Prevention & Treatment of Pressure Ulcers

Introduction

Pressure ulcers are a critical source of health care challenge because they increase patient pain and suffering, extend the length of hospital stay, and raise costs of health care provisions (Bergquist-Beringer et al., 2009). Jaul conducted a study on a pressure ulcer and observed that it was a growing problem in the whole framework of the healthcare sector, including private homes, clinics, hospitals, and other long-term care homes (Jaul, 2010). Some patients remained with the condition throughout their lifetime. In addition, many patients who had pressure ulcers of “grade 3 and 4 developed chronic wounds while some cases led to deaths due to ulcer-related complications (sepsis or osteomyelitis)” (Jaul, 2010, p. 311). Apart from deaths, pressure ulcers also lead to a geriatric condition with multifactorial pathological complications.

The U.S. Department of Health & Human Services through the National Guideline Clearinghouse provides the current specific, standardized guideline for pressure ulcers. The guideline provides recommendations on pressure ulcer treatment and clinical practices.

The quality of the clinical guideline

The authors of the guideline

Three groups that consisted of professionals in clinical guidelines authored the guideline for pressure ulcers.

  • National Pressure Ulcer Advisory Panel
  • European Pressure Ulcer Advisory Panel
  • Small Working Group Members

How the guideline was developed

The scope of the guideline was restricted to pressure ulcer. It also accounted for intended users, guideline category, clinical specialty, interventions and practices.

There were two guideline objectives:

  • To provide evidence-based recommendation for management of pressure ulcers globally
  • To guide care practices for patients with existing pressure ulcers based on evidence-based practices

The guideline targeted all vulnerable people of all ages at risk of developing pressure ulcers.

The main outcomes considered in the guideline included:

  • Cases and prevalence of the condition
  • Lengths of stay at health care facilities, rates of readmission and costs
  • Infections
  • Morbidity and mortality

Methodology

The panel used hand-searches of published literature to gather evidence from both primary and secondary sources. In addition, researchers also searched electronic databases, which included CINAHL, PubMed and the Cochrane Database of Systematic Reviews among others. Reviewed studies were published between January 1998 and January 2008. A sensitive search strategy with specific keywords was used.

Inclusion criteria focused on articles, which were specific to pressure ulcer treatment, prevention, risk assessment and prevention in patients. All articles were selected from peer-reviewed journals and they must have used specific scientific study designs, such as controlled clinical trials, case studies, survey, quasi-experimental studies and randomized controlled trials among others.

The evaluators adopted a rating scheme for all articles, identified 13 sets of pressure ulcer guidelines and reviewed almost 3000 published articles.

Evidence was analyzed through a review of published meta-analyses and systematic review with evidence tables.

The authors developed a methodology checklist to evaluate methodological quality of all articles used in the guideline. The panel adopted a consensus method to formulate guideline recommendations.

The panel summarized supporting evidence with every recommendation in the guideline. It also indicated the strength and level of all supporting materials used in the guideline.

The guideline was valid through two methods, which included external peer review and internal peer review.

The panel also published all costs associated with the analysis and development of the guideline.

All members who participated in the development of the guideline were screened for possible conflicts of interests.

Credentials and credibility of the developers of the guideline

The European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) provided high-qualified professionals, who developed the guideline on pressure ulcers. Members of the panel had qualifications in various areas in academic and nursing profession.

There were also other practitioners from Small Working Group, who also had high qualifications in nursing profession and practice.

The quality of the research base supporting the guideline

The developers of the guideline conducted a thorough research from various databases in order to identify the best articles to support the guideline. For instance, all articles used as supporting evidence had to meet specific requirements.

  • Internal validity
  • Well-developed study questions
  • Appropriate selection of research participants
  • Bias
  • Blinding
  • Outcome evaluation

In addition, the articles were also reviewed based on the methodology of the study.

  • Cohort studies
  • Case control studies
  • Quasi-experimental studies
  • Cross-sectional studies
  • Meta-analyses

Two members of the panel evaluated all articles to ensure that they met these criteria. Therefore, articles used to develop the guideline were well-developed academic, peer-reviewed papers.

New research has been published in support of the guideline

Some studies have relied on the guideline to develop the best practice for the prevention and treatment of pressure ulcers (Sibbald, Goodman, Norton, Krasner & Ayello, 2012; McInnes, Jammali-Blasi, Bell-Syer, Dumville & Cullum, 2012).

Some new studies have shown that not all pressure ulcers can be treated (Sibbald et al, 2012).

