the identificacal guidelines as stagnant documents in the face of new scientific evition of the major risk factors for an individual
dence increases the risk of providing less than optimal care.
patient and the development of an appropriate
care plan that addresses these risks.
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OstomyWound Management
Computerized pressure mapping can
be
used as a semi-quantitative measureTABLE 2
ment to evaluate the effectiveness of
HISTORY AND PHYSICAL EXAMINATION
pressure reduction or relief surfaces.11,12
This tool also can help the patient visuLess than 2 weeks
Duration of Ulcer
Recurrent Ulcer
More than 2 weeks
1st Ulcer Year
alize the effects of pressure through
Previous Diagnosis
biofeedback. This assessment must be
Previous Treatments
used in combination with clinical
Medications
assessment. In the absence of sensation,
Blood pressure
increased pressure will not be translated
X-ray, Bone scan, CT scan
into pain, and this biofeedback can be
CBC, ESR, CRP
invaluable. Educating staff is paraAlbumin, pre-albumin, Hgb AIc, blood sugar; semi-quantitative swab,
mount to the introduction of high-tech
urinalysis as indicated
equipment. Despite advancing technolPain assessment
Acute noncyclic
Acute cyclic
Chronic
ogy, all staff should be taught how to
perform a hand check to determine the
efficacy of the surface/device used and
1. life expectancy of surface
how to detect “bottoming out” before it creates a pressure
2. skin moisture control
ulcer. To perform a hand check, the caregiver should place
3. skin temperature control
an outstretched hand (palm up) under the surface below the
4. redistribution of pressure
body part at risk. If the caregiver feels less than an inch of
5. product service requirements
support, the patient has bottomed-out.
6. fail safety
Clinicians must remember that pressure management is
7. infection
only one part of a successful treatment program to prevent
8. flammability
and treat pressure ulcers. A therapy that is incorrectly used is
9. patient/product
of little benefit and may even be harmful.
10. friction.
Having patients on appropriate surfaces at all times,
Recommendation 3
8
not just when in bed, is important. Support surfaces
Assess and Control Pain
can be classified into air fluidized, low air loss, alternatKrasner reviewed wound pain assessment and manageing air, static flotation, foam, and standard (see Table 3).
ment and categorized wound pain into noncyclic acute pain
In 1999, the Cochrane Group systematically reviewed
associated with interventions, cyclic acute pain associated
beds, mattresses, and cushions for pressure ulcer prevenwith dressing changes or positioning, and chronic wound
tion and treatment. Pressure-reducing foam mattresses
pain.13 Analgesia should be provided to control the pain in
and overlays were more effective than standard hospital
anticipation of interventions as well as for maintaining conmattresses in pressure ulcer prevention in moderate- to
trol of chronic pain. Good pain management may improve
9
high-risk groups. There is good evidence of the effecmobility and prevent ulcers or facilitate healing. Pain locativeness of air-fluidized and low-air-loss devices in treattion, intensity, duration, type, and acceptable pain levels
ment. In a recent study, Russell and Lichtenstien
should be assessed and interventions targeted to the underlydemonstrated the efficacy of a multicell, pulsating,
ing cause. Accurate pain assessment is dependent on the
dynamic mattress system in the prevention of pressure
patient’s subjective assessment of the pain. Several tools have
ulcers in patients undergoing cardiovascular surgery.10
been developed to assist the patient in describing pain intenOverall, however, it is not possible to determine the
sity. A facies scale is useful for young children or those with
most effective surface for ulcer prevention or treatment.10
language difficulties; otherwise, a pain analog score is very
Decision-making algorithms such as the one in the
useful where 0 indicates no pain and 10 indicates the worst
AHCPR guidelines have been helpful in the selection of
pain the patient has ever experienced. Pain due to irritation
1
the most appropriate surface.
