The following provides a summary of the recommendations presented in the guideline document. The reader is directed to the original guideline for a detailed discussion of each of the following topics.
The levels of evidence (I-V), grades of recommendations (A-C), and strength of panel opinion (low, moderate and strong) are repeated at the end of the Major Recommendations.
Prevention
Risk Factors, Risk Assessment, and Risk Assessment Tools
- Conduct comprehensive, systematic, and consistent assessment of pressure ulcer risk factors in individuals with spinal cord injury.
- Assess and document risk on admission and reassess on a routine basis, as determined by the health-care setting, institutional guidelines, and changes in the individual's health status.
- Use clinical judgment as well as a risk assessment tool to assess risk.
Assess demographic, physical/medical, and psychosocial risk factors associated with
- pressure ulcer prevention.
Scientific evidence: I, II, III, V; Grade of recommendation: A, B, C; Strength of panel opinion: Strong
Prevention Strategies
- Implement pressure ulcer prevention strategies as part of the comprehensive management of acute spinal cord injury and review all aspects of risk when determining prevention strategies.
- Avoid prolonged positional immobilization whenever possible.
- Institute pressure relief as soon as emergency medical condition and spinal stabilization allow.
- Initiate intraoperative pressure reduction strategies.
Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong
- Conduct daily comprehensive visual and tactile skin inspections, with particular attention to the areas most vulnerable to pressure ulcer development, including, but not limited to:
- Ischii
- Sacrum/coccyx
- Trochanters
- Heels
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
- Turn or reposition individuals with spinal cord injury initially every 2 hours in the acute and rehabilitation phases if the medical condition allows.
- Eliminate stretching and folding of soft tissues and prevent shearing when individuals are repositioned.
- Avoid positioning individuals who are side-lying in bed directly on their trochanter.
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
- Evaluate the individual and his/her support environment for optimal maintenance of skin integrity.
- Apply pressure-reducing support surfaces preventively to protect soft tissues from bruise and injury.
- Prevent moisture accumulation and temperature elevation at the support surface-skin interface.
- Apply pillows and cushions to bridge contacting tissues and unload bony prominences; do not use donut-type devices.
- Establish a mechanism to follow up on equipment performance specific to pressure ulcer prevention (support surfaces for the bed and wheelchair) and determine if changes in medical or health status have altered the effectiveness of the support surface.
Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong
- Provide an individually prescribed wheelchair and pressure-reducing seating system.
- Establish and initiate a specific pressure relief regimen within the individual's capability.
- Employ a power weight-shift system when manual pressure relief is not possible.
Scientific evidence: II, V; Grade of recommendation: B, C; Strength of panel opinion: Strong
- Implement an ongoing exercise regimen for the medically stable spinal cord injured individual to promote maintenance of skin integrity, increase strength of paretic and nonparalyzed muscles, improve cardiovascular endurance, and prevent fatigue and deconditioning.
Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong
- Provide individuals with spinal cord injury, their families, significant others, and health-care professionals with specific information on effective strategies for the prevention and treatment of pressure ulcers.
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
Nutrition
- Assess nutritional status of all spinal cord injured individuals on admission and as needed, based on medical status, including:
- Dietary intake
- Anthropometric measurements
- Biochemical parameters (prealbumin, total protein, albumin, hemoglobin, hematocrit, transferrin, and total lymphocyte count)
Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong
- Provide adequate nutritional intake to meet the individual's needs, especially:
- Calories (or Energy)
- Protein
- Micronutrients (zinc, vitamin C, vitamin A, and vitamin E
- Fluids
Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong
- Implement aggressive nutritional support measures if dietary intake is inadequate or if an individual is nutritionally compromised.
Scientific evidence: II; Grade of recommendation: B; Strength of panel opinion: Strong
Assessment Following Onset of a Pressure Ulcer
Assessment of the Individual With a Pressure Ulcer
- Perform an initial comprehensive assessment of the individual with a pressure ulcer, to include:
- Complete history
- Physical examination and laboratory tests
- Psychological health, behavior, cognitive status, and social and financial resources
- Availability and utilization of personal care assistance
- Positioning, posture, and related equipment
Scientific evidence: I, II, III, V; Grade of recommendation: A, B, C; Strength of panel opinion: Strong
Assessment of the Pressure Ulcer
- Describe in detail an existing pressure ulcer. Include the following parameters:
- Anatomical location and general appearance
- Size (length width, depth, and wound area)
- Stage
- Exudate/odor
- Necrosis
- Undermining
- Sinus tracts
- Infection
- Healing (granulation and epithelialization)
- Wound margins/surrounding tissue
Scientific evidence: I, II, V; Grade of recommendation: A, B, C; Strength of panel opinion: Strong
Treatment
Nonsurgical
Cleansing
- Cleanse pressure ulcers at each dressing change.
