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Guideline Summary
Guideline Title
Guideline for prevention and management of pressure ulcers.
Bibliographic Source(s)
Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Mount Laurel (NJ): Wound, Ostomy, and Continence Nurses Society (WOCN); 2010 Jun 1. 96 p. (WOCN clinical practice guideline; no. 2).  [341 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Wound Ostomy and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Glenview (IL): Wound Ostomy and Continence Nurses Society (WOCN); 2003. 52 p.

Scope

Disease/Condition(s)

Pressure ulcers (also known as bedsore, decubitus ulcer, and pressure sore)

Note: In 2009, the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel (NPUAP/EPUAP) defined a pressure ulcer as "localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear."

Guideline Category
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Dermatology
Family Practice
Geriatrics
Nursing
Nutrition
Physical Medicine and Rehabilitation
Plastic Surgery
Preventive Medicine
Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Physical Therapists
Physician Assistants
Physicians
Guideline Objective(s)

To support clinical practice by providing consistent research-based information with the goal of improving cost-effective patient outcomes as well as stimulating wound-related research

Target Population

Patients with or at risk for developing pressure ulcers

Interventions and Practices Considered

Evaluation/Risk Assessment

  1. Assessment of individual risk for developing pressure ulcers using risk assessment tools
  2. Assessment of other intrinsic/extrinsic risk factors
  3. Assessment of skin
  4. Assessment of nutritional status
  5. Assessment for history of prior ulcer and/or presence of current ulcer, previous treatments, or surgical interventions
  6. Assessment for potential complications associated with pressure ulcers

Prevention/Management/Treatment

  1. Measures to minimize shear-related injury
  2. Measures to redistribute pressure
  3. Use of skin protectant
  4. Nutritional management
  5. Use of a low-air-loss or air-fluidized surface
  6. Bowel/bladder management program
  7. Implement strategies to optimize healing
  8. Wound management
  9. Use of antibiotics (e.g., topical, systemic)
  10. Debridement of devitalized tissue
  11. Adjunctive therapies as indicated
  12. Evaluation of need for operative repair
  13. Evaluation and management of pain
  14. Patient/caregiver education
Major Outcomes Considered
  • Incidence and prevalence of pressure ulcers
  • Efficacy of intervention for preventing the development of pressure ulcers, and facilitating wound healing
  • Validity of tools used to assess patients at risk and pressure ulcer healing
  • Morbidity
  • Cost

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The primary authors of this guideline independently conducted searches of MEDLINE, CINAHL, and Cochrane Library databases for studies, published in English from January 2003 through October 2009. The following medical subject headings (MESH) were used to search for each specific question related to pressure ulcers: pressure sore, decubitus ulcer, and bedsore. The search targeted meta-analyses, randomized controlled trials, prospective clinical trials, retrospective studies, and systematic reviews. Reference lists of selected articles were also reviewed to identify relevant studies to include.

Number of Source Documents

More than 300 articles were identified and reviewed for this guideline, but the number of actual source documents is not stated.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Rating of Evidence

Level I: A randomized controlled trial (RCT) that demonstrates a statistically significant difference in at least one important outcome defined by p <.05. Level I trials can conclude that the difference is not statistically significant if the sample size is adequate to exclude a 25% difference among study arms with 80% power.

Level II: A RCT that does not meet Level I criteria.

Level III: A non-randomized controlled trial with contemporaneous controls selected by some systematic method. A control might have been selected because of its perceived suitability as a treatment option for an individual patient.

Level IV: A before-and-after study or a case series of at least 10 patients using historical controls or controls drawn from other studies.

Level V: A case series of at least 10 patients with no controls.

Level VI: A case report of fewer than 10 patients.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Two primary reviewers read and summarized selected articles. Each study was assigned a level of evidence rating of Level I to Level VI.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The Wound, Ostomy and Continence Nurses (WOCN) Society developed this evidence-based guideline using the following process: (a) A panel of nurses from the WOCN membership, representing a wide range of experience and clinical practice backgrounds, was convened to plan the guideline format; (b) a topical outline was designed and specific questions about pressure ulcers were proposed to guide the search of the literature for evidence, and (c) studies reporting primary data relevant to pressure ulcers and specific therapies or diagnostic modalities were included in the review. The panel developed eleven questions related to the prevention and management of pressure ulcers to guide the evidence-based review of the literature.

After the two primary authors reviewed the selected studies, a written summary of the evidence was presented to all committee members for review, discussion, and clarification. A series of conference calls was conducted during 2009 and 2010 and the guideline was finalized incorporating evidence from the studies.

