Pressure ulcer prevention - stream overview

Recommendations

Identify and Treat the Cause
1 Develop a plan of care based on a validated risk assessment instrument. Re-evaluate risk weekly or when patient factors change. Level of Evidence
5
2 Assess all support surfaces and patient factors for increased pressure and modify appropriately with consideration to friction and shear. Level of Evidence
1a
3 Assess and manage nutritional status. Level of Evidence
2a
4 Reduce moisture and protect skin from excess moisture. Level of Evidence
2a
5 Encourage patient activity and mobility to minimize friction and shear. Level of Evidence
3a


Address Patient-Centered Concerns
6 Assess and minimize pain and its related etiologies. Level of Evidence
5
7 Consider patient issues such as activity, mobility, and potential skin irritation, in support surface selection. Level of Evidence
5


Provide Local Wound Care
8 If a pressure ulcer exists, follow TREATMENT recommendations. Level of Evidence
1a


Provide Organizational Support
9 Provide a coordinated interdisciplinary approach to address the needs of each patient. Level of Evidence
2a
10 Educate patients, caregivers, and health-care providers about the risk and prevention of pressure ulcers. Level of Evidence
2a


Background

Pressure ulcers are lesions caused by factors such as constant pressure, friction or shear, usually occurring over bony prominences. Their prevalence in Canadian health-care institutions is approximately 26.3%, while global prevalence rates range between 12% to 32%. Furthermore, approximately 60% of pressure ulcers develop in acute care facilities. It is considerably less expensive to prevent pressure ulcers than to treat them, so assessing and preventing risk factors is imperative for caregivers.

A systematic literature search for clinical practice guidelines on pressure ulcer prevention was completed using the Medline, CINAHL, and Embase databases and 46 guideline clearinghouses. A librarian was involved in identifying the appropriate keywords and search strategies to ensure that all guidelines on the topic were found.

20 pressure ulcer prevention clinical practice guidelines were found in the English literature from 2002 until May 2007. 9 (45%) of these published articles were excluded because they were: patient resources for preventing pressure ulcers (4), supplemental documents of a guideline (2), an experiment based on a systematic review (1), an updated version of an existing guideline (1) and a guideline for assessment and treatment of pressure ulcers (1).

Of the identified papers, 11 guidelines were appraised by a minimum of three reviewers using the AGREE instrument. (http://www.agreecollaboration.org/instrument/). 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 National Institute for Clinical Excellence (NICE) on pressure ulcer risk assessment and prevention (2005); the Royal College of Nursing (RCN) on pressure ulcer risk assessment and prevention (2000); the Registered Nurses Association of Ontario (RNAO) on risk assessment and prevention of pressure ulcers (2005); the Royal College of Nursing (RCN) on the use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care) (2005); one by Consortium for Spinal Cord Medicine (CSCM) on pressure ulcer treatment and prevention following a spinal cord injury (2000).

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

References

High Ranking Guidelines
1 Pressure Ulcer Prevention Quality Indicator
 Type: CPG (Clinical Practice Guideline)
NICE/RCN. The management of pressure ulcers in primary and secondary care A Clinical Practice Guideline. March 2005.
This guideline is useful because it provides clear, succinct and detailed recommendations and supporting evidence over a very wide range of topics relating to management of pressure ulcers in primary and secondary care.
2 Pressure Ulcer Prevention Quality Indicator
 Type: CPG (Clinical Practice Guideline)
RYCROFT-MALONE J, MCINNESS, E (2000) Pressure ulcer risk assessment and prevention. Technical Report. RCN: London
This guideline is useful because it does a thorough job of detailing how caregivers can identify patients at risk of pressure ulcers, and which prevention strategies minimize the likelihood of their development.
3 Pressure Ulcer Prevention Quality Indicator
 Type: CPG (Clinical Practice Guideline)
RNAO. Risk assessment and prevention of pressure ulcers. March 2005
This guideline is particularly useful in its analysis of possible interventions for both prevention and management of pressure ulcers, in addition to its consideration of organizational and policy concerns
4 Pressure Ulcer Prevention Quality Indicator
 Type: CPG (Clinical Practice Guideline)
RCN. The use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. 2005.
This guideline is particularly useful because it provides a detailed analysis of the economic implications of pressure ulcers, providing a scope of the benefits to health care systems that would accompany optimal prevention of pressure ulcers.
5 Pressure Ulcer Prevention Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Consortium for Spinal Cord Medicine. Pressure ulcer treatment and prevention following a spinal cord injury. August 2000.
While this guideline provides information oriented towards pressure ulcers following spinal cord injury, it is very effective in describing support surfaces and positions that can most effectively prevent pressure ulcers.


Enablers for practice

Coming Soon...