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  • Guideline Summary
  • NGC:010606
  • 2009 (revised 2014)

Special populations. In: Prevention and treatment of pressure ulcers: clinical practice guideline.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Special populations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel; 2014. p. 209-52. [202 references]

This is the current release of the guideline.

This guideline updates previous versions: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Pressure ulcer prevention recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel; 2009. p. 21-50. [214 references]

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Pressure ulcer treatment recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel; 2009. p. 51-120. [432 references]

This guideline meets NGC's 2013 (revised) inclusion criteria.

Age Group

UMLS Concepts (what is this?)

SNOMEDCT_US
Bandage (63995005), Bed (229772003), Child (410601007), Child (67822003), Cleaning wound (225150002), Cushion (706137007), Debridement (129317004), Debridement (36777000), Dressings (333453004), Elderly person (105436006), Examination of skin (271303006), External rotation (257914009), External rotation (264730003), External rotation (52019005), Family education (311403008), Family education (460616007), Geriatric medicine (394811001), Intraoperative care (133900002), Newborn (133933007), Nutrition management (386372009), Nutrition therapy (386373004), Nutritional support (278906000), Obesity (414915002), Obesity (414916001), Odor absorbing dressing (334717009), Odor absorbing dressing (463546000), Older adult care assessment (409002003), Older adult care management (409004002), Overbed trapeze device (422915004), Pain assessment (225399009), Pain management (278414003), Palliative care (103735009), Patient education (311401005), Pediatric specialty (394537008), Perioperative care (133897009), Positioning patient (229824005), Postoperative care (133899007), Preoperative care (133898004), Preschool child (410602000), Pressure ulcer (399912005), Pressure ulcer (420226006), Pressure ulcer assessment (225393005), Pressure ulcer care (225357008), Pressure ulcer care management (385914001), Pressure ulcer prevention (225996006), Prone body position (1240000), Repositioning (308739004), Risk factor (80943009), Skin care (225360001), Spinal cord injury (90584004), Surgical (257556004), Surgical (387713003), Surgical (83578000), Therapeutic electrical stimulation (169430000), Therapeutic electrical stimulation (57942008), Tissue repair (18867006), Tissue repair (298005009), Ulcer-type pain (102615007), Walker (49338004), Walker (705406009), Wheel chair (58938008), Wheelchair cushion (466492009), Wound care (225358003)
UMD
Bandages (10-274), Beds (10-342), Beds, Electric, Alternating-Pressure (18-383), Cushions (11-093), Dressings (11-315), Pressure Relief Pads, Air, Alternating (12-928), Walkers (14-393), Wheelchairs (14-449)

Major Recommendations

The strength of evidence ratings (A-C) and strength of recommendation grades (Strong positive recommendation, Weak positive recommendation, No specific recommendation, Weak negative recommendation, Strong negative recommendation) are defined at the end of the "Major Recommendations" field.

Note from the National Pressure Ulcer Advisory Panel (NPUAP), the European Pressure Ulcer Advisory Panel (EPUAP), Pan Pacific Pressure Injury Alliance (PPPIA) and the National Guideline Clearinghouse (NGC): The pressure ulcer clinical practice guideline has been divided into individual summaries covering prevention, interventions for prevention and treatment, treatment, and special populations. This summary should not be read in isolation but in conjunction with the other summaries. In addition to the current summary, the following are available:

The special populations sections of this guideline provide specific recommendations for selected at-risk populations that, for the most part, should be considered in conjunction with the recommendations throughout the full clinical guideline.

Bariatric (Obese) Individuals

Recommendations for the Organization

  1. Provide safe, respectful care and avoid injuries to both the individual and health professionals. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Maximize workplace safety by implementing organization-wide bariatric management strategies that address manual handling techniques. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  3. Provide pressure redistribution support surfaces and equipment appropriate to the size and weight of the individual. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Assessing the Bariatric Individual

  1. Calculate body mass index (BMI) and classify obesity. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  2. Assess all skin folds regularly. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    2.1. Access adequate assistance to fully inspect all skin surfaces and folds. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    2.2. Differentiate intertriginous dermatitis from Category/Stage I and II pressure ulcers. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  1. Refer bariatric individuals to a registered dietitian or an interprofessional nutrition team for a comprehensive nutrition assessment and weight management plan. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Bed Selection

  1. Ensure the individual is provided with a bed of appropriate size and weight capacity specifications. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.1. Use beds that adequately support the weight of the individual. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.2. Check routinely for 'bottoming out' of the support surface. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.3. Ensure that the bed surface area is sufficiently wide to allow turning of the individual without contact with the side rails of the bed. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  2. Consider selecting a support surface with enhanced pressure redistribution, shear reduction and microclimate control for bariatric individuals. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Equipment Selection

  1. Use wheelchairs and chairs that are wide and strong enough to accommodate the individual's girth and weight. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.1. Use a pressure redistribution cushion designed for the bariatric individual on seated surfaces. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.2 Check routinely for "bottoming out" of the cushion. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  2. Where appropriate, provide bariatric walkers, overhead trapezes on beds, and other devices to support continued mobility and independence. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Repositioning

  1. Avoid pressure on skin from tubes, other medical devices and foreign objects. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Use pillows or other positioning devices to offload the pannus or other large skin folds and prevent skin-on-skin pressure. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  3. Check the bed for foreign objects. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Pressure Ulcer Care

  1. Provide adequate nutrition to support healing. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Assess pressure ulcers carefully for signs of infection and delays in healing. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  3. Monitor wound dressing materials closely, especially in large cavity wounds. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Critically Ill Individuals

Support Surfaces

  1. Evaluate the need to change the pressure redistributing support surfaces for individuals with poor local and systemic oxygenation and perfusion to improve pressure redistribution, shear reduction, and microclimate control. Utilize additional features (e.g., turn assistance, percussion) as needed. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  2. Evaluate the need to change the support surface for individuals who cannot be turned for medical reasons including a temporary oral-pharyngeal airway, spinal instability and hemodynamic instability. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Repositioning

  1. Initiate a repositioning schedule as soon as possible after admission. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.1. Revise the repositioning schedule in response to assessment of the individual's tolerance to repositioning. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

  2. Consider slow, gradual turns allowing sufficient time for stabilization of hemodynamic and oxygenation status. (Strength of Evidence = C; Weak positive recommendation)
  3. Consider more frequent small shifts in position to allow some reperfusion in individuals who cannot tolerate frequent major shifts in body position. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    Caution: Small shifts do not replace selection of a more appropriate pressure redistribution support surface when needed or turning (major shifts in body position) when possible.

  4. Resume routine repositioning as soon as these conditions stabilize. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  5. Use a foam cushion under the full length of the calves to elevate heels. (Strength of Evidence = B; Strength of Recommendation = Strong positive recommendation)

Prone Positioning

  1. Assess critically ill individuals placed in the prone position for evidence of facial pressure ulcers with each rotation. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  2. Assess other body areas (i.e., breast region, knees, toes, penis, clavicles, iliac crest, symphysis pubis) that may be at risk when individuals are in the prone position with each rotation. (Strength of evidence = C; Strength of Recommendation = Weak positive recommendation)
  3. Offload pressure points on the face and body while in the prone position. (Strength of evidence = C; Strength of Recommendation = Strong positive recommendation)

Lateral Rotation

  1. Minimize shear strain when lateral rotation features are used. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  2. Secure the individual with bolster pads (provided by the manufacturer) to prevent sacral shearing when lateral rotation features are selected for individuals without pressure ulcers. The individual should be aligned properly in the center of the surface. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  3. Assess skin frequently for shear injury. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  4. Continue to reposition the individual when using lateral rotation features. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  5. Re-evaluate the need for lateral rotation at the first sign of tissue injury. If indicated and consistent with medical needs, change to a support system with improved pressure redistribution, shear reduction, and microclimate control. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Lateral Rotation in Individuals with Pressure Ulcers

  1. Position the individual off the pressure ulcer as much as possible. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  2. Consider alternative methods of pressure redistribution (or avoid lateral-rotation beds) in individuals with sacral or buttock pressure ulcers. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  3. Inspect the pressure ulcer and the periulcer skin for shear injury with every dressing change. Shear injury may appear as deterioration of the ulcer edge, undermining, and/or as increasing inflammation of periulcer skin or the ulcer. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Nutrition Management

