Clinical Practice Guideline Number 3

AHCPR Pub. No. 92-0047:

May 1992

Link to the National Guideline Clearinghouse

The Agency for Health Care Policy and Research (AHCPR) was established in December 1989 under Public Law 101-239 (Omnibus Budget Reconciliation Act of 1989) to enhance the quality, appropriateness, and effectiveness of health care services and access to these services. AHCPR carries out its mission by conducting and supporting general health services research, including medical effectiveness research, facilitating development of clinical practice guidelines, and disseminating research findings and guidelines to health care providers, policymakers, and the public.

The legislation also established within AHCPR the Office of the Forum for Quality and Effectiveness in Health Care (the Forum). The Forum has primary responsibility for facilitating the development, periodic review, and updating of clinical practice guidelines. The guidelines will assist practitioners in the prevention, diagnosis, treatment, and management of clinical conditions.

Other AHCPR components include the following. The Center for Medical Effectiveness Research has principal responsibility for patient outcomes research and studies of variations in clinical practice. The Center for General Health Services Extramural Research supports research on primary care, the cost and financing of health care, and access to care for underserved and rural populations. The Center for General Health Services Intramural Research uses large data sets for policy research on national health care expenditures and utilization, hospital studies, and long-term care. The Center for Research Dissemination and Liaison produces and disseminates findings from AHCPR-supported research, including guidelines, and conducts research on dissemination methods. The Office of Health Technology Assessment responds to requests from Federal health programs for assessment of health care technologies. The Office of Science and Data Development develops specialized data bases and enhances techniques for using existing data bases for patient outcomes research.

Guidelines are available in formats suitable for health care practitioners, the scientific community, educators, and consumers. AHCPR invites comments and suggestions from users for consideration in development and updating of future guidelines. Please send written comments to Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Executive Office Center, Suite 401, 2101 East Jefferson Street, Rockville, MD 20852.

Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical conditions. This guideline was developed by an independent, multidisciplinary panel of private sector clinicians and other experts convened by the Agency for Health Care Policy and Research (AHCPR). The panel employed an explicit, science-based methodology and expert clinical judgment to develop specific statements on patient assessment and management for the clinical condition selected.

Extensive literature searches were conducted and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review and field review were undertaken to evaluate the validity, reliability, and utility of the guideline in clinical practice. The panel's recommendations are primarily based on the published scientific literature. When the scientific literature was incomplete or inconsistent in a particular area, the recommendations reflect the professional judgment of panel members and consultants.

The guideline reflects the state of knowledge, current at the time of publication, on effective and appropriate care. Given the inevitable changes in the state of scientific information and technology, periodic review, updating, and revision will be done.

We believe that the AHCPR-assisted clinical guideline development process will make positive contributions to the quality of care in the United States. We encourage practitioners and patients to use the information provided in this Clinical Practice Guideline. The recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the practitioner in light of available resources and circumstances presented by individual patients.

J. Jarrett Clinton, MD

Administrator

Agency for Health Care Policy and Research

The occurrence of pressure ulcers in patients in different settings is high enough to warrant concern, especially in certain high-risk groups. Prevalence in skilled care and nursing home facilities is approximately 23 percent. In the most extensive study of acute care facilities, there was a prevalence of 9.2 percent. Special high-risk populations include quadriplegic patients (60 percent prevalence in one study) and elderly patients admitted for femoral fracture (66 percent incidence).

Prevention of pressure ulcers in adults at risk is the overall goal of this guideline. Most can be prevented, and those Stage I pressure ulcers (nonblanchable erythema of intact skin) that do form need not worsen. Recommendations target four goals: (1) identifying at-risk individuals who need preventive intervention and the specific factors placing them at risk; (2) maintaining and improving tissue tolerance to pressure in order to prevent injury; (3) protecting against the adverse effects of external mechanical forces (pressure, friction, and shear); and (4) reducing the incidence of pressure ulcers through educational programs.

This guideline is intended for clinicians who examine and treat persons at risk of developing pressure ulcers. AHCPR commissioned an external panel of multidisciplinary experts in the field to develop the guideline. Guideline development included a broad range of input from professional and consumer organizations and individuals.

To build a scientific basis for the guideline, the panel reviewed comprehensive literature searches and then evaluated approximately 800 manuscripts. The panel also solicited input from a broad array of organizations and individuals. Testimony was invited at a public meeting. A draft of the guideline was analyzed by experts at a conference sponsored by the National Pressure Ulcer Advisory Panel, the International Association for Enterostomal Therapy, and the Association of Rehabilitation Nurses. In addition, the guideline received peer review (of the literature review and the conclusions reached) and pilot review by health care agencies to evaluate the guideline both conceptually and informally on a small number of patients (some sites also provided a more formal evaluation).

This is the first edition of Pressure Ulcers in Adults: Prediction and Prevention; it will be revised and updated as needed. Future editions will reflect new research findings and experience with the incorporation of emerging technologies and innovative approaches. The panel welcomes comments and suggestions on the guideline for use in the next edition. Please send written comments to Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Executive Office Center, Suite 401, 2101 East Jefferson Street, Rockville, MD 20852.

Panel for the Prediction and Prevention of Pressure Ulcers in Adults

This guideline makes specific recommendations to identify at-risk adults and to define early interventions for prevention of pressure ulcers. The guideline may also be used to treat Stage I pressure ulcers (nonblanchable erythema of intact skin). These guideline recommendations are not intended as the basis for care of infants and children, nor do they apply to individuals with existing Stage II or greater pressure ulcers or to individuals who are fully mobile.