- Use minimum mechanical force when cleaning with gauze, cloth, or sponge.
- Use enough irrigation pressure to enhance cleansing without causing trauma to the wound.
- Use normal saline or wound cleansers.
- Avoid antiseptic agents.
- Consider hydrotherapy for ulcers containing large amounts of exudate and necrotic tissue.
Scientific evidence: I, III, V; Grade of recommendation: A, C; Strength of panel opinion: Strong
Debridement
- Debride devitalized tissue from pressure ulcers using a method appropriate to the ulcer's status and the individual's condition and goals.
- Debride areas in which there is eschar and devitalized tissue
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
Dressings
- Use dressings that will keep the ulcer bed continuously moist and the surrounding intact skin dry.
- Use a dressing that controls exudate, but does not desiccate the ulcer bed or macerate surrounding tissue.
- Loosely fill pressure ulcer cavities with dressing material to avoid dead space; avoid overpacking the ulcer
- Monitor the placement of all dressings, especially those in anatomical areas in which they are difficult to keep intact
- Perform dressing changes on a specific schedule based on assessment of the individual, the ulcer, and the condition of the dressing. Consult the dressing manufacturer's package insert for general information and about the frequency of dressing changes.
Scientific evidence: I, II; Grade of recommendation: A, B; Strength of panel opinion: Strong
Electrical Stimulation
- Use electrical stimulation to promote closure of stage III or IV pressure ulcers combined with standard wound care interventions.
Scientific evidence: I, II; Grade of recommendation: A; Strength of panel opinion: Strong
Reassessment
- Monitor and assess the pressure ulcer on a consistent, ongoing basis to determine the adequacy of the plan of care.
- Monitor the pressure ulcer at each dressing change.
- Document ulcer assessment at least weekly and every time the condition of the pressure ulcer or the individual changes.
Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong
- Modify the treatment plan if the ulcer shows no evidence of healing within 2 to 4 weeks.
- Review individual risk factors when assessing the healing of pressure ulcers.
- Evaluate healing progress using an instrument or other quantitative measurements.
Scientific evidence: I, V; Grade of recommendation: A, C; Strength of panel opinion: Strong
Surgical
- Refer appropriate individuals with complex, deep stage III pressure ulcers (i.e., undermining, tracts) or stage IV pressure ulcers for surgical evaluation. When surgery is indicated, include the following tenets of surgical treatment:
- Excising of ulcer, surrounding scar, bursa, soft tissue calcification, and underlying necrotic or infected bone
- Filling dead space, enhancing vascularity of the healing wound, and distributing pressure off the bone
- Resurfacing with a large regional pedicle flap, with suture line away from the area of the direct pressure, and one that does not encroach on adjacent flap territories
- Preserving options for future potential breakdowns
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
Preoperative Care
- Assess, treat and optimize the following factors preoperatively:
- Local wound infection
- Nutritional status
- Bowel regulation
- Severe spasm and contractures
- Comorbid conditions
- Previous ulcer surgery
- Smoking
- Osteomyelitis
- Urinary tract infection
- Heterotopic ossification
Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong
Postoperative Care
- Be cognizant of postoperative care procedures.
- Position the individual in a manner that keeps pressure off a fresh surgical site.
- Use an air-fluidized bed when pressure on the surgical flap is unavoidable.
- Progressively mobilize the individual to a sitting position over at least 4 to 8 weeks to prevent reinjury of the ulcer or surgical site.
- Provide subsequent patient education on pressure management and skin inspection.
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
Complications of Pressure Ulcers
Nonsurgical
- Identify the pressure of tissue and/or bone infection
- Obtain quantitative tissue and/or bone cultures in ulcers not responding to routine therapeutic measures.
- Obtain a tissue and/or bone biopsy to confirm infection, if necessary.
Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong
- Identify the potential complications of immobility associated with pressure ulcer management and implement preventive and therapeutic measures for:
- Nutritional deficiencies and dehydration
- Decreased range of motion
- Deconditioning (cardiopulmonary, cardiovascular, and musculoskeletal)
Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong
- Manage hypergranulation tissue that may impede ulcer healing.