of the normal nerve fiber is usually represented by a dull
November 2000 Vol. 46 Issue 11
41
The patient’s response to illness, injury, or infection is an
TABLE 3
amplification of the fightSELECTED CHARACTERISTICS FOR SPECIAL
flight reaction. This hormonSUPPORT SURFACES (AHCPR 1994)
ally induced metabolic
Performance
Support Devices
response produces a marked
characteristics
Air
Low Alternating Static Foam Standard
increase in energy demands
air
floatation
fluidized air loss
and changes nutrient utilizaSupport area
yes
yes
no
yes
yes
yes
tion.17 An energy deficit is
Low moisture
no
no
no
yes
yes
no
retention
common among patients
Reduced heat
no
no
no
yes
yes
no
with wounds. A study by
accumulation
Hsia Liu et al18 demonstrated
Shear reduction
yes
yes
no
yes
yes
no
that patients with quadriplePressure reduction
yes
yes
yes
no
yes
yes
gia and pressure ulcers have a
Dynamic
yes
no
no
no
yes
yes
high metabolic demand for
Cost
high
moderate
low
low
low
high
the healing of pressure ulcers.
1
Modified from AHCPR
An accurate assessment of
nutritional demands is essenache and is referred to as nociceptive pain. This pain is best
tial. According to Demling and Desanti,17 these demands
controlled with aspirin or a nonsteroidal anti-inflammatory
fall into three categories:
drug with an adjunctive agent. Neurogenic pain may be due
1. Energy or caloric requirements:
to nerve irritation or nerve damage. Nerve irritation generala. determine BMR (Basal Metabolic Rate)
ly produces a burning or stinging pain and is often relieved
b. adjust BMR for added stress
by low-dose tricyclic agents. Nerve damage results in a stabc. determine physical activity of the patient
bing or lancinating pain and is often relieved by gabapentin.
2. Protein requirements
With wound management procedures, pain can be cona. healthy patients need 0.8 g of protein/kg/day
trolled with presedation orally, intralesional anesthetic
b. stressed patients need 1.5 g to 2.0 g of
around the lesion, and topical anesthetic agents occluded on
protein/kg/day (heavily exudating wounds
the wound surface (topical EMLA, Astra-Zeneca, Wayne,
increase protein losses)
Pa. is approved in Canada and other countries for use in
3. Micronutrient requirements
open wounds, but not in the United States).14
a. marked deficiency occurs during the severe
The patient must be comfortable with the plan of care
stress response
and the caregiver’s competency to alleviate unnecessary anxib. measurement is difficult and prevention of a
ety that may aggravate pain.
deficiency is usually accomplished by
providing increased intake.17
Recommendation 4
There are several ways to monitor nutritional status.
Maximize Nutritional Status
The patient, caregiver, or healthcare professional can estiIn addition to a strong association between protein-calomate daily caloric intake by the portion of food left on a
rie malnutrition and pressure ulcers, other factors are associpatient’s tray after each meal. However, serum albumin is
ated with wound healing, including vitamins A, C, and E,
the most commonly used laboratory measurement of
zinc, and individual amino acids.15 Unless adequate nutrinutrition. Pre-albumin is a better predictor of recent
ents, calories, and protein are provided, excellent wound
changes in nutritional status with a half-life of 2 days
care will not heal the wound at an optimal rate.16 The level
compared to 20 days for albumin. Absolute lymphocyte
of nutrition should be compatible with the patient and/or
counts less than 1.5 x 109 may be associated with malnufamily’s wishes, and a nutritional screening should be pertrition or immunodeficiency. Hemoglobin less than 100
formed. When evaluating caloric requirements of a patient
may be associated with poor wound healing in some
with a wound, a stress-response factor needs to be applied.
patients.
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OstomyWound Management
Patients and their caregivers should be instructed on the importance of nutrition in relation to wound healing, and nutritional support should be offered as
needed.19 Assessment and correction of dehydration is important to optimize healing. Fluid may be lost through exudating wounds, and in elderly patients, fluid
intake may be poor and replacement inadequate.