Rating Scheme for the Strength of the Recommendations

Levels-of-Evidence Rating*

Level A: Two or more supporting randomized controlled trials (RCTs) of at least 10 humans with pressure ulcers (at Levels I or II), a meta-analysis of RCTs, or a Cochrane Systematic Review of RCTs.

Level B: One or more supporting controlled trials of at least 10 humans with pressure ulcers or two or more supporting non-randomized trials of at least 10 humans with pressure ulcers (at Level III).

Level C: Two supporting case series of at least 10 humans with pressure ulcers or expert opinion.

*The rating refers to the strength of the evidence for a recommendation and does not relate to the importance of the recommendation.

Cost Analysis

The following cost-effective analyses were reviewed:

  • A prospective, randomized clinical trial to assess the cost-effectiveness of a modern foam dressing versus traditional saline gauze dressing in the treatment of stage II pressure ulcers
  • Hydrocolloid versus saline-gauze dressings in treating pressure ulcers: A cost-effectiveness analysis
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

After the two primary authors reviewed the selected studies, a written summary of the evidence was presented to all committee members for review, discussion, and clarification. A series of conference calls was conducted during 2009 and 2010 and the guideline was finalized incorporating evidence from the studies.

Recommendations

Major Recommendations

A level of evidence rating (A-C) has been assigned specific recommendations and is defined at the end of the "Major Recommendations" field. Citations in support of individual recommendations are identified in the original guideline document.

Assessment

  1. Risk assessment should be performed upon entry to a health care setting, and repeated on a regularly scheduled basis, or when there is a significant change in the individual's condition. Level of Evidence= C
  2. Use of a valid and reliable risk assessment tool is recommended. Level of Evidence= B
  3. Assess for intrinsic/extrinsic risk factors. Risk factors can be defined as anything that increases the chance of developing a pressure ulcer. Level of Evidence= C
  4. Identify high-risk settings and groups to identify where to target prevention efforts to minimize risk. Level of Evidence= C
  5. Assess and inspect skin regularly. Level of Evidence= C
  6. Patients who have some degree of immobility need more frequent monitoring to minimize risk of pressure ulcer formation. Level of Evidence= C
  7. Assess for incontinence; differentiate between pressure ulcers and moisture lesions caused by incontinence from urine/feces (incontinence associated dermatitis [IAD]). Level of Evidence= C
  8. Nutritional assessment should be performed upon entry to a new health care setting and whenever there is a change in the individual's condition. Level of Evidence= C
  9. Assess for history of prior ulcer and/or presence of current ulcer, previous treatments or surgical interventions. Level of Evidence= C
  10. Assess and regularly monitor pressure ulcer(s) on admission to care setting, and with any signs of skin/wound deterioration. Level of Evidence= C
  11. Assess factors that impede healing status. Level of Evidence= C
  12. Assess/evaluate healing. Level of Evidence= C
  13. Assess for potential complications associated with pressure ulcer(s). Level of Evidence= C

Prevention

  1. Implement measures to reduce the risk of developing pressure ulcers. Level of Evidence= C
  2. Maintain head of bed at/or below 30 degrees or at the lowest degree of elevation consistent with the patient's medical condition to prevent shear-related injury. Level of Evidence= C
  3. Schedule regular repositioning and turning for bed and chair bound individuals. Level of Evidence= B
  4. Position sitting patients with special attention to the individual's anatomy, postural alignment, distribution of weight, and support of the feet. Level of Evidence= C
  5. Heel protection devices should completely offload (float) the heel. Level of Evidence= C
  6. Utilize support surfaces (on beds and chairs) to redistribute pressure. Pressure redistribution devices should serve as adjuncts and not replacements for repositioning protocols. Level of Evidence = C
  7. Individuals at-risk should be placed on a pressure redistribution surface. Level of Evidence = C
  8. Pressure redistribution surfaces should be used in the operating room for individuals assessed to be at high risk for pressure ulcer development. Level of Evidence = B
  9. Avoid foam rings, foam cut-outs, or donut-type devices. Level of Evidence= C
  10. Use of a skin protectant is recommended for individuals with frequent fecal incontinence or double urinary and fecal incontinence. Level of Evidence= C
  11. Offer individuals with nutritional and pressure ulcer risks a minimum of 30-35 kcal per kg body weight per day with 1.25-1.5 g/kg/day protein and 1 ml of fluid intake per kcal per day (National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel [NPUAP/EPUAP], 2009). Level of Evidence = C
  12. Educate patient/caregiver about the causes and risk factors for pressure ulcer development and ways to minimize risk. Level of Evidence = C