  1. Due to insufficient evidence to support or refute the use of specific additional nutrition interventions in critical care patients, specific additional nutrition interventions are not recommended for routine use in this population. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Older Adults

Assessment and Care Planning

  1. Consider the individual's cognitive status when conducting a comprehensive assessment and developing a pressure ulcer prevention and/or treatment plan. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.1. Incorporate the individual's cognitive ability into the selection of a pain assessment tool. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

  2. Ensure pressure ulcers are correctly differentiated from other skin injuries, particularly incontinence-associated dermatitis or skin tears. (Strength of evidence = C; Strength of Recommendation = Weak positive recommendation)
  3. Set treatment goals consistent with the values and goals of the individual. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    3.1. Engage the family or legal guardian when establishing goals of care and validate their understanding of these goals. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  4. Educate the individual and his or her significant others regarding skin changes in aging and at end of life. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Care of Vulnerable Aged Skin

  1. Protect aged skin from skin injury associated with pressure and shear forces. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Use a barrier product to protect aged skin from exposure to excessive moisture in order to reduce the risk of pressure damage. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  3. Select atraumatic wound dressings to prevent and treat pressure ulcers in order to reduce further injury to frail older skin. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  4. Develop and implement an individualized continence management plan. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Repositioning

  1. Regularly reposition the older adult who is unable to reposition independently. (Strength of Evidence = A; Strength of Recommendation = Strong positive recommendation)
  2. Consider the condition of the individual and the pressure redistribution support surface in use when deciding if repositioning should be implemented as a prevention strategy. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  3. Exercise caution in position selection and manual handling technique when repositioning the older adult. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  4. Frequently reposition the head of older adults who are sedated, ventilated or immobile. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Medical Device Related Pressure Ulcers

  1. Consider older adults with medical devices to be at risk for pressure ulcers. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Ensure that medical devices are correctly sized and fit appropriately to avoid excessive pressure. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  3. Consider using a prophylactic dressing for preventing medical device related pressure ulcers. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Individuals in the Operating Room

  1. Consider additional risk factors specific to individuals undergoing surgery including:
    • Duration of time immobilized before surgery
    • Length of surgery
    • Increased hypotensive episodes during surgery
    • Low core temperature during surgery
    • Reduced mobility on day one postoperatively (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Use a high specification reactive or alternating pressure support surface on the operating table for all individuals identified as being at risk of pressure ulcer development. (Strength of Evidence = B; Strength of Recommendation = Weak positive recommendation)
  3. Position the individual in such a way as to reduce the risk of pressure ulcer development during surgery. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    3.1. Use additional support surfaces (e.g., facial pads) to offload pressure points on the face and body while in the prone position. (Strength of evidence = C; Strength of Recommendation = Strong positive recommendation)

    3.2. Do not position the individual directly on a medical device unless it cannot be avoided. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

  4. Ensure that the heels are free of the surface of the operating table. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    4.1. Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. (Strength of Evidence = B; Strength of Recommendation = Strong positive recommendation)

  5. Position the knees in slight flexion when offloading the heels. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  6. Consider pressure redistribution prior to and after surgery. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    6.1. Place the individual on a high specification reactive or alternating pressure support surface both prior to and after surgery. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    6.2. Document the individual's position and the anatomical areas under increased interface pressure during surgery. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    6.3. Position the individual in a different posture preoperatively and postoperatively than the posture adopted during surgery. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Individuals in Palliative Care

Patient and Risk Assessment

  1. Complete a comprehensive assessment of the individual. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.1. Consider using the Marie Curie Centre Hunters Hill Risk Assessment Tool, specific to adult individuals in palliative care. (Strength of Evidence = C; Strength of Recommendation = No specific recommendation)

Pressure Redistribution

  1. Reposition and turn the individual at periodic intervals, in accordance with the individual's wishes, comfort and tolerance. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.1. Pre-medicate the individual 20 to 30 minutes prior to a scheduled position change for individuals who experience significant pain on movement. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.2. Consider the individual's choices in turning, including whether she/he has a position of comfort, after explaining the rationale for turning. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.3. Consider changing the support surface to improve pressure redistribution and comfort. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.4. Strive to reposition an individual receiving palliative care at least every 4 hours on a pressure redistributing mattress such as viscoelastic foam, or every 2 hours on a regular mattress. (Strength of Evidence = B; Strength of Recommendation = Weak positive recommendation)

    1.5. Document turning and repositioning, as well as the factors influencing these decisions (e.g., individual wishes or medical needs). (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Nutrition and Hydration

  1. Strive to maintain adequate nutrition and hydration compatible with the individual's condition and wishes. Adequate nutritional support is often not attainable when the individual is unable or refuses to eat, based on certain disease states. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Offer nutritional protein supplements when ulcer healing is the goal. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Pressure Ulcer Care

  1. Set treatment goals consistent with the values and goals of the individual, while considering input from the individual's significant others. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.1. Assess the impact of the pressure ulcer on quality of life for the individual and his/her significant others. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.2. Set a goal to enhance quality of life, even if the pressure ulcer cannot be healed or treatment does not lead to closure/healing. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.3. Assess the individual initially and at any change in their condition to re-evaluate the plan of care. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

  2. Assess the pressure ulcer initially and with each dressing change, but at least weekly (unless death is imminent), and document findings. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    2.1. Monitor the pressure ulcer in order to continue to meet the goals of comfort and reduction in wound pain, addressing wound symptoms that impact quality of life such as malodor and exudate. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

  3. Control wound odor. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    3.1. Manage malodor through regular wound cleansing; assessment and management of infection; and debridement of devitalized tissue, with consideration to the individual's wishes and goals of care. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    3.2. Consider use of topical metronidazole to effectively control pressure ulcer odor associated with anaerobic bacteria and protozoal infections. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    3.3. Consider use of charcoal or activated charcoal dressings to help control odor. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    3.4. Consider use of external odor absorbers or odor maskers for the room (e.g., activated charcoal, kitty litter, vinegar, vanilla, coffee beans, burning candle, and potpourri). (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  4. Manage the pressure ulcer and periwound area on a regular basis as consistent with the individual's wishes. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Pain Assessment and Management

  1. Do not under treat pain in individuals receiving palliative care. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Select a wound dressing that requires less frequent changing and is less likely to cause pain. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Resource Assessment

  1. Assess psychosocial resources initially and at routine periods thereafter (psychosocial consultation, social work, etc.). (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  2. Assess environmental resources (e.g., ventilation, electronic air filters, etc.) initially and at routine periods thereafter. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  3. Educate the individual and his or her significant others regarding skin changes at end of life. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  4. Validate that family care providers understand the goals and plan of care. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Pediatric Individuals

Pressure Ulcer Risk Assessment

  1. Perform an age appropriate risk assessment that considers risk factors of specific concern for pediatric and neonate populations, including:
    • Activity and mobility levels
    • Body mass index and/or birth weight
    • Skin maturity
    • Ambient temperature and humidity
    • Nutritional indicators
    • Perfusion and oxygenation
    • Presence of an external device
    • Duration of hospital stay (Strength of Evidence = B; Strength of Recommendation = Strong positive recommendation)

    1.1. Consider children with medical devices to be at risk for pressure ulcers. (Strength of Evidence = B; Strength of Recommendation = Strong positive recommendation)

  2. Consider using a reliable and valid pediatric pressure ulcer risk assessment tool to facilitate a structured assessment. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Assessment and Monitoring

  1. Engage the family or legal guardian involved in the individual's care when establishing goals of care. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Conduct and document a skin assessment at least daily and after procedures for changes related to pressure, friction, shear, moisture. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    2.1. Assess the skin on occiput for neonate and pediatric individuals. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    2.2. Inspect the skin under and around medical devices at least twice daily for the signs of pressure related injury on the surrounding tissue. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Nutritional Management

  1. Conduct an age appropriate nutritional assessment for neonates and children. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.1. Regularly reassess the nutritional requirements of critically ill neonates and children who have, or are at risk of, a pressure ulcer. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