Recommendation 5
Control Moisture and Incontinence
Excessive moisture on the skin may be a result of perspiration, wound
drainage, soaking during bathing, or fecal or urinary incontinence. This may
cause maceration of the skin and put the skin at an increased risk for trauma.
Moisture – particularly moisture secondary to incontinence – is acknowledged
as a primary risk factor for the development of pressure ulcers. Fecal incontinence is a greater risk factor than urinary incontinence.20 Nursing staff need to
be aware of the medical problems that may lead to incontinence, the symptoms describing the many types of incontinence, and the therapies that may
lead to control.21 Research has shown, that when properly assessed and treated,
urinary incontinence can be corrected in about 30% of nursing home residents.21
In adults, a single event of incontinence is unlikely to lead to skin breakdown.
Rather a series of events that weaken the skin and make it vulnerable to further
damage is what is likely to result in this breakdown.20 Increased friction and shear,
poor nutrition, disease, and pressure all aggravate compromised skin. Even the
chemical irritation of frequent washings with soaps can cause irritation.22 The
adhesiveness of moist skin to bed linens is estimated to increase the risk of ulceration fivefold.23 The underlying etiology of the moisture needs to be identified and
removed. Catheters often are used to control incontinence when trying to heal a
pressure ulcer to eliminate urinary contamination entirely. Long-term, indwelling
catheters have been associated with increased incidence of sepsis and death and
should be used with caution.
Barrier creams, ointments, and polymeric film-forming skin protectants can
be used to reduce the impact of moisture from urine and feces on the skin.24
The compatibility of the cream or ointment with the absorbent pads used to
manage incontinence should be determined. Absorbent products are not
equal, and their benefits need to be evaluated according to the needs of the
patient. Odor control, wick-away properties, absorbency, concealability, comfort, and cost all must be considered. Condom catheters, pouches, and collection devices are also available. Trauma related to incorrect application of condom catheters is common, and correct sizing and application is important.
Extensive information on continence is available via the Canadian Continence
Foundation website at: http://www.continence-fdn.ca/.
Excessive sweating can be related to medication, infection, or the environment
and may not be controllable. The patient should be instructed on how sweating
impacts skin integrity and that wearing breathable clothing can make a big impact
and can lower the risk of yeast infection in skin folds. Excessive wound exudate
may be managed with appropriate dressing selection (alginates, foams, composites,
and hydrofibers), or pouching may be considered if the wound is appropriate.
Recommendation 6
Maximize Activity and Mobility, Reducing or
Eliminating Friction and Shear
Shear is a mechanical force that moves the bony structures in a direction opposite the overlying skin (tearing
force). The effects of pressure are compounded by the addition of shear. This may reduce the amount of pressure needed to produce vascular occlusion by one-half. Shear also may
account for clinical observations of large areas of tunneling
or deep sinus tracts beneath sacral ulcers. Maintaining the
head of the bed below 30 degrees and appropriate positioning in wheelchairs will decrease the risk of shearing.23
Friction is the force of two surfaces moving across one
another, creating local heat and often resulting in an abrasion. Postoperative patients may be at increased risk from
complications, including immobilization as well as low
blood pressure.25 Friction commonly occurs in patients who
are unable to lift themselves sufficiently for repositioning.
Turning sheets and trapeze bars may assist with mobility
and decrease risk of friction.23
The interdisciplinary team and patient should determine
the relevant etiology of the ulcer and develop a corresponding patient-centered treatment program.
Recommendation 7
Assess and Assist with Psychosocial Needs
Pressure ulcers impact patients not only physically, but
also psychologically, stripping away dignity and independence.26 The complex interplay of psychosocial factors that
occurs as a result of pressure ulcer development can increase
the risk of pressure ulcer formation. Kiecolt et al27 demonstrated in their study the detrimental effect psychological
stress has on the healing of wounds. The psychological
impact of a pressure ulcer can cause social isolation and create an immeasurable level of burden and frustration for the
patient, healthcare professionals, family, and caregivers.