The best evidence that supports the standardized guideline

Research Study Citation Brief Summary of the
Study and Results
Levels of Evidence
Moore, Z., and Cowman, S. (2008). A systematic review of wound cleansing for pressure ulcers. Journal of Clinical Nursing, 17(15), 1963–1972. Web.
  • The study established that there was statistically significant healing when saline spray with Aloe vera, silver chloride and decyl glucoside (Vulnopur) was used to clean wounds
  • No change was noticed in healing when water was used and compared with saline
  • No change was observed in healing for ulcers cleansed with, or without, a whirlpool
Level I
Sipponen, A., Jokinen, J. J., Sipponen, P., Papp, A., Sarna, S., & Lohi, J. (2008). Beneficial effect of resin salve in treatment of severe pressure ulcers: a prospective, randomized and controlled multicentre trial. British Journal of Dermatology, 158(5), 1055-62. Web.
  • The traditional resin salve was important in treating both infected and non-infected severe ulcers relative to cellulose polymer gauze.
Level II
Page, J. C., Newswander, B., Schwenke, D. C., Hansen, M., & Ferguson, J. (2004). Retrospective analysis of negative pressure wound therapy in open foot wounds with significant soft tissue defects. Advances in Skin & Wound Care, 17(7), 354-64.
  • Patients treated with negative pressure wound therapy (NPWT) recorded low cases of foot-related challenges, less additional foot surgery, and fewer readmissions for the foot relative to patients treated with standard therapy.
  • Further studies with randomized research design were required to verify findings of the current study’s data
Level III
Baumgarten, M., Margolis, D., Localio, A. R., Kagan, S., Lowe, R., Kinosian, B., Abbuhl, S.,…Mehari, T. (2008). Extrinsic Risk Factors for Pressure Ulcers Early in the Hospital Stay: A Nested Case–Control Study. J Gerontol A Biol Sci Med Sci., 63(4), 408–413.
  • Pressure ulcers were extremely high at the ICU whereas those who did not stay at the ICU had fewer cases of pressure ulcers
  • Nurses should use any possible immobilizing drugs during the early inpatient period at the ICU
  • Many techniques used in the ED and during early patient stay do not exert excess pressure ulcer risks
  • ICU stay doubled patients’ risks for pressure ulcer
  • Hence, it is necessary to develop and evaluate interventions to prevent pressure ulcers among patients in the ICU
Level IV
Heyneman, A., Beele, H., Vanderwee, K., & Defloor, T. (2008). A systematic review of the use of hydrocolloids in the treatment of pressure ulcers. Journal of Clinical Nursing, 17(9), 1164-1173.

Hydrocolloids were effective for dressing in the treatment of pressure ulcers, but further studies were necessary to confirm these results

Level V
Günes, Ü. Y. (2008). A Descriptive Study of Pressure Ulcer Pain. Ostomy Wound Manage, 54(2), 56-61.
  • Pressure ulcers are extremely painful
  • Thus, health care providers must offer adequate management of pressure ulcers
  • There should be individual pain assessment for standard verification alongside the use of the Faces Rating Scale for patients who cannot describe their distress and pain
  • All care providers should respond and report pain a professional manner
  • There should pain-reducing interventions in the plan of care
Level VI
Stokowski, L. A. (2010). Web.
  • Experts concur that not all pressure ulcers are preventable, particularly in long hospital stay
  • Pressure ulcers should be monitored, evaluated and treated with appropriate interventions
  • Introduce new interventions as necessary
Level VII

How the guideline fits into a practice setting

The guideline identifies methods of pressure ulcer assessment for practitioners. It states that health care providers should rely on a consistent, standardized approach for evaluating the extent of pressure ulcers. At the same time, health care providers should be cautious to avoid causing further insults when assessing the depth of the patient’s pressure ulcer. In addition, they should use appropriate intervention measures and adopt change as necessary.

Possible barriers and facilitators to the change

There are several stakeholders in the health care service provision. For instance, the guideline identifies its intended users, who are also key stakeholders in pressure ulcer management and prevention. These stakeholders may resist or facilitate in addressing pressure ulcers in different ways.