  2. Develop an individualized nutrition care plan for neonates and children with, or at risk of, a pressure ulcer. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  3. Ensure all neonates and children maintain adequate hydration. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  4. When oral intake is inadequate, consider age appropriate nutritional supplements for neonates and children who are at risk of a pressure ulcer and are identified as being at risk of malnutrition. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  5. When oral intake is inadequate, consider age appropriate nutritional supplements for neonates and children who have an existing pressure ulcer and are identified as being at risk of malnutrition. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  6. When oral intake is inadequate, consider enteral or parenteral nutritional support in neonates and children who are at risk of a pressure ulcer or have an existing pressure ulcer and who are also identified as being at risk of malnutrition. (Strength of Evidence= C; Strength of Recommendation = Weak positive recommendation)

Selection of Support Surfaces

  1. Select an age appropriate, high specification support surface for children at high risk of pressure ulcers. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.1. Select a high specification support surface for premature infants and younger children to prevent occipital pressure ulcers. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  2. Ensure that the individual's height, weight and age are consistent with the manufacturer's recommendations when placing a pediatric individual on a low-air-loss bed or alternating pressure support surface. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Repositioning

  1. Ensure that the heels are free of the surface of the bed. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  2. Frequently reposition the head of neonates and infants when they are sedated and ventilated. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Individuals with Spinal Cord Injury

Preventing Pressure Ulcers during the Acute Care Phase

  1. Transfer the individual off a spinal hardboard/backboard as soon as feasible after admission to an acute care facility in consultation with a qualified health professional. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)
  2. Replace an extrication cervical collar with an acute care rigid collar as soon as feasible in consultation with a qualified health professional. (Strength of Evidence = C; Strength of Recommendation = No specific recommendation)

Seating Surfaces

  1. Individualize the selection and periodic re-evaluation of a wheelchair/seating support surface and associated equipment for posture and pressure redistribution with consideration to:
    • Body size and configuration
    • The effects of posture and deformity on pressure distribution
    • Mobility and lifestyle needs. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.1. Refer individuals to a seating professional for evaluation. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  2. Select a pressure redistribution cushion that:
    • Provides contour, uniform pressure distribution, high immersion or offloading
    • Promotes adequate posture and stability
    • Permits air exchange to minimize temperature and moisture at the buttock interface
    • Has a stretchable cover that fits loosely on the top cushion surface and is capable of conforming to the body contours (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  3. Assess other seating surfaces commonly used by the individual and minimize the risk they may pose to skin. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Additional Support Surface Recommendations for Individuals with Existing Pressure Ulcers

  1. Seat individuals with pressure ulcers on a seating support surface that provides contour, uniform pressure distribution, and high immersion or offloading. (Strength of Evidence = B; Strength of Recommendation = Strong positive recommendation)
  2. Use alternating pressure seating devices judiciously for individuals with existing pressure ulcers. Weigh the benefits of off-loading against the potential for shear based on the construction and operation of the cushion. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Repositioning and Mobility

  1. Maintain proper positioning and postural control. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.1. Provide adequate seat tilt to prevent sliding forward in the wheelchair/chair, and adjust footrests and armrests to maintain proper posture and pressure redistribution. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

    1.2. Avoid the use of elevating leg rests if the individual has inadequate hamstring length. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  2. Use variable-position seating (tilt-in-space, recline, and standing) in manual or power wheelchairs to redistribute load off of the seat surface. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    2.1. Tilt the wheelchair before reclining. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  3. Encourage the individual to reposition regularly while in bed and seated. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    3.1. Provide appropriate assistive devices to promote bed and seated mobility. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

  4. Establish pressure relief schedules that prescribe the frequency and duration of weight shifts. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    4.1. Teach individuals to do "pressure relief lifts" or other pressure relieving maneuvers as appropriate. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    4.2. Identify effective pressure relief methods and educate individuals in performance of methods consistent with the ability of the individual. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

Additional Repositioning Recommendations for Individuals with Existing Pressure Ulcers

  1. Weigh the risks and benefits of supported sitting versus bed rest against benefits to both physical and emotional health. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.1. Consider periods of bed rest to promote ischial and sacral ulcer healing. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

    1.2. Develop a schedule for progressive sitting according to the individual's tolerance and pressure ulcer response in conjunction with a seating professional. (Strength of Evidence = C; Strength of Recommendation = Weak positive recommendation)

  2. Avoid seating an individual with an ischial ulcer in a fully erect posture in chair or bed. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Electrical Stimulation for Preventing Pressure Ulcers

  1. Consider the use of electrical stimulation for anatomical locations at risk of pressure ulcer development in individuals with spinal cord injury. (Strength of Evidence = C; Strength of Recommendation = No specific recommendation)

Education and the Individual's Involvement in Care

  1. Promote and facilitate self-management for individuals with spinal cord injury. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)
  2. Provide individuals with spinal cord injury and their caregivers with structured and ongoing education on prevention and treatment of pressure ulcers at a level appropriate to their education background. (Strength of Evidence = C; Strength of Recommendation = Strong positive recommendation)

Definitions:

Strength of Evidence Rating

A The recommendation is supported by direct scientific evidence from properly designed and implemented controlled trials on pressure ulcers in humans (or humans at-risk for pressure ulcers), providing statistical results that consistently support the guideline statement (Level 1 studies required).
B The recommendation is supported by direct scientific evidence from properly designed and implemented clinical series on pressure ulcers in humans (or humans at-risk for pressure ulcers), providing statistical results that consistently support the recommendation (Level 2, 3, 4, 5 studies).
C The recommendation is supported by indirect evidence (e.g., studies in normal human subjects, humans with other types of chronic wounds, animal models) and/or expert opinion.

Strength of Recommendation Grade

Recommendation Description Implication
Do it (Strong recommendation for using an intervention) Indicates a judgment that most well informed people would make. For patient consumers—Most people would want the recommended course of action and only a small proportion would not.
For health professionals—Most people should receive the intervention. If health professionals choose not to follow the recommendation, they should document their rationale.
For quality monitors—Adherence to this recommendation could be used as a quality criterion or performance indicator.
Don't do it (Strong recommendation against using an intervention)
Probably do it (Weak recommendation for using an intervention) Indicates a judgment that a majority of well informed people would make, but a substantial minority would not. For patient consumers—Most people would want the suggested course of action, but many would not.
For health professionals—Examine, and be prepared to discuss, the evidence with patients, as well as their values and preferences.
For quality monitors—Clinicians' discussion and consideration of pros and cons of the intervention, and documentation of discussion, could be used as a quality indicator.
Probably don't do it (Weak recommendation against using an intervention)
No specific recommendation Trade-offs between risk and benefit unclear or lack of agreement between voting participants. The advantages and disadvantages are equivalent; and/or the target population has not been identified; and/or there is insufficient evidence on which to formulate a strength of recommendation.

Clinical Algorithm(s)

None provided

Disease/Condition(s)

Pressure ulcers

Guideline Category

Evaluation

Management

Prevention

Risk Assessment

Treatment

Clinical Specialty

Critical Care

Dermatology

Family Practice

Geriatrics

Internal Medicine

Nursing

Nutrition

Pediatrics

Preventive Medicine

Surgery

Intended Users

Advanced Practice Nurses

Allied Health Personnel

Dietitians

Health Care Providers

Hospitals

Nurses

Patients

Physician Assistants

Physicians

Guideline Objective(s)

  • To provide evidence-based recommendations for the prevention and treatment of pressure ulcers that could be used by health care professionals throughout the world
  • To provide evidence-based guidance on the most effective strategies to prevent the development of pressure ulcers and to promote pressure ulcer healing in specific patient populations and/or those in specific clinical settings who are at greater risk of pressure ulcers
  • To provide evidence-based guidance on the most effective strategies related to special populations to be used in conjunction with the general recommendations on prevention and treatment of pressure ulcers

Target Population

Specific patient populations and/or those in specific clinical settings who are at greater risk of pressure ulcers and for whom particular attention should be paid to preventive planning:

  • Bariatric individuals
  • Critically ill individuals
  • Older adults
  • Individuals in the operating room
  • Individuals with spinal cord injury
  • Individuals in palliative care
  • Pediatric individuals

Interventions and Practices Considered

  1. Bariatric (obese) individuals
    • Implementing organization-wide bariatric management strategies that address manual handling techniques
    • Providing pressure redistribution support surfaces and equipment appropriate to the size and weight of the individual
    • Assessing the bariatric individual
    • Bed selection (appropriate size and weight capacity specifications and adequate support surfaces)
    • Equipment selection (wheelchairs, cushions, bariatric walkers, overhead trapezes)
    • Repositioning
    • Pressure ulcer care: nutritional support, pressure ulcer assessment, monitoring wound dressing materials
  2. Critically ill individuals
    • Evaluating support surfaces
    • Repositioning and repositioning schedules
    • Prone positioning
    • Lateral rotation
    • Nutrition support (specific additional nutrition interventions are not recommended for routine use)
  3. Older adults
    • Assessment and care planning
    • Care of vulnerable aged skin
    • Repositioning
    • Considerations for medical device related pressure ulcers
  4. Individuals in the operating room
    • Consideration of additional risk factors specific to individuals undergoing surgery
    • Use of a high-specification reactive or alternating pressure support surface on the operating table
    • Positioning the individual in such a way as to reduce the risk of pressure ulcer development during surgery
    • Ensuring that the heels are free of the surface of the operating table
    • Positioning the knees in slight flexion when offloading the heels
    • Considering pressure redistribution prior to and after surgery
  5. Individuals in palliative care
    • Comprehensive assessment of the individual
    • Pressure redistribution
    • Nutrition and hydration
    • Pressure ulcer care
    • Pain, odor, and exudate management for comfort
    • Resource assessment
  6. Pediatric individuals
    • Age-appropriate risk assessment that considers risk factors of specific concern for pediatric and neonate populations
    • Assessment and monitoring of skin
    • Nutritional management
    • Selection of support surfaces
    • Repositioning
  7. Individuals with spinal cord injury
    • Preventing pressure ulcers during the acute care phase
    • Seating surfaces (wheelchair/seating support surface and associated equipment)
    • Seating and support surfaces for individuals with existing pressure ulcers
    • Repositioning and mobility
    • Electrical stimulation for preventing pressure ulcers
    • Education and the individual's involvement in care

Note: The pressure ulcer clinical practice guideline was divided into four individual summaries. Additional interventions are discussed in the following summaries:

Major Outcomes Considered

  • Incidence of facility-acquired pressure ulcers
  • Development of a new pressure ulcer
  • Category/Stage I or greater pressure ulcer or equivalent
  • Validity of risk assessment tools
  • Effectiveness of prophylactic measures

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Identifying the Evidence

Databases

The Guideline Development Group (GDG) identified clinical questions to guide literature searches. To identify the scientific literature on pressure ulcer prevention and treatment, several electronic databases were consulted, including: PubMed, CINAHL, MEDLINE, EMBASE, Scopus, Biomedical Reference Collection, Health Business Elite, The Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials, Health Technology Assessment, and AMED databases. As the guideline builds on a previously published body of evidence, the search dates for this update were 1st January 2008 through 1st July 2013. Some Small Working Groups (SWGs), particularly those that were addressing evidence in topics newly introduced in this version of the guideline, used different inclusion dates, as per the inclusion and exclusion criteria detailed below.

Search Strategy

A sensitive search strategy was developed and made available on the guideline website. The SWGs were permitted to conduct additional focused searches to ensure the full depth and breadth of their topic area has been covered.

Inclusion and Exclusion Criteria

All references retrieved by the electronic literature search were screened by the methodologist (during the interim period between guideline development periods from 2009 to 2012) based on the following inclusion criteria:

General Eligibility Criteria

Inclusion criteria:

  • The articles must be primarily focused on pressure ulcer prevention, risk assessment, or pressure ulcer treatment in human subjects.
  • The articles must have been published in a peer reviewed journal.
  • An abstract must be available.
  • The studies should have used one of the following designs: randomized controlled trials (RCTs), controlled clinical trials (CCTs), quasi-experimental studies, cohort studies, cross-sectional studies, survey studies, prevalence or incidence studies, case-control studies, and case series.
  • At least ten subjects must have been included in any case series.
  • Systematic reviews or meta-analyses were included if they used the Cochrane methodology or met at least 9 out of 11 quality criteria of the critical appraisal tool Assessment of Multiple Systematic Reviews (AMSTAR).
  • SWG members reviewed, analyzed and used the original articles cited in systematic reviews and meta-analyses as the basis for guideline recommendations and systematic reviews were cited as additional supporting evidence. In order to rate the level of evidence, the quality of the systematic review was assessed, using the AMSTAR checklist. Meta-analyses should not be equated with systematic reviews.
  • Studies using established qualitative methodologies were considered as appropriate to the research question.
  • There was no restriction on the basis of the language of a study. However, studies published in languages other than English were required to indicate a high level of quality and unique data in the abstract report to warrant translation.

Exclusion criteria:

  • Non-systematic literature reviews, narrative papers, opinion, commentary and descriptive papers. Papers falling into this category were used only to support expert opinion as required.
  • Case series with less than 10 participants.
  • Conference abstracts or other short papers with insufficient detail to enable an appraisal of the study methodology.
  • Duplicate reports of research.
  • Computational modeling and other research conducted in non-human subjects.
  • Systematic reviews and meta-analyses that do not meet at least 9 of 11 criteria on the AMSTAR checklist.
  • Papers without a substantial focus on pressure ulcer prevention or treatment or risk assessment.
  • Foreign language studies for which the abstract does not indicate a high level study (i.e., at least Level 2) with unique data.

Eligibility Criteria for Research Reporting on Quality Improvement and Education

In addition to the criteria outlined above, additional inclusion criteria were:

  • Articles with a time series design with at least three outcome measurement time points.
  • Project should be institution-wide (i.e., not individual units). Projects in individual units could be covered in special population sections as appropriate (e.g., pediatrics, critical care).
  • Outcomes should be incidence or facility-acquired pressure ulcer rates.
  • Quality improvement projects should be described in sufficient detail to enable replication (i.e., specific methods used, barriers and facilitators).

Exclusion criteria:

  • Publications before January 2008 and after December 2012 were not appraised for this guideline section.

Eligibility Criteria for Research Reporting on Risk Factor for Pressure Ulcers

The systematic review by Coleman et al., 2013 (see the "Availability of Companion Documents" field) was used as a basis for literature selection to identify patient characteristics that increase the probability of pressure ulcer development. This was supplemented by a search for literature published from 31st March 2010 to July 1st 2013.

Refer to Appendix 1: Methodology in the original guideline document for inclusion and exclusion criteria used by Coleman et al. (see also the Methodology addendum [see the "Availability of Companion Documents" field]).

Eligibility Criteria for Research Reporting on Risk Assessment Tools

Additional inclusion criteria for papers addressing the reliability of risk assessment tools were:

  • Risk assessment tools are completed by qualified health professionals.
  • The research involved comparing pressure ulcer risk assessment tool scores of different raters using the same scale (interrater) or comparing pressure ulcer risk assessment tool scores of the same raters using the same scale at different times (intrarater).

The systematic review by Chou et al., 2013 (see the "Availability of Companion Documents" field) was used as a basis for literature selection related to identifying the validity of risk assessment tools. This was supplemented by literature published after the end of the review period (i.e., from 31st July 2012 to 1st July 2013).

Additional inclusion criteria for papers addressing the validity of risk assessment tools were:

  • Prospective study design (i.e., RCTs, CCT, prospective cohort study).
  • Reporting the evaluation of one or more risk assessment tool in the prevention of pressure ulcers (analytical methods).
  • Follow-up data included on at least 75% of participants.
  • Participants were aged over 18 years.
  • Individuals were assessed systematically for the development of new pressure ulcers (e.g., all participants have baseline skin assessment and at follow-up intervals suitable to identify new pressure ulcers in the study population). Assessment only at baseline and discharge is not a suitable follow-up to detect all new pressure ulcers.
  • Risk assessment tools are completed at baseline.
  • Outcome clearly defined as development of a Category/Stage I or greater pressure ulcer.
  • Analysis methods: sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), relative risk and area under the receiver operating characteristic (AUROC) curve.