Treatment

  1. For patients with large stage III or IV pressure ulcers or ulcers on multiple turning surfaces, a low-air-loss or air-fluidized surface may be indicated. Level of Evidence = B
  2. Establish a bowel/bladder management program for the patient with incontinence. Level of Evidence = C
  3. Implement pressure ulcer strategies to optimize the healing recognizing that complete healing may be unrealistic in some patients. Level of Evidence = C
  4. Cleanse the wound and periwound at each dressing change. Level of Evidence = C
  5. Water can be used for cleaning wounds. Level of Evidence = B
  6. Determine the bacterial bioburden by tissue biopsy or quantitative swab technique. Level of Evidence = C
  7. Consider a two-week course of topical antibiotics for nonhealing clean pressure. Level of Evidence = C
  8. Use systemic antibiotics in the presence of bacteremia, sepsis, advancing cellulitis, or osteomyelitis. Level of Evidence = C
  9. Debride the pressure ulcer of devitalized tissue. Level of Evidence = C
  10. Reassess the wound with each dressing change to determine whether modifications are needed as the wound heals or deteriorates. Level of Evidence = C
  11. Consider adjunctive therapies as indicated.
    1. Platelet-derived growth factor (PDGF). Level of Evidence = B
    2. Electrical stimulation. Level of Evidence = B
    3. Negative pressure wound therapy. Level of Evidence = B
  12. Evaluate the need for operative repair. Level of Evidence = C
  13. Implement measures to eliminate or control the source of pain. Level of Evidence = C
  14. Educate patient/caregiver that measures to promote healing and prevent recurrence are life long. Level of Evidence = C

Definitions:

Rating of Evidence

Level I: A randomized controlled trial (RCT) that demonstrates a statistically significant difference in at least one important outcome defined by p <.05. Level I trials can conclude that the difference is not statistically significant if the sample size is adequate to exclude a 25% difference among study arms with 80% power.

Level II: A RCT that does not meet Level I criteria.

Level III: A non-randomized controlled trial with contemporaneous controls selected by some systematic method. A control might have been selected because of its perceived suitability as a treatment option for an individual patient.

Level IV: A before-and-after study or a case series of at least 10 patients using historical controls or controls drawn from other studies.

Level V: A case series of at least 10 patients with no controls.

Level VI: A case report of fewer than 10 patients.

Levels-of-Evidence Rating*

Level A: Two or more supporting RCTs of at least 10 humans with pressure ulcers (at Levels I or II), a meta-analysis of RCTs, or a Cochrane Systematic Review of RCTs.

Level B: One or more supporting controlled trials of at least 10 humans with pressure ulcers or two or more supporting non-randomized trials of at least 10 humans with pressure ulcers (at Level III).

Level C: Two supporting case series of at least 10 humans with pressure ulcers or expert opinion.

*The rating refers to the strength of the evidence for a recommendation and does not relate to the importance of the recommendation.

Clinical Algorithm(s)

An algorithm for the differential assessment of a wound with unknown etiology is provided in the original guideline document.

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate identification of individuals at risk for developing pressure ulcers and initiating early prevention programs
  • Implementation of appropriate strategies/plans may:
    • Attain/maintain intact skin
    • Prevent complications
    • Promptly identify or manage complications
    • Optimize potential for wound healing
    • Involve patient/caregiver in self-management
  • Implementation of cost-effective strategies/plans that prevent and treat pressure ulcers
Potential Harms
  • All briefs increase moisture to the perineal region because of their occlusiveness. Some products are more absorbent than others. Briefs are not usually recommended for fecal incontinence management because of the increased risk of incontinence associated dermatitis (IAD). However, they may be used in the ambulatory individual but should be changed frequently with the perineal skin assessed for signs of IAD.
  • Avoid using cleansing products or solutions in open wounds that are intended for use on intact skin. Avoid cleansers designed to remove fecal material. Both of these products can be toxic to the wound bed. Also, when an antiseptic is added to a cleanser the toxicity increases.
  • Wounds scrubbed with coarse sponges are significantly more at risk for infection than wounds scrubbed with softer sponges.
  • Environmental contamination such as splashing is possible with high-pressure irrigation devices and infection control precautions should be routinely followed (e.g., wearing protective clothing, gloves, and eyewear).
  • Any of the debridement methods may increase the size of the pressure ulcer since the necrotic tissue is being removed.
  • Sharp debridement should be used with caution in individuals that are immune incompetent, on anticoagulants, or have bleeding disorders.
  • Leakage or strike-through of occlusive dressings can cause a break in the dressing barrier, which can expose the wound to external contamination.
  • Rates of surgical complications and recurrence rates are high. Complication rates have been reported at 7-49%. Osteomyelitis has been cited as the major cause of breakdown after surgery and a bone biopsy is recommended to diagnose osteomyelitis in stage IV pressure ulcer patients.

