Pressure ulcer treatment - stream overview

Recommendations

Identify and Treat the Cause
1 Complete a patient history and a targeted physical examination to determine general health, and factors that may cause, or delay, the healing of a pressure ulcer Level of Evidence
5
2 Assess and modify situations where pressure may be increased; provide appropriate support surfaces. Level of Evidence
5
3 Assess and manage nutritional status. Level of Evidence
5


Address Patient-Centered Concerns
4 Assess and control pain, and assist with psychosocial needs Level of Evidence
5


Provide Local Wound Care
5 Stage and assess the wound and treat required components (debridement, infection/inflammation, moisture). Level of Evidence
3b
6 Document wound characteristics and evaluate rate of healing Level of Evidence
1a
7 Use appropriate moisture balance-dressings that minimize friction and shear Level of Evidence
1a
8 Introduce adjunctive modalities or biologically active dressings where appropriate, such as in cases with edge effects. Level of Evidence
1a
9 Consider surgical intervention for stalled, deep and non-infected pressure ulcers (Stage III and Stage IV). Level of Evidence
5


Provide Organizational Support
10 Develop an interprofessional team specific to the needs of the patient, including appropriate patient education. Level of Evidence
5


Background

If preventative techniques are not effective in averting pressure ulcers, the care provider’s focus must shift to treatment. Treatment of pressure ulcers is largely based on offsetting the factors that caused the ulcer. It is essential to address patient-centered concerns by controlling pain and managing psychosocial needs. Pressure ulcers can be treated by applying local wound care, and in special cases, alternative treatment methods such as adjunctive modalities or surgical treatment may be used.


The guidelines reviewed were from the 3rd Congress of the World Union of Wound Care, 2008 PRESSURE ULCER STREAM AGREE Summary Report. The searches for, and reviewing of, all guidelines presented below were completed by the Registered Nurses Association of Ontario.

9 pressure ulcer treatment clinical practice guidelines were included in the report. The top five guidelines were examined in depth according to the overall assessment scores provided. If the overall assessment scores were the same, AGREE scores were compared to see which one had the highest score on rigour of development. The one with the higher score in rigour of development was assigned a higher overall score.

Of the 9 identified papers, 7 guidelines were appraised by a minimum of three reviewers using the AGREE instrument. (http://www.agreecollaboration.org/instrument/), 1 guideline was appraised by two reviewers while the last one was not reviewed. The AGREE instrument has six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. It is not recommended that the scores obtained for the domains be aggregated. Instead the guidelines that received the highest scores for most of the domains and particularly for rigour of development were ranked highest and their recommendations will be reported throughout this pressure ulcer stream.

The most highly ranked guidelines were developed by the Registered Nurses Association of Ontario (RNAO) on the Assessment and Management of Stage I to IV Pressure Ulcers (2002); the Paralyzed Veterans of America (PVA) on the Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health Professionals (2000); the Agency for Health Care Policy and Research (AHCPR) on the Treatment of Pressure Ulcers.(1994); the Wound Healing Society (WHS) on the Guidelines for the Treatment of Pressure Ulcers (2006); the Ministry of Health in Singapore (Singapore) on the Nursing Management of Pressure Ulcers in Adults (2001).

The following figure indicates the AGREE domain scores for these pressure ulcer guidelines.

References

High Ranking Guidelines
1 Pressure ulcer management Quality Indicator
 Type: CPG (Clinical Practice Guideline)
WOCN 2003: Wound Ostomy and Continence Nurses Society (2003). Guideline for Prevention and Management of Pressure Ulcers. # 2. Clinical Practice Guideline Series. Glenview, IL: WOCN.
This guideline is useful because it provides clear and succinct recommendations that can be easily followed by care providers. The simple and effective layout facilitates use of the recommendations in clinical settings.
2 Pressure ulcer management Quality Indicator
 Type: CPG (Clinical Practice Guideline)
RNAO: Registered Nurses’ Association of Ontario (2002). Assessment and Management of Stage I to IV Pressure Ulcers. Toronto, Canada: Registered Nurses’ Association of Ontario
This guideline is an outstanding resource for a number of reasons. In addition to providing a detailed set of recommendations regarding all treatment aspects, the guideline addresses potential organizational barriers that may obstruct its implementation.
3 Pressure ulcer management Quality Indicator
 Type: CPG (Clinical Practice Guideline)
AHCPR 1994: Bergstrom N, Bennett MA, Carlson CE. (1994). Treatment of Pressure Ulcers. Clinical Practice Guideline No. 15. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 95-0652
This guideline is extremely effective at providing substantial detail with respect to a wide range of treatment strategies for pressure ulcers. Furthermore, the recommendations are easily applicable and well-substantiated
4 Pressure ulcer management Quality Indicator
 Type: CPG (Clinical Practice Guideline)
EPUAP 1998: European Pressure Ulcer Advisory Panel (1998). Pressure Ulcer Treatment Guidelines. [Online]. Available: www.epuap.org/gltreatment.html
This guideline’s brevity enables the reader to isolate the most relevant recommendations relating to the treatment of pressure ulcers.
5 Pressure ulcer management Quality Indicator
 Type: CPG (Clinical Practice Guideline)
SINGAPORE 2001: Ministry of Health – Singapore (2001). Nursing Management of Pressure Ulcers in Adults. Ministry of Health – Singapore
This guideline is useful because it provides analysis on treatment of pressure ulcers from a purely nursing perspective, enabling nurses to comfortably use the recommendations in clinical practice.
6 Pressure ulcer management Quality Indicator
 Type: CPG (Clinical Practice Guideline)
WHS 2006: Whitney J. (2006). Guidelines for the treatment of pressure ulcers. Wound Repair and Regeneration, 14(6), 663-679.
This guideline is relevant because its recommendations have an increased focus on wound bed preparation, and the guideline addresses this principle in depth
7 Pressure ulcer management Quality Indicator
 Type: CPG (Clinical Practice Guideline)
IOWA 1997: Folkedahl B, Frantz R, Goode C. (2002). Treatment of Pressure Ulcers - Evidence-based guideline. University of Iowa Gerontological Nursing Interventions Research Center. Research Translation and Dissemination Core.
This guideline is useful because it focuses primarily on geriatric patients, making it more applicable to readers who are providing treatment for the elderly.
8 Pressure ulcer management Quality Indicator
 Type: CPG (Clinical Practice Guideline)
PVA 2000: Consortium for Spinal Cord Care (2000). Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health Professionals. Paralyzed Veterans of America.
This guideline is particularly useful in its comparison between surgical and non-surgical methods of treating pressure ulcers, including associated complications. Furthermore, its emphasis on pressure ulcers following spinal cord injuries is beneficial to guideline users with this specific focus.


Enablers for practice

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