Patients with debilitating wounds often have body image
disturbances and low self-esteem.19 Therefore, completing a
psychosocial assessment to identify any psychological stressors is beneficial. The interdisciplinary team is required to
assess the need for and focus intervention on the following
three areas:
1. The patient’s network: social interaction in the
family, circle of acquaintances, culture and ethnicity, and social support
2. The patient’s living space/environment: living conditions, everyday capabilities, and occupational
resources (ie, availability and skill of caregivers,
finances, and equipment)
3. The patient’s personal space: patient compliance,
cognitive and emotional state, depression, quality
of life, mental status, learning ability, multiple
medications, or overmedication, alcohol and/or
drug abuse, goals, values and lifestyle, sexuality,
stressors, and pain as a symptom.3
Educational programs can be offered to assist with a
proactive approach to the prevention of pressure ulcers.19
When patients are involved in their own care, they can
become committed to seeing a positive outcome because
they feel responsible for the success of the treatment regimen. This can help patients gain a sense of self-control.19
Ultimately, the aims of therapy should be to relieve suffering and to achieve a healed wound as efficiently and efficaciously as possible.
TABLE 4
NPUAP STAGING SYSTEM
Stage Description
I
II
III
IV
44
Nonblanchable erythema of intact skin; the heralding lesion of skin ulceration. In individuals with darker
skin, discoloration of the skin, warmth, edema, induration, or hardness also may be indicators.
Partial-thickness skin loss involving epidermis or dermis or both.The ulcer is superficial and presents
clinically as an abrasion, blister, or shallow crater.
Full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to
but not through underlying fascia.The ulcer presents clinically as a deep crater with or without
undermining of adjacent tissue.
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (such as tendon and joint capsule)
OstomyWound Management
TABLE 5
PUSH TOOL 3.0
Length
x Width
Exudate
amount
Tissue
type
0
0 cm2
1
2
3
4
< 0.3 cm2 0.3 – 0.6 cm2 0.7–1.0 cm2
1.1-2.0cm2
6
7
8
9
3.1– 4.0 cm2 4.1–8.0 cm2 8.1-12.0 cm2 12.1-24.0 cm2
0
1
2
3
none
light
moderate
heavy
0
1
2
3
4
closed epithelial granulation
slough
necrotic
tissue
tissue
tissue
5
2.1-3.0cm2
10
> 24.0cm2
Subscore
Subscore
Subscore
Total score
Recommendation 8
Stage, Assess, and Treat the Wound. Provide an
Optimal Wound Environment (Debridement,
Infection Control, Moisture Balance, and
Biologicals)
Assessment. An effective tool to provide an accurate basis
for the description of tissue trauma is the staging system recommended by the National Pressure Ulcer Advisory Panel
(NPUAP, 1989, see Table 4).28 The original stage of wounding should remain static over time even as the wound heals.
This reflects that, despite healing, the trauma was at a Stage
IV level, and the replacement tissue cannot replicate the
characteristics of the original tissue.
Successful ulcer management requires a parameter to
judge the effectiveness of the treatment plan. For the clinician to say, “The ulcer is healing,” requires comparison
between the present state and previous state of the ulcer and
evidence that the ulcer has improved.
The most common method for wound assessment is
length times width (width is measured at right angles to the
length), using the change in size as the parameter to judge
healing.29 This technique used alone has flaws. When a
wound is in the process of debridement, it may appear larger even though healing is occurring. Also, there may be large
variations in clinicians’ approach to measurement, especially
of irregularly shaped wounds. The comparison must be
accurate, stable, and reproducible. The Pressure Ulcer Scale
for Healing (PUSH) Tool (see Table 5) is an example of a
user-friendly quantitative tool for continuous assessment.
