New Practice Guidelines from ACP to Address Pressure Ulcers

In March, the American College of Physicians (ACP) published a set of evidence-based clinical guidelines that address pressure ulcers (localized injury to the skin and/or underlying tissue, typically over a bony prominence, due to pressure alone or in combination with shear) and enable imparting quality wound care. With the aging population in the U.S., it becomes critical to address pressure ulcers since they primarily affect older adults. It is estimated that up to 3 million U.S. adults are affected by pressure ulcers with prevalence ranging from 0.4% to 38% in acute care hospitals, 2% to 24% in long-term care nursing facilities, and 0% to 17% in home care settings. Pressure ulcers were reported as a cause of death in nearly 115000 persons between 1990 and 2001, and were listed as the underlying cause of death in more than 21000.

The ACP guideline team makes the following three recommendations for clinicians that will help prevent pressure ulcers in their clinical practice guidelines published in the official journal, Annals of Internal Medicine.

  • Perform a risk assessment to identify patients who are at risk of developing pressure ulcers
  • Choose advanced static mattresses or advanced static overlays for patients having an increased risk of developing pressure ulcers
  • Do not use alternating-air mattresses or alternating-air overlays for patients having an increased risk of developing pressure ulcers

The team examined a number of factors to formulate their recommendations, such as the incidence and severity of pressure ulcer, resource use including the duration of hospital stay or cost, diagnostic accuracy (sensitivity, specificity, and positive and negative likelihood ratios), measures of risk (hazard ratios, odds ratios and relative risks), and harms (dermatologic reactions, discomfort and infection).

When it comes to risk assessment, the guideline authors identify a number of specific risk factors for pressure ulcers such as:

  • Older age
  • Black race or Hispanic ethnicity
  • Lower body weight
  • Cognitive impairment
  • Physical impairments
  • Other co-morbid conditions that affect soft-tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition

The authors also suggest instruments to assess patients’ risk of developing pressure ulcers. Numerous preventive interventions are recommended for patients identified with an increased risk for pressure ulcers to reduce friction and shear. This includes support surfaces (for example, mattresses, integrated bed systems, overlays and cushions), repositioning, nutritional supplementation, skin care (dressing and management of incontinence) and topical creams.

The guideline team associated with evaluating pressure ulcer treatment options came up with the following recommendations regarding treatment modalities.

  • Clinicians should use protein or amino acid supplementation to reduce wound size
  • Clinicians should use hydrocolloid or foam dressings to reduce wound size
  • Clinicians should use electrical stimulation as adjunctive therapy to accelerate wound healing

According to the American College of Physicians, the treatment for pressure ulcers should involve multiple strategies aimed at eliminating the conditions that contribute to ulcer development (support surfaces, repositioning and nutritional support), protecting the wound from contamination and creating and maintaining a clean wound environment, promoting tissue healing through local wound applications, debridement and wound cleansing, using adjunctive therapies and considering possible surgical repair.

Comprehensive wound documentation is critical to understand the risk factors and make effective treatment decisions. Wound EMR with wound-specific templates records very specific wound details, and makes it easy to retrieve those details whenever the physician or nurse wants. The specific details within wound EMR will give physicians and nurses a clearer view of pressure ulcers and help them to incorporate strategies that take care of all aspects of wound care. Faster information exchange across physicians, nurses and wound care specialists help to provide effective treatment more quickly. If wound EMR is supported with an interface for physicians and nurses, this process will become even more efficient.