Exclusion criteria:

  • Data used to generate the risk assessment tool are the same data used for the calculation of validity measures.

Number of Source Documents

A total of 356 papers were newly included in the guideline after the appraisal of papers in the updated literature search (search dates: 1st January 2008 through 1st July 2013).

As the 2014 guideline builds on the 2009 guideline, this number does not include papers that were already identified and included in the 2009 guideline.

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

Level of Evidence for Intervention Studies

Level 1 Randomized trial(s) with clear-cut results and low risk of error OR systematic literature review or meta-analysis according to the Cochrane methodology or meeting at least 9 out of 11 quality criteria according to Assessment of Multiple Systematic Reviews (AMSTAR) appraisal tool
Level 2 Randomized trial(s) with uncertain results and moderate to high risk of error
Level 3 Non randomized trial(s) with concurrent or contemporaneous controls
Level 4 Non randomized trial(s) with historical controls
Level 5 Case series with no controls. Specify number of subjects

Levels of Evidence for Diagnostic Studies

Level 1 Systematic review of high quality (cross sectional) studies according to the quality assessment tools with consistently applied reference standard and blinding
Level 2 Individual high quality (cross sectional) studies according to the quality assessment tools with consistently applied reference standard and blinding among consecutive persons
Level 3 Non-consecutive studies, or studies without consistently applied reference standards
Level 4 Case-control studies, or poor or non-independent reference standard
Level 5 Mechanism-based reasoning, study of diagnostic yield (no reference standard)

Levels of Evidence for Prognostic Studies

Level 1 Systematic review of high quality (longitudinal) prospective cohort studies according to the quality assessment tools
Level 2 A prospective cohort study
Level 3 Analysis of prognostic factors amongst persons in a single arm of a randomized controlled trial
Level 4 Case-series or case-control studies, or poor quality prognostic cohort study, retrospective cohort study
Level 5 Not applicable

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Direct vs. Indirect Evidence

Studies of pressure ulcers in humans and individuals at risk of, or with existing pressure ulcers were considered 'direct evidence' and were required to support an A or B 'strength of evidence' rating (see the "Rating Scheme for the Strength of the Recommendations" field). When studies of pressure ulcers in humans at risk of, or with existing pressure ulcers were not available, studies in normal human subjects, human subjects with other types of chronic wounds, laboratory studies using animals, or computational models were used as indirect evidence to support recommendations with a C 'strength of evidence' rating.

Evaluating the Evidence

Appraisal of Methodological Quality

The methodological quality of each study was evaluated by two members of the Small Working Groups (SWGs). Where large discrepancy of opinion was noted (such that the paper's overall quality was rated differently by the two reviewers), a third reviewer evaluated the paper. The methodologist completed a quality check on a random sample of 80% of the critical appraisals for papers selected for potential appraisal, including those papers that the SWG assessed as not meeting inclusion criteria.

The methodological quality of each study was assessed by two reviewers using methodology checklists that were based on tools developed by the Scottish Intercollegiate Guidelines Network. Evaluation of study quality focused on the internal and external validity of the studies. The following quality criteria were considered: internal validity of the study; clear and appropriate research question(s); selection of subjects; allocation; baseline comparability; outcomes; blinding; confounding factors; statistical analysis; overall assessment of the study; and bias. A range of critical appraisal tools were used based on different types of study design: cross-sectional/survey/prevalence studies, case-control studies, cohort studies, randomized controlled trials (RCTs), quasi-experimental studies, diagnostic studies, SQUIRE guideline checklist for quality improvement papers, Critical Appraisal Skills Program (CASP) Qualitative Research Checklist, AMSTAR criteria for systematic reviews.

Each criterion on the critical appraisal forms was assessed as being fully met (++), partially met (+), not met/not reported/unclear (—), or not applicable (NA). Studies were generally described as high, moderate, or low quality using the following criteria:

  • High quality studies: fully met at least 80% of applicable criteria
  • Moderate quality studies: partially or fully met at least 70% of applicable criteria
  • Low quality studies: did not partially or fully met at least 70% of applicable criteria

Appraisal of Methodological Quality for Risk Factor Papers

In the absence of guidelines for the quality assessment of risk factor studies, Coleman et al., 2013 (see the "Availability of Companion Documents" field) used an assessment framework based upon guidelines for assessing quality and risk of bias in prognostic studies and methodological considerations in the analysis, meta-analysis and publication of observational studies. Each study was appraised using the method described by Coleman et al. and the following factors were considered:

  • Baseline characteristics are adequately described
  • Study attrition: clear definition of risk factors
  • Continuous variables used or appropriate cut-points for continuous data
  • Risk factor measurement valid and reliable
  • Method/sampling of measurement used for all individual patients
  • Appropriate imputation methods
  • Appropriate classification for outcome
  • Potential confounders accounted for in study design
  • Potential confounders accounted for in analysis
  • No selective reporting

See Appendix 1 in the original guideline document and the Methodology addendum (see the "Availability of Companion Documents" field) for more information on appraisal of methodological quality for risk factor papers.

Level of Evidence

The level of evidence for individual intervention studies was noted for each study containing direct evidence, using a classification system adapted from Sackett, 1989 (see the "Rating Scheme for the Strength of the Evidence" field).

Levels of evidence are typically applied to intervention studies (e.g., RCTs, controlled clinical trials [CCTs], or case series studies) because these types of studies are regarded as most important knowledge sources for clinical decision making. However, there are many more study designs (e.g., epidemiological or descriptive studies) that provide valuable evidence to guide practice, yet cannot be classified with an intervention-based level of evidence system.

Studies on diagnostic and prognostic validity of pressure ulcer risk and pressure ulcer classification form an important body of knowledge in pressure ulcer management that should be appraised independently from intervention studies. Diagnostic accuracy studies are studies in which results of index tests are compared with results from reference standards at the same point in time. Therefore, cross-sectional designs are needed to establish the concurrent existence of both index test and reference standard results. Most studies in pressure ulcer risk research are not diagnostic accuracy studies according to this widely agreed upon definition, because the measured pressure ulcer risk is often compared with subsequent pressure ulcer occurrence. These designs resemble those of prognostic studies or diagnostic accuracy studies with imperfect reference standards.

Comparable to different phases of intervention research phases of diagnostic and prognostic research can also be distinguished. In diagnostic research, Phase I and II studies focus on differentiation between individuals with the target from those without. Phase III studies are typical diagnostic accuracy studies whereas phase IV research investigates the clinical impact of diagnostic procedures. Prognostic studies are comparable with diagnostic accuracy studies with the difference that based on factors or diagnostic cues future events are predicted. These types of studies are typically used to develop prognostic models. Prognostic models (e.g., pressure ulcer risk assessment tool scores), are used to predict the probability of future events in individuals or groups.

Test accuracy and validity estimates are only surrogate measures for clinical effectiveness. The clinical effectiveness of diagnostic test procedures can only be adequately investigated by diagnostic RCTs. In case of diagnostic or prognostic RCTs the described level of evidence hierarchy of intervention studies is used.

Corresponding "level of evidence" hierarchies for diagnostic and prognostic accuracy and many other studies have been proposed and have been adopted by the Guideline Development Group (GDG) in the guideline update (see the "Rating Scheme for the Strength of the Evidence" field).

The technical documents summarizing critical appraisals of included studies are made available at the guideline website (see the "Availability of Companion Documents" field).

Data Extraction

The full papers of selected references were obtained and made available to the relevant SWGs on a web-based (GoogleDocs) platform.

A data extraction template was used to extract relevant data from individual papers, including study design, description of participants, study groups and interventions, outcome measures, length of follow up, study results, and comments and limitations. Preliminary data extraction tables were prepared in the interim development period (i.e., period between the publication of the 2009 guideline and the commencement of the 2014 guideline development period).

The members of the SWGs were provided with the preliminary data extraction tables for checking, expanding on details and adding studies that had not yet undergone data extraction. The methodologist completed a quality check of a random sample of 80% of the completed evidence tables and the GDG completed a quality check of a random sample of 10% of the completed evidence tables.