For more information on the tool and its use, visit the
NPUAP website: http://www.npuap.org/push3-0.htm.
Two alternate tools used to measure healing are the
Pressure Ulcer Status Tool (PSST) and the Sessing Scale.
Like the risk assessment tool, a pressure ulcer assessment
tool should be chosen based on staff mix and clinical setting.
Woodbury et al30 preformed a critical review of the literature
and suggested that the Sessing tool may be more appropriate
for a clinical setting while the PSST is more appropriate for
research. Their review raised concerns regarding the adequate reliability and validity of the PUSH tool. The use of
standard tools provides a common language to be used by
all staff when discussing healing. Acetate tracing and photos
also are used as adjuncts to decision-making on wound
assessment. The accepted measurement technique must be
easily used and portable. Assessment using digital records
has become available, and in one recent clinical trial is as
accurate and reproducible as acetate tracings without the
need for wound contact.31
Manage bacterial colonization and infection. Since the
publication of the original AHCPR guideline in 1994,
debate has been ongoing about the assessment and management of bacterial colonization and infection. All chronic
wounds are presumed to be bacterially contaminated, but
the point at which this contamination becomes problematic
needs to be determined. Dow et al32 view all chronic
wounds as existing somewhere on a continuum from contaminated to infected. In contaminated wounds, the bacteria
are not attached or replicating; in colonized wounds, the
bacteria are attached to the surface and replicating. In both
contamination and colonization, the bacteria are noninvasive and do not interfere with wound healing. As bacteria
become invasive and the host mounts a response, the wound
moves on to become locally infected, which may ultimately
lead to systemic infection. The extent of infection will be
directly proportional to the number of organisms and their
virulence and inversely related to the host response. As
November 2000 Vol. 46 Issue 11
45
wounds change from being colonized to infected, a subtle
period of critical colonization will occur (increased bacterial
burden, subclinical infection).
The most thorough review of this topic is the AHCPR
guidelines.1 The recommendation to minimize pressure
ulcer colonization and enhance wound healing by effective
wound cleansing and debridement remains valid. Evidence
that good debridement enhances wound healing is mounting.33 Clinicians should cleanse wounds with irrigation pressures adequate to remove nonviable tissue and not disturb
healthy granulation tissue should take place. Cleansing
agents should be nontoxic.34 Pressure ulcers should be protected from exogenous sources of contamination (eg, feces).
Using swab cultures to diagnose wound infection is
one of the more controversial recommendations.
Deciding if pressure ulcers have progressed from colonization to critical colonization or infection is often
based on clinical judgment. Classical signs of inflammation (erythema, induration, and increased pain),
increased exudate, change in the nature of the exudate, or
more subtle signs such as friable granulation tissue or
nonstable epithelial bridges may signal progression
towards infection. In critically colonized or infected
wounds, appropriately performed semi-quantitative
swabs may be helpful in determining the invasive organism and in directing the choice of antimicrobial therapy.35
Quantitative bacterial cultures of ulcer base tissues
remain unavailable in most centers in Canada.
A 2-week trial of topical antibiotics for use with clean
pressure ulcers that are not healing or are continuing to produce exudate after 2 to 4 weeks of optimal patient care
remains valid. The antibiotic should be effective against
Gram-negative, Gram-positive, and anaerobic organisms.
The guidelines recommend silver sulfadiazine or triple
antibiotic as the topicals of choice. Cadexomer iodine36
and ionized silver37 dressings that have more recently
come on the market offer an alternative. Patients should
be evaluated for osteomyelitis when the ulcer does not
respond to topical antibiotic therapy.
The use of topical antiseptics (eg, providone iodine, sodium hypochlorite, hydrogen peroxide, and acetic acid) to
reduce bacteria in wound tissues is not recommended.
