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. 40 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. 42 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. 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