Contraindications

Contraindications

Electrical stimulation is contraindicated in the presence of metallic ions, such as iodine and silver in the wound.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Clinical Algorithm
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Mount Laurel (NJ): Wound, Ostomy, and Continence Nurses Society (WOCN); 2010 Jun 1. 96 p. (WOCN clinical practice guideline; no. 2).  [341 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2003 (updated 2010 Jun 1)
Guideline Developer(s)
Wound, Ostomy, and Continence Nurses Society - Professional Association
Source(s) of Funding

Wound, Ostomy, and Continence Nurses Society

Guideline Committee

Wound, Ostomy, and Continence Nurses (WOCN) Pressure Ulcer Panel

Wound Guidelines Task Force

Composition of Group That Authored the Guideline

Primary Authors: Catherine R. Ratliff, PhD, APRN-BC, CWOCN, CFCN, Pressure Ulcer Guidelines Chair, University of Virginia Health System, Charlottesville, VA; Nancy Tomaselli, MSN, RN, CRNP, CWOCN, LNC, President & CEO, Premier Health Solutions, LLC, Cherry Hill, NJ

Guidelines Task Force: Margaret Goldberg, MSN, RN, CWOCN (Chair), Delray Wound Treatment Center, Delray Beach, FL; Phyllis Bonham, PhD, MSN, RN, CWOCN, DPNAP, FAAN, Medical University of South Carolina, College of Nursing, Charleston, SC; Penny S. Crawford, RN, MSN, FNP, BC, CWOCN, Atlantic Shores Wellness Clinic, Virginia Beach, VA; Bonny G. Flemister, MSN, RN, CWOCN, ANP, GNP-BC, Bethany Healthcare, Dallas, TX; Jan J. Johnson, MSN, ANP-BC, CWOCN, Duke University Medical Center, Durham, NC; Teresa J. Kelechi, PhD, MSN, RN, GCNS-BC, CWCN, Medical University of South Carolina, College of Nursing, MSC160, Charleston, SC; Myra Fields Varnado, BS, RN, CDE, CWOCN, LSU Health System, New Orleans, LA

Scribe: Ronald Palmer, Fullerton, CA

Financial Disclosures/Conflicts of Interest

Individuals involved in developing clinical practice guidelines are charged by the Wound, Ostomy and Continence Nurses (WOCN) Society to develop guidelines that are objective, comprehensive, and practical. To ensure the integrity of the WOCN Society and the Clinical Practice Guideline Program, prior to participating in any guideline activity, participants submit a disclosure form to WOCN regarding any financial relationships with commercial companies that could create a conflict when the company's products or services are related to the subject of the guideline. Members of the guideline panel submitted a disclosure form, which was reviewed by the WOCN executive director, who determined that no conflict of interest exists with any individual panel member.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Wound Ostomy and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Glenview (IL): Wound Ostomy and Continence Nurses Society (WOCN); 2003. 52 p.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase for a nominal fee from the Wound Ostomy and Continence Nurses Society (WOCN),15000 Commerce Parkway, Suite C, Mt. Laurel, NJ, 08054; Web site: www.wocn.org External Web Site Policy. Orders can be placed thru the WOCN Web site or via telephone at (888) 224-9626.

Availability of Companion Documents

Wound assessment tools including a Braden Scale for predicting pressure sore risk, nutritional assessment forms, and a pressure ulcer healing chart are available in the original guideline document.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on January 14, 2004. The information was verified by the guideline developer on February 16, 2004. This NGC summary was updated by ECRI Institute on September 28, 2010. The updated information was verified by the guideline developer on December 13, 2010. This summary was updated by ECRI Institute on March 16, 2011 following the U.S. Food and Drug Administration advisory on negative pressure wound therapy (NPWT) systems.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Per the guideline developer, the Wound, Ostomy and Continence Nurses (WOCN) Society retains the copyright to the material in the Guideline for Prevention and Management of Pressure Ulcers. Any reproduction without consent is prohibited. Written requests to reproduce any portion of the material contained within this guideline may be directed to Pete Pomilio, MBA, Executive Director, Wound, Ostomy and Continence Nurses Society national office: 15000 Commerce Parkway, Suite C, Mt. Laurel, NJ 08054.

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