The technical documents summarizing data extraction of included studies are made available at the guideline website (see the "Availability of Companion Documents" field).

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Participants

All members of the development team were screened for experience, expertise and potential conflicts of interest. In the interest of transparency, all guideline developers were asked to complete a form identifying potential conflicts of interest that covered the guideline review period.

Guideline Development Group

This second edition of the guideline was conducted by European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA). The Pan Pacific Alliance consists of the Australian Wound Management Association Incorporated (AWMA), the New Zealand Wound Care Society (NZWCS), the Hong Kong Enterostomal Therapist Society and the Wound Healing Society of Singapore.

The Guideline Development Group (GDG) determined and monitored each step of the guideline development process, as well as managing guideline dissemination strategy. Each of the three partner organizations nominated four representatives each to form the 12 member GDG. From its nominated representatives, each partner organization appointed a Chair. The three partner organizations each had four votes during joint deliberations, with the majority deciding. Examination of the evidence and consensus building preceded all voting. Minority opinions were represented in meeting minutes. A full description of the GDG role is available on the guideline website.

A nonvoting observer from the Japanese Society of Pressure Ulcers (JSPU) attended GDG meetings during the 2014 revision process, with the option to join the GDG for the next revision.

Small Working Groups

The guideline content was divided into working topic areas, and Small Working Groups (SWGs) were formed to review the evidence available for each topic. The SWG members were selected by each participating organization based on an experience and expertise. Representatives of industry were excluded from SWGs. The SWGs were formed based on the principle of equal contribution from all participating organizations. A full description of the SWG role is available on the guideline website. A total of 104 SWG members contributed to the guideline development process, with many members contributing to more than one SWG.

Guideline development was an iterative process, with GDG and SWG members maintaining communication via the methodologist. Evidence summaries and draft recommendations developed by the SWGs were reviewed by the GDG for:

  • Comprehensiveness and accuracy of literature reviews
  • Methodological rigor in evidence analysis and application to clinical practice
  • Clarity and appropriateness of recommendations for an international audience

Methodologist

The guideline process was overseen by an experienced guideline methodologist. The methodologist assisted the SWG members in implementing the documented methodology, appraising and summarizing the new literature, revising the 2009 guideline recommendations and developing new recommendations, and presenting the evidence. The methodologist also managed the confidential consensus voting process (Grading of Recommendations Assessment, Development and Evaluation [GRADE]). The methodologist provided a link between the GDG and the SWG, managing communication and maintaining progress. The methodologist attended GDG and SWG meetings, but did not participate in GDG voting.

Stakeholders

The entire process of developing the guideline was made available to stakeholders on the guideline website. Anyone was invited to register as a stakeholder, either as an individual or as a representative for a society/organization. All members of the EPUAP, NPUAP and PPPIA were invited to register as stakeholders and participate in this process. When new sections of the guideline were made available on the guideline website, registered stakeholders were notified by electronic mail. The GDG reviewed all stakeholder comments and any additional evidence recommended by stakeholders before approving final recommendations.

Drafting/Revising Recommendations

Based on the identified, appraised and summarized empirical evidence recommendations were formed. Each SWG formulated conclusions about the body of available evidence based on the evidence tables and critical appraisals and levels of evidence. Evidence tables from previous guidelines were also made available to SWGs to ensure the full body of scientific literature was reviewed. A first draft of recommendations was developed by the respective SWGs using the 2009 guideline recommendations as a guide. The GDG reviewed the draft recommendations, making revisions as necessary.

To ensure uniformity and internal consistency in the final guideline, the GDG provided the following guidance.

  • Each recommendation should start with an action verb and be a simple, short, direct, declarative statement, free of jargon.
  • Multiple complex recommendations were broken down into a series of smaller, discrete recommendations.
  • The SWGs were advised to start with broad, directive statements, followed by subsequent statements with more detail (how, when, how often).
  • Recommendations should be specific and unambiguous.
  • When available, information on health benefits, side effects and risks should be provided.
  • Spelling will be based on the conventions of American English.

The GDG reviewed all recommendations to ensure the wording of the recommendations accurately translated available research into best practice while being sensitive to the many different individual cultures and professional standards represented among the international audience for these guidelines.

The term "individual" was selected to describe the patient, client, resident, or person with a pressure ulcer or at risk for a pressure ulcer. The terms "health professional" and "interprofessional team" were used when referring to health professional providing professional health care services to the individual. The disciplines of professionals performing a given service may vary from country to country based on the laws and regulations governing health care providers. Products available in one country may not be available in another. Generic names were used when referring to drugs and other products.

Assigning Strength of Evidence Ratings

'Strength of evidence' ratings were assigned to recommendations (see the "Rating Scheme for the Strength of the Recommendations" field). This rating identifies the strength of cumulative body of evidence supporting each recommendation.

A 'strength of evidence' rating of A requires Level 1 studies conducted in individuals with pressure ulcers or at risk for pressure ulcers. This rating is consistent with recommendations derived using the Cochrane methodology. 'Strength of evidence' ratings of B required Level 2, 3, 4, and/or 5 studies in these populations. Recommendations supported by A and B 'strength of evidence' ratings were developed first. This strategy provided recommendations with very direct evidentiary support. Where the guideline was considered to lack the breadth and depth of guidance necessary to provide care, additional recommendations based on expert opinion and/or indirect evidence and given a 'strength of evidence' rating of C were developed to fill the evidence gap.

The 'strength of evidence' supporting the recommendation is not the same as the 'strength of the recommendation'. For example, there are no randomized controlled trials in individuals with pressure ulcers that evaluate debridement compared to no debridement. Therefore, this recommendation would have a relatively low 'strength of evidence' supporting the recommendation, yet the recommendation is strongly recommended in many clinical situations based on evidence from studies of other types of chronic wounds, proof of principle from basic science research, and/or expert opinion.

In this guideline, evidence gaps have been explicitly identified. Systematic literature reviews were conducted to identify indirect evidence from studies of normal subjects, studies with intermediate or surrogate outcomes, studies of humans with other types of chronic wounds, and animal studies. For many recommendations, indirect evidence may be identified to support C 'strength of evidence' ratings. In the absence of indirect evidence, consensus from previous guidelines or expert opinion may support C 'strength of evidence' ratings, providing a broader base of expert opinion than that available in the SWGs and GDG. The SWG members were encouraged to evaluate previous guidelines for quality using the AGREE II Tool. All recommendations, including those supported solely by expert opinion were reviewed by stakeholders.

Summarizing Supporting Evidence

The SWGs summarized the evidence supporting each recommendation. An explicit link between the recommendation and supporting evidence was expected. The strengths and limitations of this body of evidence were clearly described. All recommendations with a 'strength of evidence' rating of A or B required an explicit summary of one or more studies conducted with human subjects with pressure ulcers or at risk for pressure ulcer development. The 'level of evidence' for each study is also identified in the summary.

The summary statements for recommendations with a 'strength of evidence' of C clarify whether the recommendation was supported by:

  • Indirect evidence from studies of normal subjects
  • Studies with intermediate or surrogate outcomes
  • Studies of humans with other types of chronic wounds, and animal studies or other basic bench research
  • Expert opinion supported by previous evidence-based guidelines
  • The expert opinion of the SWG and GDG members as reviewed by international stakeholders

Evidence gaps identified in these summary statements serve as an agenda for future research efforts.

Assigning Strength of Recommendation Grades

The recommendations are rated based on their importance and their potential to improve individual patient outcomes. The 'strength of recommendation' is the extent to which a health professional can be confident that adherence to the recommendation will do more good than harm. The grading of importance is not necessarily related to the strength of internal or external evidence. The overall aim is to help health professionals to prioritize interventions. See the original guideline document for points to be considered in grading the strength of recommendations.

The 'strength of recommendation' grades were achieved via a formal consensus process using the GRADE grid (see Table 5 in Appendix 1 in the original guideline document and in the Methodology addendum [see the "Availability of Companion Documents" field]). In this consensus process all SWG and the GDG members were invited to take part, each voting on every recommendation in the guideline. The consensus voting process (GRADE) was conducted on the website. Each guideline development team member was provided with a unique identification. Before commencing in the GRADE process, the methodology was outlined, including the considerations to be made in casting a vote. The participant was required to nominate their understanding of the procedure before commencing, or to request further information.

