Guidelines for the treatment of pressure ulcers

Abstract

Health care providers face the challenge of providing effective care for increasing numbers of patients with chronic wounds. Pressure ulcers, one type of chronic wound, are estimated to affect 1.3–3 million individuals in the United States.1 Prevalence varies among specific clinical populations, with higher percentages reported for the elderly, the acutely ill, and those who have sustained spinal cord injuries.2,3,4 The first comprehensive clinical practice guidelines for the treatment of patients with pressure ulcers were published by the Agency for Healthcare Research and Quality (AHRQ) in 1994. Since that time, a number of professional groups have also developed and published guidelines. The acceptance and adoption of guideline recommendations in practice is variable and influenced by several factors, including (1) guideline currency with the most recent and comprehensive evidence, (2) recognition and acceptance of guideline validity, (3) breadth of interprofessional representation in guideline development, and (4) guideline presentation and format.5 These issues pertain to guidelines in general, but are also applicable to those specific to chronic wounds. Despite many recent advances in wound care, the challenge of managing chronic wounds remains compounded by the current lack of consensus on clearly defined, comprehensive wound care principles and uniformly accepted analytical methods to evaluate outcomes. With these concerns in mind, the following guidelines were developed to facilitate use by multiple groups in the wound care community of clinicians, researchers, industry, governing agencies, and third-party payers. The guidelines provide recommendations for treatment of pressure ulcers supported by current evidence. However, treatment decisions also depend on specific patient characteristics, pressure ulcer characteristics/stage, patient circumstances, and overall goals. The development of a treatment plan of care begins with the determination of the goals of therapy. In most cases, the goal of therapy is to produce complete healing with restoration of functional skin integrity to the highest extent possible. However, in certain cases, the goal of therapy may not be complete healing of the wound. For example, in patients who are terminally ill, the goal of therapy may be palliative and focused on reducing discomfort or deterioration of the pressure ulcer, rather than complete healing of the wound. In other cases, the treatment may produce added discomfort or increased risk to the patient. Individual evaluation of each case is necessary within the context of the optimum outcome for that patient. The specific objectives of this project were to: Develop comprehensive, evidence- and consensus-based guidelines for pressure ulcer treatment. Present these guidelines in a clear, simple format designed to enable health care providers to make informed, evidence-supported treatment decisions to manage pressure ulcers appropriately. A search of health care databases for current published evidence-based guidelines addressing the treatment of pressure ulcers was conducted between July 2004 and January 2006 using electronic and online resources. In addition to published guidelines, PubMed, EMBASE, and the Cochrane Database of Systematic Reviews were reviewed for evidence on pressure ulcer treatment. The following guidelines were located and reviewed by the panel and used in the development of the categories of treatment and individual guidelines. American Family Physician Pressure Ulcer Guideline Panel. Pressure Ulcer Treatment. Am Fam Phys 1995; 51: 1207–23. American Medical Directors Association (AMDA). Pressure Ulcers, Clinical Practice Guideline. 1996. Columbia, MD: American Medical Directors Association. AMDA Pressure Ulcer Therapy Companion, Clinical Practice Guideline. 1999. Columbia, MD: American Medical Directors Association. Bergstrom N, Allman RM, Alvarez OM, Bennett MA, Carlson CE, Frantz RA, Garber SL, Jackson BS, Kaminski Jr MV, Kemp MG, Krouskop TA, Lewis Jr VL, Maklebust J, Margolis DJ, Marvel EM, Reger SI, Rodeheaver GT, Salcido R, Xakellis GC, Yarkony GM. Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. 1994. AHCPR Publication No. 95-0652. Rockville, MD: U.S. Department of Health and Human Services. Public Health service, Agency for Health Care Policy and Research. Brem H, Lyder C. Protocol for the successful treatment of pressure ulcers. Am J Surg 2004 (Suppl. to July 2004); 188: 9S–17S. 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