Pressure ulcers affect approximately 3 million adults in the United States and cause significant morbidity, with treatment costs of approximately $11 billion per year. The prevalence varies between 0.4% and 38% in acute care settings and 2%-24% in long-term care settings. Because of the high prevalence and cost associated with pressure ulcers, there has been a push toward prevention and appropriate treatment.
Pressure ulcers are defined as damage to a localized area of skin resulting from pressure or pressure and shear. They are most common in patients who are limited in their mobility. Other risk factors include advanced age, black or Hispanic ethnicity, cognitive and physical impairments, and low body weight. Any comorbid condition that decreases skin integrity or healing may also be considered a risk factor, including fecal or urinary incontinence, diabetes, prolonged edema, a low albumin level, or malnutrition.
Dr. Neil Skolnik
The American College of Physicians’s guidelines grade its recommendations by the strength and basis of the supporting data. A strong recommendation is one for which the benefits clearly outweigh the risks and burdens; a weak recommendation is defined as one in which the benefits do not outweigh the risks and burdens. There are three levels of evidence quality: low, moderate, and high.
The first recommendation for the prevention of pressure ulcers is to perform a risk assessment on all patients in order to identify who is at risk. There was no specific recommendation as to which, if any, risk assessment tool should be used. This was a weak recommendation supported by low-quality evidence. There are various scales available for assessing a patient’s risk of pressure ulcer development, including the Braden, Cubbin, Jackson, Norton, and Waterlow scales. There are pitfalls with each tool, and they have all been found to have a low sensitivity and specificity. There has not been any evidence to show that the use of a risk assessment scale is superior to clinical judgment in assessing a patient’s risk for developing pressure ulcers. Although there have been a few studies that directly compared the various risk assessment tools, none of the tools emerged as superior.
The second recommendation for the prevention of pressure ulcers is to use advanced static mattresses or mattress overlays in patients who are at increased risk for developing pressure ulcers. This was a strong recommendation supported by moderate-quality evidence. There are few studies that exist on interventions for pressure ulcer prevention, and the different types of interventions are often each used in only one study. This made comparing the strategies for prevention difficult.
The third recommendation for the prevention of pressure ulcers is not to use alternating air mattresses or air overlays in patients at increased risk for developing pressure ulcers. This weak recommendation is supported by moderate-quality evidence. Most of the studies compared found no significant difference between these and static mattresses; however, air-alternating mattresses were less tolerable to patients and cost more.
It should be noted that the analysis of commonly used methods for the prevention of pressure ulcers – heel support boots, wheelchair cushions, nutritional supplementation, dressings, and repositioning – found no statistically significant difference in the prevention of pressure ulcers. Therefore, they are not part of the recommendations from the ACP. Multicomponent team-based interventions do appear to show a benefit.
The first recommendation for the treatment of pressure ulcers is that protein and amino acid supplementation be used to decrease wound size. This was a weak recommendation based on low-quality evidence. There was no recommendation as to what dose of protein supplementation to use, and it should be noted it is unclear whether this is applicable to the entire population or reserved for patients with nutritional deficiencies. There was no evidence to suggest other supplementation with vitamin C should be recommended.
The second recommendation for the treatment of pressure ulcers is that hydrocolloid or foam dressings be used to decrease wound size. This was a weak recommendation based on low-quality evidence. There was insufficient evidence to comment on complete wound healing with hydrocolloid or foam dressings, and the relationship between the reduction of wound size and complete healing has not been well defined. The analysis evaluated other dressing types – dextranomer paste, topical collagen, and radiant heat dressings – and did not recommend their use.
The third recommendation for the treatment of pressure ulcers from the ACP is the use of electrical stimulation as an adjunctive therapy to help accelerate wound healing. This was a weak recommendation based on moderate-quality evidence. It should be noted that this treatment modality was associated with an increase in adverse events, especially skin irritation, in the elderly population.