  • Advanced Practice Nurses: these are nurse leaders who advocate for effective quality care, patient safety and outcomes and would support change
  • Allied Health Personnel: this group may facilitate change and ensure improved patient safety outcomes because of collective advocacy.
  • Dietitians: these care providers want to realize positive outcomes in their patients and advocate for patients’ well-being.
  • Health Care Providers: this category may support change because of the roles to patients. However, other factors, such time for adequate care and lack of knowledge in intervention strategies among others may hinder their efforts.
  • Hospitals, nurses, physicians and physicians assistants: health care facilities, physicians and nurses promote change and strive for good reputations, but may have poor managers who may not support change or may lack adequate resources to facilitate changes in pressure ulcer management.
  • Patients: patients want effective health care services and would support change to alleviate their distress

The decision to change health care practices depends on the nurses and physicians recommendations, which health care facility management must approve. In some instance, lawmakers may get involved to facilitate nationwide changes.

Planning for Change

The implementation phases will involve all stakeholders, particularly health care providers who provide direct care to patients. They would follow the best practices as indicated in the guideline and record the observed improvements. Implementation would enhance best practices in pressure ulcer prevention and management. The guideline should apply to all patients at the ED and ICU, particularly patients with long hospital stay.

Cost factors associated with implementing the guideline may result from resources, such as antiseptics and other pain management medications required.

Outcomes

Effective implementation of the guideline would result in few cases of pressure ulcers, effectual management of existing cases in patients while nurses would have reduced workload that result from constant calls from patients under distress.

Evaluation of the outcomes would involve collection of data by care providers and nurses on a long-term basis for comparative analysis. Nurses may analyze collected data and implement changes or involve physicians as appropriate.

Summary

  • Pressure ulcers are extremely painful and results in high costs of health care provision
  • All stakeholders should engage in pressure ulcer prevention and management at the levels
  • Health care providers should adopt evidence-based practices and recommendations from the guideline
  • It is necessary to conduct further studies and collect data to improve quality of care for patients

Reflection

Developing an evidence-based presentation introduces students to vast literature done by experts in the field of pressure ulcers. This presentation indicates that evidence-based practices rely on well-developed research methodologies to ensure reliability of results. Overall, developing an effective guideline requires inputs from various panels of experts who undertake thorough studies and review of available literature.

Clinical practice changes require evidence-based outcomes from professionals to improve quality of car among patients.

References

Baumgarten, M., Margolis, D., Localio, A. R., Kagan, S., Lowe, R., Kinosian, B., Abbuhl, S.,…Mehari, T. (2008). Extrinsic Risk Factors for Pressure Ulcers Early in the Hospital Stay: A Nested Case–Control Study. J Gerontol A Biol Sci Med Sci., 63(4), 408–413.

Bergquist-Beringer, S., Davidson, J., Agosto, C., Linde, N. K., Abel, M., Spurling, K.,… Christopher, A. (2009). Evaluation of the National Database of Nursing Quality Indicators (NDNQI) Training Program on Pressure Ulcers. The Journal of Continuing Education in Nursing, 40(6), 252-258.

Günes, Ü. Y. (2008). A Descriptive Study of Pressure Ulcer Pain. Ostomy Wound Manage, 54(2), 56-61.

Heyneman, A., Beele, H., Vanderwee, K., & Defloor, T. (2008). A systematic review of the use of hydrocolloids in the treatment of pressure ulcers. Journal of Clinical Nursing, 17(9), 1164-1173.

Jaul, E. (2010). Assessment and management of pressure ulcers in the elderly: current strategies. Drugs & Aging, 27(4), 311-25. Web.

McInnes, E., Jammali-Blasi, A., Bell-Syer, S., Dumville, J., & Cullum, N. (2012). Preventing pressure ulcers—Are pressure-redistributing support surfaces effective? A Cochrane systematic review and meta-analysis. International Journal of Nursing Studies, 49(3), 345-359. Web.

Moore, Z., and Cowman, S. (2008). A systematic review of wound cleansing for pressure ulcers. Journal of Clinical Nursing, 17(15), 1963–1972. Web.

Page, J. C., Newswander, B., Schwenke, D. C., Hansen, M., & Ferguson, J. (2004). Retrospective analysis of negative pressure wound therapy in open foot wounds with significant soft tissue defects. Advances in Skin & Wound Care, 17(7), 354- 64.

Sibbald, G., Goodman, L., Norton, L., Krasner, D. L., & Ayello, E. (2012). Prevention and Treatment of Pressure Ulcers. Skin Therapy Letter, 17(8), 3-7.

Sipponen, A., Jokinen, J. J., Sipponen, P., Papp, A., Sarna, S., & Lohi, J. (2008). Beneficial effect of resin salve in treatment of severe pressure ulcers: a prospective, randomized and controlled multicentre trial. British Journal of Dermatology, 158(5), 1055-62. Web.

Stokowski, L. A. (2010). Pressure Ulcers: The Source of the Controversy. Web.

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