Toxicity of these agents to healthy granulation tissue is well
documented. However, the studies were conducted with full
strength solutions, and some experts feel that all of these,
except hydrogen peroxide, may have limited usefulness in
diluted form. For example, acetic acid diluted to a strength
46
OstomyWound Management
of 0.1% may help to reduce Pseudomonas colonization without harming granulation tissue. Acetic acid may, however,
select out Staphylococcus aureus. Concern also exists that
hydrogen peroxide may cause air emboli in closed cavities.38
Appropriate systemic antibiotic therapy should be instituted for patients with bacteremia, sepsis, advancing cellulitis, or osteomyelitis. Blood cultures may be required to
direct the choice of antibiotic. Although the guidelines recommend against systemic antibiotics for pressure ulcers with
only clinical signs of local infection, some experts now feel
that some local infections also may require treatment with
systemic antibiotics, especially when the clinician takes into
account the virulence of the organism and the host defenses.
In 1999, Krasner revisited the literature regarding infection control in pressure ulcers.39 Since the publication of the
AHCPR guidelines in 1994, no new evidence that would
support changes in evidence ratings for the five recommendations made has been presented. However, two studies suggest that the use of nonsterile dressings needs to be evaluated
and the patient and environmental factors taken into
account in order to implement a common sense approach.
Dressing selection. Dressing selection should provide
a moist wound environment that minimizes both trauma
and the risk of infection. Selection should be based on
the wound’s characteristics to provide local moisture balance.40 Modern, moist interactive dressings include foams
(high absorbency), calcium alginates (absorbent, hemostasis), hydrogels (moisture balance), hydrocolloids
(occlusion), and adhesive membranes (protection). For a
detailed look at wound dressings, refer to
Recommendation 11 in Preparing the Wound Bed, by
Sibbald et al on page 30.41
Recommendation 9
Introduce Adjunctive Modalities as Required
Many adjunctive therapies have been developed to treat
chronic wounds, including therapeutic modalities such as
ultrasound, ultraviolet light, laser, electrical current, and
superficial heat. Candidates for adjunctive therapy include
patients with chronic pressure ulcers that have failed to heal
despite good conventional wound care. An extensive
review of the research literature was performed by
Houghton and Campbell in 1999.42 This section updates
these references and discusses additional therapies and
new advances in this area.
Using electrical current may be beneficial in treating
chronic pressure ulcers that are not responding to conven-
tional therapy. More than 10 clinical reports exist in the
recent literature that consistently demonstrate the ability of
electrical current to accelerate wound closure rate of chronic
pressure ulcers. Eight of these clinical trials are properly
designed, randomized controlled studies.42 This evidence
supports the AHCPR recommendation regarding the use of
electrical stimulation for the treatment of chronic pressure
ulcers that failed to heal by conventional treatment.1 These
guidelines were revisited in a 1998 review of the literature.40
Based on results from new clinical reports, the strength of
evidence of the use of electrical stimulation on chronic
wounds was upgraded to the highest rating.
Chronic pressure ulcers treated with therapeutic ultrasound, ultraviolet light, or pulsed electromagnetic fields may
have accelerated rates of closure. At least four research studies, including two well-designed, randomized controlled trials, have assessed the effectiveness of ultrasound in the treatment of chronic pressure ulcers.42 These clinical studies, performed on chronic pressure ulcers, together with other
reports of the benefits of therapeutic ultrasound on chronic
venous ulcers, suggest that therapeutic ultrasound may promote closure of chronic wounds.43 Some conflicting clinical
reports failed to demonstrate a significant effect of ultrasound on wound closure.
Inhibitory effects of ultra violet light in the C range
(UVC) on bacterial growth are well established and are
believed to occur through direct effects on the cell nucleus
and DNA synthesis of the bacteria.44,45 Recent reports of the
inhibitory action of UVC on antibiotic resistant strains of
bacteria46 warrant consideration of the use of this modality
for the treatment of chronic infected wounds. At least four
clinical reports, including two randomized clinical trials,
document that ultraviolet light treatments accelerate closure
of chronic infected pressure ulcers.47,48 UVC has a mutagenic
effect on human cells and should be used with caution especially in younger individuals.