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
- Identify the potential psychosocial impacts of pressure ulcers and immobility and provide referral for therapeutic interventions based upon the individual's characteristics and circumstances. Refer to appropriate resources for problem resolution, including:
- Vocational rehabilitation services
- Peer counseling and support groups
- Formal psychotherapy and/or family therapy
Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong
Surgical
- Identify potential complications of surgical intervention, including:
- Wound dehiscence/wound separation
- Delayed infection and abscess
- Hematoma and seroma
Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong
Support Surfaces and Positioning for Managing Tissue Loads
Bed Positioning
- Use bed-positioning devices and techniques to prevent and treat pressure ulcers. Use devices and techniques that are compatible with the bed type and the individual's health status.
- Avoid positioning individuals directly on a pressure ulcer.
- Avoid positioning individuals directly on the trochanter
- Use cushions and positioning aids to relieve pressure on pressure ulcers or vulnerable skin areas by elevating them away from the support surface.
- Avoid close cutouts or donut-type cushions
- Prevent contact between bony prominences.
- Limit the amount of time the head of the bed is elevated
- Develop, display, and use an individualized
positioning regimen and repositioning schedule.
Scientific evidence: II, V; Grade of recommendation: B, C; Strength of panel opinion: Strong
Bed Support Surfaces
- Use pressure-reducing bed support surfaces for individuals who are at risk for or who have pressure ulcers.
- Select a static support surface for individuals who can be positioned without weight bearing on an ulcer and without bottoming out on the support surface.
- Select a dynamic support surface if the individual cannot be positioned without pressure on an ulcer, when a static support surface bottoms out, if there is no evidence of ulcer healing, or if new ulcers develop.
- Use low-air loss and air-fluidized beds in the treatment of pressure ulcers if one or more of the following conditions exist:
- Pressure ulcers on multiple turning surfaces
- Compromised skin temperature and moisture control in the presence of large stage III or IV pressure ulcers
Scientific evidence: I, II, V; Grade of recommendation: A, B, C; Strength of panel opinion: Strong
Wheelchair Positioning
- Prescribe wheelchairs and seating systems according to individualized anthropometric, ergonomic, and functional principles.
- Obtain specific body measurements for optimal selection of seating system dimensions.
- Measure the effects of posture and deformity on interface pressure distribution.
- Prescribe a power weight-shifting wheelchair system for individuals who are unable to independently perform an effective weight shift.
- Use clinical judgment as well as objective data in determining the compatibility of the individual's shape with the seating system.
Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong
- Evaluate the individual's postural alignment, weight distribution, balance, stability, and pressure reduction capabilities to establish a proper sitting schedule.
- Avoid positioning the wheelchair-seated individual directly on a pressure ulcer.
- Allow limited sitting in individuals capable of performing weight shifts every 15 minutes.
- Reposition the wheelchair-seated individual at least
every hour; if this is not possible and the individual is unable to perform
weight shifts, return the individual to bed.
Scientific evidence: II, III; Grade of recommendation: B, C; Strength of panel opinion: Strong
Wheelchair Support Surfaces
- Use appropriate wheelchair cushions with all individuals with spinal cord injury.
- Inspect and maintain all wheelchair cushions at regularly scheduled intervals.
Scientific evidence: II, V; Grade of recommendation: B, C; Strength of panel opinion: Strong
Definitions:
Hierarchy of the Levels of Scientific Evidence:
- Large randomized trials with clear-cut results (and low risk of error)
- Small randomized trials with uncertain results (and moderate to high risk of error)
- Nonrandomized trials with concurrent or contemporaneous controls
- Nonrandomized trials with historical controls
- Case series with no controls
Categories of the Strength of Evidence Associated With the Recommendations
- The guideline recommendation is supported by one or more level I studies
- The guideline recommendation is supported by one or more level II studies
- The guideline recommendation is supported only by level III, IV, or V studies
Levels of Panel Agreement with the Recommendation
Based on a 5-point scale (1 corresponding to neutrality; 5 representing maximum agreement)
Low
Mean agreement score of 1.00 to less than 2.33
Moderate
Mean agreement score of 2.33 to less than 3.67
Strong
Mean agreement score of 3.67 to 5.00
Note: If the literature supporting a guideline recommendation came from two or more levels, the number and the level of evidence supporting the studies are reported (e.g., a guideline recommendation that is supported by two studies, one a level III and the other a level V, the scientific evidence would be indicated as III, V). Likewise, if a guideline recommendation is supported by literature that crossed two categories, both categories are reported (e.g., a recommendation that includes both level II and III studies would be classified as category B, C).