See the "Rating Scheme for the Strength of the Recommendations" field and the original guideline document for additional information on assigning strength of recommendation grades.

Rating Scheme for the Strength of the Recommendations

Strength of Evidence Rating

A The recommendation is supported by direct scientific evidence from properly designed and implemented controlled trials on pressure ulcers in humans (or humans at-risk for pressure ulcers), providing statistical results that consistently support the guideline statement (Level 1 studies required).
B The recommendation is supported by direct scientific evidence from properly designed and implemented clinical series on pressure ulcers in humans (or humans at-risk for pressure ulcers), providing statistical results that consistently support the recommendation (Level 2, 3, 4, 5 studies).
C The recommendation is supported by indirect evidence (e.g., studies in normal human subjects, humans with other types of chronic wounds, animal models) and/or expert opinion.

Strength of Recommendation Grade

Recommendation Description Implication
Do it (Strong recommendation for using an intervention) Indicates a judgment that most well informed people would make. For patient consumers—Most people would want the recommended course of action and only a small proportion would not.
For health professionals—Most people should receive the intervention. If health professionals choose not to follow the recommendation, they should document their rationale.
For quality monitors—Adherence to this recommendation could be used as a quality criterion or performance indicator.
Don't do it (Strong recommendation against using an intervention)
Probably do it (Weak recommendation for using an intervention) Indicates a judgment that a majority of well informed people would make, but a substantial minority would not. For patient consumers—Most people would want the suggested course of action, but many would not.
For health professionals—Examine, and be prepared to discuss, the evidence with patients, as well as their values and preferences.
For quality monitors—Clinicians' discussion and consideration of pros and cons of the intervention, and documentation of discussion, could be used as a quality indicator.
Probably don't do it (Weak recommendation against using an intervention)
No specific recommendation Trade-offs between risk and benefit unclear or lack of agreement between voting participants. The advantages and disadvantages are equivalent; and/or the target population has not been identified; and/or there is insufficient evidence on which to formulate a strength of recommendation.

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

Stakeholders

The entire process of developing the guideline was made available to stakeholders on the guideline website. A stakeholder is someone who has interest in pressure ulcers and wishes to contribute to the guideline by reading the methodology, search strategies, references under consideration, and draft recommendations, ensuring that all relevant evidence had been included and commenting on the draft guideline within the timeframes allowed. All members of the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) were invited to register as stakeholders and participate in this process.

In 2009, a total of 903 individuals and 146 societies/organizations registered as stakeholders. These stakeholders were all invited to register as stakeholders for the 2014 guideline. Additionally, patient representative organizations were also invited to participate in the stakeholder review process to provide a consumer perspective. A total of 988 individuals were formally invited to register as stakeholders, and many more received information about the process through colleagues and organizations. A total of 698 individuals registered as stakeholders to provide feedback as an individual or in representation of a society/organization.

When new sections of the guideline were made available on the guideline website, registered stakeholders were notified by electronic mail. The Guideline Development Group (GDG) reviewed all stakeholder comments and any additional evidence recommended by stakeholders before approving final recommendations.

Final Review and Recommendations

Following review and approval of individual recommendations, the methodologist and the GDG reviewed all guideline documents for internal consistency, logical coherence and adherence to the guideline methodology. Based on this final review, the GDG will provide a global assessment of the strengths and limitations of the body of evidence supporting the guideline and recommendation for future research.

Type of Evidence Supporting the Recommendations

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

Potential Benefits

Appropriate prevention and management of individuals at risk of and with pressure ulcers in special population groups

Potential Harms

  • Sudden change in position, changes in position greater than 30° elevation, and use of the prone position may result in hypotension and/or hypoventilation in older individuals.
  • Prophylactic dressings should be selected and implemented with caution in older adults due to their thin and often fragile skin.

Qualifying Statements

The recommendations in this guideline are a general guide to appropriate clinical practice, to be implemented by qualified health professionals subject to their clinical judgment of each individual case and in consideration of the patient consumer's personal preferences and available resources. The guideline should be implemented in a culturally aware and respectful manner in accordance with the principles of protection, participation and partnership.

Limitations and Appropriate Use of This Guideline

  • Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical conditions. The recommendations may not be appropriate for use in all circumstances.
  • The decision to adopt any particular recommendation must be made by the health care professional in light of available resources and circumstances of the individual patient. Nothing contained in this guideline is to be considered medical advice for specific cases.
  • Because of the rigorous methodology used to develop this guideline, the Guideline Development Group members believe that the research supporting these recommendations is reliable and accurate. Every effort has been made to critically appraise the research contained within this document. However, they do not guarantee the reliability and accuracy of individual studies referenced in this document.
  • This guideline is intended for educational and informational purposes only.
  • This guideline contains information that was accurate at the time of publication. Research and technology change rapidly and the recommendations contained in this guideline may be inconsistent with future advances. The health care professional is responsible for maintaining a working knowledge of the research and technological advances that may affect his or her clinical decision making.
  • Generic names of products have been provided. Nothing in this guideline is intended as an endorsement of a specific product.
  • Nothing in this guideline is intended as advice regarding coding standards or reimbursement regulations.
  • The guideline does not seek to provide full safety and usage information for products and devices; however commonly available safety and usage tips have been included. Adverse events reported in the included research have been reported in the evidence summaries and caution statements. All products should be used according to manufacturer's directions.

Description of Implementation Strategy

The newly introduced implementation section of the guideline addresses systems and strategy at an organization and professional level that are required for effective implementation of the clinical recommendations in this guideline. This includes sections addressing implementation strategy, health professional education, recommendations specifically for patient consumers and their caregivers, and quality indicators for monitoring guideline implementation.

Facilitators, Barriers and Implementation Strategy

This section of the guideline provides a review of quality improvement research published from 1st January, 2008 to 31st December, 2012. Quality of evidence in this field is extremely varied, and the Small Working Group (SWG) narrowed the research by seeking evidence of sustained effectiveness of reproducible interventions. Assessment of potential barriers and facilitators to guideline implementation, including education level of staff and appropriate equipment is essential prior to the introduction of a pressure ulcer prevention protocol. The evidence supporting practical strategies including nurse-led quality improvement, introduction of wound care specialists and awareness campaigns is presented.

Health Professional Education

Negative attitudes and lack of knowledge are common barriers to using guidelines in clinical practice. This section of the guideline provides a review of research on the effectiveness of strategies related to health professional education published from 1st January, 2008 to 31st December, 2012. Recommendations on the format, content and evaluation of education programs are made.

Patient Consumers and Their Caregivers

The patient consumer and his or her informal caregivers play an important role in pressure ulcer prevention. Knowledge of pressure ulcers and their prevention is important, and requires a special emphasis in those at high risk. This section of the guideline discusses responsibilities of the patient consumer to attain information and work with health professionals in order to prevent and treat pressure ulcers. The section also provides guidance on the selection and maintenance of equipment.

Quality Indicators for This Guideline

Monitoring of practice is an important component of continuous quality improvement. The quality indicators identified in this section of the guideline are intended for auditing the implementation of this clinical guideline in practice. The identified quality indicators are those that are considered important indicators of successful implementation of the guideline and delivery of quality pressure ulcer prevention and treatment. The indicators could be used by organizations who introduce the evidence-based practices recommended within this guideline, and may be measured in conjunction with other quality indicators (e.g., those associated with facility accreditation) to determine progress in provision of quality care and identify areas for improvement.

See the "Implementing the Guideline" section of the original guideline document for specific implementation recommendations.

