The so-called aging of America has been widely acknowledged, and the medical community is preparing -- to the best of its ability -- to deal with an impending onslaught of health conditions that affect primarily older adults, particularly those in long-term care facilities. This week, the American College of Physicians (ACP) released a pair of evidence-based clinical guidelines that address one such condition: pressure ulcers.
The two guidelines, "Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians"(annals.org) and "Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians,"(annals.org) appear in the March 3 issue of Annals of Internal Medicine.
Epidemiology, Risk Assessment and Prevention
Previous studies have estimated that as many as 3 million adults in the United States suffer from pressure ulcers. Prevalence estimates range from 0.4 percent to 38 percent in acute-care hospitals and 2 percent to 24 percent in long-term care nursing facilities. In addition, nearly one in six individuals in home care settings may be affected.
- This week, the American College of Physicians released a pair of evidence-based clinical guidelines that address prevention and treatment of pressure ulcers.
- The prevention guideline team identified the use of advanced static mattresses or overlays as a key preventive tactic in patients who are at an increased risk of developing pressure ulcers.
- Although evidence was suboptimal, treatment guideline authors recommended protein or amino acid supplementation and use of hydrocolloid or foam dressings to reduce wound size.
According to an ACP news release,(www.acponline.org) those figures make pressure ulcers big business. "Up to $11 billion is spent annually in the United States to treat bedsores, and a growing industry has developed to market various products for pressure ulcer prevention,” said ACP President David Fleming, M.D., in the release. "ACP's evidence-based recommendations can help physicians provide quality care to patients while avoiding wasteful practices."
Based on a comprehensive literature review of research published through February 2014, members of the ACP prevention guideline team examined a number of factors in formulating their recommendations, such as pressure ulcer incidence and severity, resource use (including duration of hospital stay or cost), diagnostic accuracy (i.e., sensitivity, specificity, and positive and negative likelihood ratios), measures of risk (i.e., hazard ratios, odds ratios and relative risks), and harms (e.g., dermatologic reactions, discomfort and infection).
Overall, the ACP prevention guideline makes the following three recommendations:
- Clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers.
- Clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers.
- Do not use alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers.
Regarding risk assessment, the guideline authors identified a number of specific risk factors for pressure ulcers:
- older age;
- black race or Hispanic ethnicity;
- lower body weight;
- cognitive impairment;
- physical impairments; and
- other comorbid conditions that affect soft-tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition.
Instruments designed to assess patients' risk of developing pressure ulcers include the Braden, Cubbin and Jackson, Norton, Ramstadius, and Waterlow scales, said the authors. However, all showed relatively low sensitivity and specificity, and the authors found no conclusive evidence that any one risk-assessment instrument was superior to the others. Moreover, none performed any better than clinical judgment alone.
For patients in whom an increased risk for pressure ulcers can be detected, numerous preventive interventions are available to reduce friction and shear. Intervention categories include various support surfaces (e.g., mattresses, integrated bed systems, overlays and cushions), repositioning, nutritional supplementation, skin care (e.g., dressing and management of incontinence) and topical creams.
Although the ACP guideline team's analysis revealed a significant number of mixed results, the most reliable moderate-quality evidence pointed to the use of an advanced static mattress (i.e., a mattress made of foam or gel that does not move when a person lies on it) or overlay (i.e., a material such as sheepskin or a pad filled with air, water, gel or foam that is secured atop the bed mattress) as yielding better outcomes than a standard hospital bed. Advanced static mattresses are both more effective and less expensive than alternating air or low-air-loss mattresses (a.k.a., dynamic mattresses) and can be used as part of a multicomponent preventive approach.
The guideline team charged with evaluating pressure ulcer treatment options came up with the following recommendations:
- Clinicians should use protein or amino acid supplementation to reduce wound size.
- Clinicians should use hydrocolloid or foam dressings to reduce wound size.
- Clinicians should use electrical stimulation as adjunctive therapy to accelerate wound healing.
It's worth noting that the authors characterized all three as weak recommendations, based on low- or moderate-quality evidence.
Regarding nutritional supplementation, evidence showed that supplementation with protein or amino acids can reduce pressure ulcer wound size, but evidence demonstrating the optimal dose or form of protein was lacking. Vitamin C supplementation showed no benefit compared with placebo.
In addition, low-quality evidence showed that hydrocolloid dressings outperform gauze dressings in reducing wound size and lead to complete wound healing at a rate similar to that seen with foam dressings (hydrocellular or polyurethane).
Finally, moderate-quality evidence supported the use of electrical stimulation in conjunction with standard treatment to accelerate the healing rate of stage 2 to 4 ulcers. Evidence was insufficient, however, to determine its effect on complete wound healing.
Overall, said the authors, treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.
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