Application of electromagnetic fields (EMFs) has been
shown in three clinical reports and one randomized controlled clinical trial to significantly accelerate the closure of
pressure ulcers.49-51 In addition, significant changes in local
blood flow, skin temperature, subcutaneous tissue oxygenation, and local edema have been demonstrated following
administration of pulsed magnetic fields.52-58
Limited clinical research evidence, including case
reports,59 retrospective analysis,60 and noncontrolled clinical
studies,61 document the benefits of constant tension approximation and vacuum-assisted closure on chronic pressure
ulcers. Research evidence suggests that both of these relatively new wound treatments can stimulate cell activity via
mechanical stretching of key cellular components of the
wound healing process.
Laser treatment for chronic pressure ulcers should be
considered experimental and used only when other
adjunctive modalities are not available. Although numerous reports suggest that lasers can stimulate the proliferative phase of wound healing, this experimental research
has been plagued by inconsistent results. Skepticism
regarding the effects of laser treatment on wound healing
has been fuelled by the lack of randomized controlled
clinical trials demonstrating the benefits of laser for the
treatment of chronic wounds. Because the clinical effectiveness of laser treatment has not been well documented,
the use of laser in the United States can only occur under
an investigational FDA exemption (Center for Devices
and Radiological Health, FDA Fact Sheet: Laser
Biostimulation. Division of Consumer Affairs, 1984).
Three recent clinical reports document accelerated closure
of recalcitrant pressure ulcers following the application of a
noncontact moist heat bandage to the local wound environment.55-57 The benefits on wound healing may be due to
heat-induced local tissue perfusion and oxygen produced in
the wound bed.58 None of these reports involve comparisons
to an appropriate control group.
Hydrotherapy may be used to cleanse and debride
necrotic pressure ulcers but should be discontinued when
the ulcer is considered clean. Clinical reports suggest that
hydrotherapy can reduce bacterial contamination of chronic
ulcers.62,63 However, conflicting research suggests that
wounds treated with hydrotherapy are at risk for waterborne infection64 and other complications.65 Hydrotherapy
administered via jet lavage has been suggested for use on
necrotic wounds with undermining.66 The benefits of
hydrotherapy in promoting new tissue formation of clean,
nonhealing ulcers have not been documented.
To date, electrical stimulation and ultrasound are the only
adjunctive therapies that have been recommended for use
on chronic ulcers. Other therapeutic modalities have limited
clinical research evidence to support their use in clinical
practice.
Recommendation 10
Consider Surgical Intervention for Deep,
Nonhealing Ulcers (Stages III and IV)
In the infected or high-risk patient, operative intervention
November 2000 Vol. 46 Issue 11
47
TABLE 6
WOUND CARE TEAM ACTIVITIES
Education
Research
Patient Care
Therapeutic and support surfaces Inpatient consultations and
Wound Care Policies and procedures
Staff development workshops Comparisons of wound care
follow-up
Team
Annual conference
products
Sharp debridement
Point prevalence survey
is still indicated despite improvement in current outpatient
regimens. The surgical debridement of deep ulcers and
infected vital structures still requires the specialized facilities
of an operating room; albeit, increasingly on an outpatient
basis.2 However, optimal wound debridement often requires
combined use of surgery and other modalities.67,68 One study
has shown that pulsatile lavage is more effective than
whirlpool therapy.69 Collagenase has now been shown to be
cost-effective and significantly faster than hydrogel in the
debridement of heel ulcers and dermal leg ulcers.70 The fact
that collagenase is a temperature-sensitive enzyme supports
the use of warming in pressure ulcer patients. Use of fasciocutaneous flaps were shown to be of greater benefit in providing stable closure in one series of patients71-73 and in some
nonhealing pressure ulcer patients. Myocutaneous flaps and
island fasciocutaneous flaps are still popular as surgical alternatives which, if carefully planned, can provide a stable
cover.74,75 Prevention of ulcers by warming and methods of
recording pressure in intraoperative patients has been studied by Scott et al.11,74
Early rehabilitation and inclusion of a rehabilitation team
in postoperative management has been found effective in
reducing hospital costs.75
Certainly, with the use of multidisciplinary teams, the
outcomes of surgical pressure ulcer management, the outcomes of surgical and nonsurgical pressure ulcer management, the number of ulcers has been on the decline for inhospital managed patients. Regardless of how wound management is carried out, the recognized endpoint accepted by
the FDA is total wound closure. All preventative measures
must be reinstituted in postsurgical patients on discharge or
the recurrence rate is unacceptably high.