Implementation Tools

Audit Criteria/Indicators

Quick Reference Guides/Physician Guides

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

End of Life Care

Getting Better

Living with Illness

Staying Healthy

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Special populations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel; 2014. p. 209-52. [202 references]

Adaptation

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

Date Released

2009 (revised 2014)

Guideline Developer(s)

European Pressure Ulcer Advisory Panel - Independent Expert Panel

National Pressure Ulcer Advisory Panel - Independent Expert Panel

Pan Pacific Pressure Injury Alliance - Professional Association

Source(s) of Funding

The National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) gratefully acknowledge the contributions of the following individuals and groups for financially supporting the presentation and dissemination of the guideline. All financial contributions were made after the guideline development phase and in no way influenced the development of the guideline or its final content. Financial contributions are being used for the printing and dissemination of the guideline and associated educational products. The following companies provided unrestricted education grants:

Diamond Level Sponsors ($20,000 or greater)

  • EHOB, Inc.
  • Smith & Nephew PLC

Platinum Level Sponsors ($10,000 to $19,999)

  • ArjoHuntleigh Inc.
  • Mölnlycke Health Care

Gold Level Sponsors (up to $9,999)

  • Sage Products LLC

Guideline Committee

Guideline Development Group (GDG)

Small Working Group (SWG)

Composition of Group That Authored the Guideline

National Pressure Ulcer Advisory Panel (NPUAP) Guideline Development Group Members: Diane Langemo, PhD, RN, FAAN (NPUAP Chair), Professor Emeritus, University of North Dakota College of Nursing, Grand Forks, ND, USA; Janet Cuddigan, PhD, RN, CWCN, FAAN, Associate Professor, University of Nebraska Medical Center College of Nursing, Omaha, NE, USA; Laurie McNichol, MSN, RN, GNP, CWOCN, CWON-AP, Clinical Nurse Specialist/WOC Nurse, Cone Health, Greensboro, North Carolina, USA; Joyce Stechmiller, PhD, ACNP-BC, FAAN, Associate Professor and Chair, Adult and Elderly Nursing, University of Florida, College of Nursing, Gainesville, FL, USA

European Pressure Ulcer Advisory Panel (EPUAP) Guideline Development Group Members: Lisette Schoonhoven, PhD (EPUAP Chair), Senior Researcher Nursing Science, Radboud University Medical Center, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands, Associate Professor, University of Southampton, Faculty of Health Sciences, UK; Michael Clark, PhD, Professor in Tissue Viability, Birmingham City University, Birmingham, UK, Director, Welsh Wound Network, Welsh Wound Innovation Centre, Pontyclun, Wales, UK; Jan Kottner, PhD, Scientific Director Clinical Research, Clinical Research Center for Hair and Skin Science, Department of Dermatology and Allergy, Charité-Universitätsmedizin, Berlin, Germany; Cees Oomens, PhD, Ir, Associate Professor, Biomedical Engineering Department, Eindhoven University of Technology, Eindhoven, The Netherlands

Pan Pacific Pressure Injury Alliance (PPPIA) Guideline Development Group Members: Keryln Carville, PhD, RN (PPPIA Chair), Professor, Primary Health Care and Community Nursing, Silver Chain Group and Curtin University, Western Australia, Australia; Pamela Mitchell, MN, RN, PGDipWHTR (Wales), Clinical Nurse Consultant, Wound Management, Christchurch Hospital, Christchurch, New Zealand; Siu Ming Susan Law, BScN, MScN, RN, RM,ET, Nurse Consultant (Wound Management), Princess Margaret Hospital, Lai Chi Kok, Kowloon, Hong Kong; Ai Choo Tay, BN, Oncology Nursing, CWS, Senior Nurse Clinician, Singapore General Hospital, Singapore, Republic of Singapore

Japanese Society of Pressure Ulcers Observer: Takafumi Kadono, MD, PhD, Associate Professor, Department of Surgical Science, University of Tokyo, Tokyo, Japan

Methodologist and Editor-in-Chief: Emily Haesler, BN, PGDipAdvNursing, Honorary Associate, Department of Nursing and Midwifery, La Trobe University, Victoria, Australia, Visiting Fellow, Academic Unit of General Practice, Australian National University, Canberra, Australia

Small Working Group Members (Special Populations)

Bariatric Individuals: Mary Ellen Posthauer (Leader), Jeannie Donnelly and Tracy Nowicki

Critically Ill Individuals: Jill Cox (Co-leader), Ang Shin Yuh (Co-leader), Maarit Ahtiala, Paulo Alves, and Alison Stockley

Older adults: Tracey Yap (Leader), Jill Campbell, Emily Haesler and Susan Kennerly

Individuals in the Operating Room: David Huber (Leader), Steven Black, Ray Samuriwo, Susie Scott-Williams and Geert Vanwalleghem

Individuals in Palliative Care: Trudie Young (Leader), Wayne Naylor and Aletha Tippett

Pediatric Individuals: Emily Haesler, Mona Baharestani, Carmel Boylan, Holly Kirkland-Walsh and Wong Ka Wai

Individuals with Spinal Cord Injury: Emily Haesler (Leader), Amy Darvall, Bernadette McNally and Gillian Pedley

Financial Disclosures/Conflicts of Interest

All guideline developers were required to complete a Conflict of Interest Disclosure form in order to be involved in the guideline development process and to receive acknowledgement as a member of the guideline development team within the guideline. The Guideline Development Group (GDG) and Small Working Group (SWG) members were required to be free of major competing (or conflicting) interests and were requested to disclose the nature of any minor competing interest and recuse themselves from related decisions. Additionally, the SWG members were instructed that appraisal of a study in which he or she was an author or significantly involved in the study undergoing appraisal presents a potential conflict of interest, and other SWG members undertook the appraisal.

See the "Methodology Addendum" companion document for more information on conflict of interest and all disclosures (see the "Availability of Companion Documents" field).

Guideline Status

This is the current release of the guideline.

This guideline updates previous versions: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Pressure ulcer prevention recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel; 2009. p. 21-50. [214 references]

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Pressure ulcer treatment recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel; 2009. p. 51-120. [432 references]

This guideline meets NGC's 2013 (revised) inclusion criteria.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase through the International Pressure Ulcer Guideline Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: quick reference guide. Emily Haesler (Ed.). Cambridge Media: Perth (Australia); 2014. 75 p. Electronic copies: Available from the International Pressure Ulcer Guideline Web site External Web Site Policy.
  • National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: methodology addendum. Emily Haesler (Ed.). Cambridge Media: Osborne Park (Australia); 2014. 36 p. Electronic copies: Available from the International Pressure Ulcer Guideline Web site External Web Site Policy.
  • Clinical practice guideline for pressure ulcer prevention and treatment. Literature identified in data base searches. 2013 Aug. 166 p. Electronic copies: Available from the International Pressure Ulcer Guideline Web site External Web Site Policy.
  • Prevention and treatment of pressure ulcers: technical documents: critical appraisal tables. 2014. 102 p. Electronic copies: Available from the International Pressure Ulcer Guideline Web site External Web Site Policy.
  • Prevention and treatment of pressure ulcers: technical documents: data extraction tables. 2014. 307 pages. Electronic copies: Available from the International Pressure Ulcer Guideline Web site External Web Site Policy.
  • Coleman S, Gorecki C, Nelson EA, Closs SJ, Defloor T, Halfens R, Farrin A, Brown J, Schoonhoven L, Nixon J. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013 Jul; 50(7):974-1003. Electronic copies: Available from the International Journal of Nursing Studies Web site External Web Site Policy.
  • Chou R, Dana T, Bougatsos C, Blazina I, Starmer A, Reitel K, Buckley D. Pressure ulcer risk assessment and prevention: comparative effectiveness. Comparative effectiveness review No. 87. (Prepared by Oregon Evidence-based Practice Center under Contract No. 290-2007-10057-I.) AHRQ Publication No. 12(13)-EHC148-EF. Rockville (MD): Agency for Healthcare Research and Quality; 2013 May. 358 p. Electronic copies: Available from the Agency for Healthcare Research and Quality (AHRQ) Web site External Web Site Policy.

In addition, quality indicators are available in the original guideline document.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 21, 2011. The information was verified by the guideline developer on May 4, 2011. This summary was updated by ECRI Institute on March 6, 2014 following the U.S. Food and Drug Administration advisory on Over-the-Counter Topical Antiseptic Products. This summary was updated by ECRI Institute on February 5, 2015. The updated information was verified by the guideline developer on March 1, 2015.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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