Pressure ulcers--management of pressure related tissue damage.

GRADES OF RECOMMENDATION

These Grades of Recommendation have been based on the JBI-developed 2006 Grades of Effectiveness (JBI 2006)

Grade A Strong support that merits application

Grade B Moderate support that warrants consideration of application

Grade C Not supported

Recommendations

* Optimal management requires comprehensive and accurate assessment of wound history, aetiology recurrence and characteristics regarding location, staging, size, base, exudates and condition of surrounding skin (Grade 13)

* Patients with a Grade 1-2 pressure ulcer should be placed on a high specification mattress or cushion with pressure reducing capabilities and be subject to very close observation of skin changes and a documented repositioning regime. If any deterioration occurs an alternating pressure or CLP system should be implemented (Grade B)

* Patients with Grade 3-4 pressure ulcers should be placed on an alternating pressure or CLP system (Grade B)

* Dressings (such as hydrocolloids) create an environment most optimal for wound healing (Grade B)

* Patients with pressure ulcers should actively mobilise, change their position independently or be repositioned as clinically indicated (Grade B)

Background

The management of pressure ulcers pose a significant problem in acute care and community health settings. There are substantial costs associated with treating an established pressure ulcer, for example in 1993 a 600 bed hospital in the UK estimated the cost of preventing and treating pressure ulcers varied between 600,000 [pounds sterling] and 3 million [pounds sterling] a year. It is estimated that the current annual cost for treating pressure ulcers in the UK is approximately 1.4 [pounds sterling]-2.1 billion, which is equivalent to 4% of the total National Health Service expenditure. Additionally, the patient with a pressure ulcer faces emotional and physical difficulties. They suffer pain, inconvenience, reduced quality of life, and often require extended contact with the health care system. Although prevention of pressure ulcers is optimal, the management of existing pressure ulcers focuses on quality care in the areas of wound dressing, use of appropriate support surfaces, repositioning, nutrition and surgery.

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Definition of terms

For the purposes of this information sheet the following definitions are used:

Alternating pressure (AP) surfaces--these surfaces mechanically vary the pressure beneath a patient, thereby reducing the duration of the applied pressure

Constant low pressure (CLP)--these surfaces aim to mould around the shape of a patient to redistribute pressure over a greater surface area

Pressure ulcer--an area of localised injury to the skin and/or underlying tissue, usually over a long prominence, as a result of pressure or pressure in combination with shear and/or friction (European Pressure Ulcer Advisory Panel 2003)

Objectives

The purpose of this Best Practice information sheet is to provide health care professionals with evidence based recommendations regarding the management of pressure sores.

Grades of Pressure Ulcer

A number of tools have been specifically developed to grade pressure ulcers. The classification system often referred to in the literature and recommended for use was developed by the European Pressure Ulcer Advisory Panel (see Table 1).

Guidelines Concerning Management

Assessment

Managing a patient with an existing pressure ulcer begins with an assessment of the patient entering the health care system. Following a global assessment of the patient, a specific assessment of the pressure ulcer that includes the aetiology and a detailed wound evaluation should be undertaken. The evidence suggests that the existence of a Grade i pressure ulcer is a significant risk factor for the development of a more severe pressure ulcer.

Support surfaces

Pressure relieving support surfaces aim to reduce the amount or duration of pressure between an individual and the support surface and there have been many studies comparing different support surfaces. Due to the many methodological limitations inherent in the studies it is not possible to recommend one support surface over another.

Consensus agreement, however, recommends that any patient with a Grade 1 or Grade 2 pressure ulcer should be placed on a high specification mattress or cushion with pressure reducing capabilities and be subject to very close observation of skin changes and a documented repositioning regime. Furthermore, if any deterioration occurs an alternating pressure or constant low pressure (CLP) system should be implemented. Patients with Grade 3-4 pressure ulcers should be placed on an alternating pressure or CLP system.

Dressing and topical agents

Currently, the literature provides insufficient evidence to indicate which dressings are the most effective in treating pressure ulcers. However, the choice of dressing or topical agent should be based on assessment of skin and ulcer condition, treatment objective, dressing characteristics, previous positive effect of particular dressing, dressing or a topical agent's indications and contraindications for use, risk of adverse events and patient preference.

Dressings that create an environment most optimal for wound healing (eg. hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, soft silicones) should be used in preference to basic dressing types (eg. gauze, paraffin gauze and simple dressing pads).

The potential positive effects of debridement in the management of pressure ulcers should be recognised and considered by clinicians.

Antimicrobial agents 

RCTs (randomised controlled trials) that focus on the effectiveness of antimicrobial agents were small and generally of poor methodological quality. Therefore there is insufficient evidence to indicate whether antimicrobials are effective in treating pressure ulcers. It is suggested that where patients are exhibiting systemic or clinical signs of infection, antimicrobial therapy should be considered.