Recommendation 11
Develop an Interdisciplinary Team Specific to the
Needs of the Patient
Increased complexity of patients, fragmentation of
48
OstomyWound Management
care, the proliferation of wound care products, new technology, legal responsibilities, and best practice issues can
overwhelm the bedside caregiver of a patient with a pressure ulcer. Wound care teams provide support in the
areas of education, research, and patient care (see Table
6)77 and may consist of RNs, LPNs, PTs, OTs, physicians, dietitians, social workers, and others as required by
the needs of the patient.
Granick and Ladin77 report that after the integration
of a multidisciplinary team, the overall prevalence of
pressure ulcers declined from 22.6% in 1993 to 8% in
1996 in one hospital. A 15% decrease in 1 year was
reported in their investigation in another hospital. The
prevalence of ulcers, as well as the recurrence rate in
high-grade ulcers treated surgically, was reduced as a
result of multidisciplinary teams.75-77 Bateman78 states
the strongest component that differentiates one wound
care program from another is the wound care team.
She brings forth four key questions to ask about the
team:
1. How qualified is the staff?
2. What educational tools do they utilize?
3. How do they measure patient outcomes?
4. What does their patient population have to say
about their program?
Best practice carried out by a dedicated wound team
can be an effective means of achieving improved outcomes in pressure ulcer management. A panel discussion from the 12th Annual Clinical Symposium cautions that developing and maintaining a team is an art.
The team members must understand and apply the literature on team building to the unique characteristics
of ones facility.79 Panel member David Thomas states,
“Teams must be built in terms of human relationships.
In practical ways, you have to become involved with
each other and break down barriers that may exist
between disciplines.”
Recommendation 12
Educate Patients, Caregivers, and Healthcare
Professionals on the Prevention and Treatment of
Pressure Ulcers
The importance of preventing recurrence bears repeating.
Education of the patient is tantamount to preventing recurrence and requires education of the primary caregiver, the
patient’s family, and other involved healthcare professionals.
Phillips80 recommends that educational programs for healthcare providers, patients, families, and caregivers cover the
following topics, with content modified according to the
audience:
• pathophysiology and risk factors for pressure
damage
• risk assessment tools and their application
• skin assessment
• selection and instruction in the use of pressure
redistribution and other devices
• developing and implementing individualized programs of care
• principles of positioning to decrease risk of pressure
damage
• documenting processes and patient outcome data
• clarifying responsibilities for all concerned with the
problem
• health promotion
• development and implementation of guidelines.
2.
3.
4.
5.
6.
7.
8.
9.
Phillips advises that the content should be updated regularly on the basis of best evidence.
Conclusion
Six years have passed since the publication of the
AHCPR guidelines. Because it is an evolutionary document,
it needs to be updated periodically so that the guidelines can
be revisited. This task is a large one, requiring the input of
consensus groups. The Canadian Association of Wound
Care advisory panel on pressure ulcer management intended
to create a more international approach while maintaining
the quality of content and has proposed the new recommendations included in this paper with the hope that all practitioners will be able to use the recommendations to serve as
best practice enablers. - OWM
10.
11.
12.
13.
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