Most pressure ulcers can be prevented, and those Stage I pressure ulcers that do appear need not worsen under most circumstances. However, even the most vigilant nursing care may not prevent the development and worsening of ulcers in some very high-risk individuals. In those cases, intensive therapy must be aimed at reducing risk factors (such as improving nutritional status), at preventive measures (such as frequent turning, and the use of mattress overlays), and at treatment.

Recommendations target four overall goals: (1) identifying at-risk individuals who need prevention and the specific factors placing them at risk, (2) maintaining and improving tissue tolerance to pressure in order to prevent injury, (3) protecting against the adverse effects of external mechanical forces (pressure, friction, and shear), and (4) reducing the incidence of pressure ulcers through educational programs.

Interventions include early detection maneuvers such as risk factor identification by assessing mobility, nutritional factors, continence, and level of consciousness. Treatments evaluated included those broadly conceptualized as pressure reduction and relief and strategies to maintain tissue tolerance.

This document is in the public domain and may be used and reprinted without special permission, except for those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. AHCPR will appreciate citation as to source, and the suggested format is provided below:

Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, Number 3. AHCPR Publication No. 92-0047. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. 5Department of Health and Human Services. May 1992.

Nancy Bergstrom, PhD, RN, FAAN, Chair

Professor of Nursing

College of Nursing

University of Nebraska Medical Center

Omaha, Nebraska

Specialty: Nurse Researcher and Educator

Richard M. Allman, MD

Associate Professor of Medicine

Director of the Division of Gerontology and Geriatric Medicine

University of Alabama at Birmingham

Birmingham, Alabama

Specialty: Geriatric Physician

Carolyn E. Carlson, PhD, RN

Professor of Nursing

Cedarville College

Associate Director of Nursing and Allied Health for Research and Evaluation,

Divisions of Nursing and Allied Health, and Department of Research

Rehabilitation Institute of Chicago

Chicago, Illinois

Specialty: Nurse Educator and Researcher

William Eaglstein, MD

Professor and Chairman Department of Dermatology and Cutaneous Surgery

University of Miami School of Medicine

Miami, Florida

Specialty: Dermatologist

Rita A. Frantz, PhD, RN, FAAN

Associate Professor, College of Nursing

University of Iowa

Clinical Associate in Nursing,

Iowa Veteran's Home

Iowa City, Iowa

Specialty: Nurse Educator and Researcher

Susan L. Garber, MA, OTR

Assistant Director for Research

Department of Occupational Therapy

The Institute for Rehabilitation and Research

Assistant Professor

Department of Physical Medicine and Rehabilitation

Baylor College of Medicine

Houston, Texas

Specialty: Occupational Therapist

Davina Gosnell, PhD, RN, FAAN

Professor and Dean

Kent State University School of Nursing

Kent, Ohio

Specialty: Nurse Educator and Researcher

Bettie S. Jackson, EdD, MBA, FAAN

Director of Professional Nursing Services

Moses Division, Montefiore Medical Center

Associate Research Scientist

Columbia University School of Nursing

Bronx, New York

Specialty: Enterostomal Therapy Nurse

Mildred G. Kemp, PhD, RN, CETN, FAAN

Associate Professor

Rush University College of Nursing

Practitioner/Teacher

Department of Operating Room and Surgical Nursing

Rush-Presbyterian-St. Luke's Medical Center

Chicago, Illinois

Specialty: Enterostomal Therapy Nurse

Thomas A. Krouskop, PhD

Professor, Department of Physical Medicine and Rehabilitation

Baylor College of Medicine

The Institute for Rehabilitation and Research

Houston, Texas

Specialty: Bioengineer

Elena M. Marvel, MSN, MA, RN

State Coordinator

Health Advocacy Services Program in New Jersey

American Association of Retired Persons

Short Hills, New Jersey

Specialty: Consumer Representative

George T. Rodeheaver, PhD

Professor and Director of Plastic Surgery Research

University of Virginia Health Sciences Center

Charlottesville, Virginia

Specialty: Researcher, Wound Management

George C. Xakellis, MD

Associate Professor of Family Medicine

University of Iowa College of Medicine

Iowa City, Iowa

Specialty: Family Practice Physician

Many organizations and individuals made significant contributions during the development of this guideline, and their assistance only can be briefly noted. Peer reviewers, individuals at institutions that provided pilot review, and consultants are acknowledged individually in the Contributors section.

All persons, organizations, and agencies with an interest in the pressure ulcer guideline were invited to participate at a public meeting held in Washington, DC, on December 6, 1990. The panel gratefully acknowledges the valuable input received.

The guideline certainly benefitted from review at the National Pressure Ulcer Advisory Panel (NPUAP) conference, March 6-8, 1991. Experts analyzed the guideline for its legal, ethical, fiscal, administrative, clinical medicine and nursing, educational, and research impact. Small group sessions analyzed how the guideline would affect acute care, long-term care, and home care. NPUAP, the International Association for Enterostomal Therapy (IAET), and the Association of Rehabilitation Nurses sponsored the conference and suspended plans in order to accommodate the need of the panel for multidisciplinary input.

Contributions of product manufacturers to the guideline development process are also gratefully acknowledged by the panel. Many companies responded to requests for published and unpublished information describing results of product research.

Margaret Coopey, MGA, RN; Marietta Anthony, PhD; Sue Hopkinson, MPP, RN; and Kathleen Hastings, RN, JD, MPH; were health policy analysts for the guideline at different times for the Office of the Forum for Quality and Effectiveness in Health Care, AHCPR. William N. LeVee, Center for Research Dissemination and Liaison, AHCPR, provided editorial review and production management.

Finally, the panel thanks the support staff members for their tireless efforts: Janet Cuddigan, MSN, RN, project coordinator and research analyst; Brenda Bergman, MS, RNC, research analyst; and Elizabeth Gavin, panel secretary.