Repositioning

Health care professionals routinely engage in interventions to reduce the effects of impaired mobility on the healing of pressure ulcers. The optimal frequency for this to occur in terms of patient benefit and use of resources, however, is not clear. The literature reports a range of timeframes for repositioning from two hourly to six hourly. Due to the lack of evidence the following recommendations are consensus-based:

* Patients with pressure ulcers should actively mobilise, change their position independently or be repositioned frequently

* Avoid positioning patients directly on pressure ulcers or bony prominences

* Frequency of repositioning should be determined by the individual patient's needs and the following factors should be considered; general health status of the patient, location of the ulcer, general skin assessment and acceptability to the patient.

Nutrition

It has been reported that malnutrition is positive[y correlated with pressure ulcer incidence and severity, however the evidence is inconclusive. The guideline suggested that nutritional support should be given to patients with identified nutritional deficiency and any support/supplementation be based on nutritional assessment using a recognised tool, general health status, patient preference and expert dietician and/or specialist input.

Surgery

Surgery is generally reserved to treat Grade 3-4 pressure ulcers. The current surgical management of pressure ulcers consists of debridement, which can be superficial and may or may not include the removal of bone tissue followed by flap coverage. Pressure ulcers can be surgically debrided and left as an open wound to heal, surgically closed with or without debridement or repaired using skin flaps or grafting. The literature consists of case reports, case series and retrospective chart reviews of variable quality. Therefore the effectiveness of surgery and optimal technique for the treatment of pressure ulcers is unclear.

Adjunct therapies

When conventional therapies have failed to make improvements in wound healing, adjunct therapies are being increasingly used.

However, the cost- and clinical effectiveness of many of these treatments have not been rigorously tested.

Topical negative pressure

One small trial with methodological limitations assessed topical negative pressure. The trial suggested that topical negative pressure may increase healing rates of pressure ulcers compared to sterile gauze dressings. The findings, however, must be treated with extreme caution and further research is required.

Electrotherapy and therapeutic ultrasound 

There is no evidence that electrotherapy or therapeutic ultrasound for the treatment of pressure ulcers is beneficial. However, the possibility of a beneficial or harmful effect cannot be discounted due to the small number of trials with small sample sizes and methodological weaknesses.

Electromagnetic therapy 

A meta-analysis of three trials assessing the effect of electromagnetic therapy demonstrated no benefit. It consisted of only 137 participants and further research is required before definitive recommendations can be made for this particular practice.

Conclusions

The best method of treatment for managing existing pressure ulcers remains unclear, but it is evident that reducing firstly their incidence and secondly, variability in treatment is necessary. Further well-designed, large scale research is required most urgently in the areas of risk of delayed healing/complications to healing, pressure ulcer assessment, support surfaces, use of antimicrobials, nutrition and surgery.

INFORMATION SOURCE

This Best Practice information sheet, which supersedes the JBI information sheet of the same title published in 1997, (JBI, 1997) is based on a clinical practice guideline developed by the Royal College of Nursing and National Institute for Health and Clinical Excellence (2005).

In addition this Best Practice information sheet has been reviewed by nominees of International Joanna Briggs Collaborating Centres:

Petra Brysiewicz, South African Centre for Evidence Based Nursing and Midwifery, School of Nursing, Faculty of Community and Development Disciplines, University of KwaZulu-Natal, South Africa.

Catherine Edgar, Bundoora Extended Care Centre, Bundoora, Victoria, Australia.

Peter Davis, School of Nursing, Nottingham University, Nottingham, UK.

Prof Samantha Pang, Hong Kong Centre EBN, Chinese University of Hong Kong, Hong Kong Special Administrative Region.

REFERENCES

Pearson, A., Wiechula, R., Court, A. and Lockwood, C. 2005, The JBI model of evidence-based healthcare. International Journal of Evidence-Based Healthcare 2005. 3(8):207-215.

The Joanna Briggs Institute. 1997. Pressure Sores--Part 2: management of pressure related tissue damage. Best practice: evidence-based practice information sheets for health professionals. 1(2):1-6.

The management of pressure ulcers in primary and secondary care. A clinical practice guideline. 2005. Royal College of Nursing and National Institute for Health and Clinical Excellence.

The Joanna Briggs Institute, Systematic reviews--the review process, levels of evidence. Available at: http://www.joannabriggs.edu,au/pubs/approach.php (accessed 2006).

This Best Practice information sheet presents the best available evidence on this topic. Implications for practice are made with an expectation that health professionals will utilise this evidence with consideration of their context, their client's preference and their clinical judgement. (Pearson et al 2005)

The Joanna Briggs Institute Margaret Graham Building, Royal Adelaide Hospital, North Terrace, South Australia, 5000 www.joannabriggs.edu.au ph: [phone] fax: [phone] email: [e-mail]

Published by Blackwell Publishing

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Table 1. Classification of pressure ulcer severity

Grade I     Non-blanchable erythema of intact skin.
            Discolouration of the skin, warmth, oedema,
            induration or hardness may also be indicators,
            particularly on individuals with darker skin.

Grade II    Partial thickness skin loss involving epidermis,
            dermis or both. The ulcer is superficial and presents
            clinically as an abrasion or blister.

Grade III   Full-thickness skin loss involving damage to or
            necrosis of subcutaneous tissue that may extend
            down to, but not through underlying fascia.

Grade IV    Extensive destruction, tissue necrosis or damage to
            bone, muscle or supporting structures with or
            without full-thickness skin loss.