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A direct comparison of the Consortium for Spinal Cord Medicine (CSCM) and the Registered Nurses' Association of Ontario (RNAO) recommendations for the treatment of pressure ulcers is provided in the tables below.
The guidelines differ somewhat in scope. In addition to addressing treatment of pressure ulcers, CSCM also addresses ulcer prevention, a topic that is beyond the scope of this synthesis. (NGC Note: see the synthesis, Prevention of Pressure Ulcers). While the RNAO guideline provides recommendations for the general population of adults at risk for pressure ulcers (including adults in acute and long-term care facilities), the CSCM guideline focuses specifically on persons with spinal cord injury.
Both guideline groups reviewed the recommendations of the 1994 Agency for Health Care Policy and Research (AHCPR) guideline, "Treatment of Pressure Ulcers". (NGC note: because of its 1994 publication date, the AHCPR guideline does not meet criteria for inclusion in NGC). RNAO also reviewed the CSCM guideline.
The tables below provide a side-by-side comparison of the key attributes of each guideline, including specific interventions and practices that are addressed. The language used in these tables, particularly in Table 3, Table 4, and Table 5 is in most cases taken verbatim from the original guidelines:
A summary discussion of the areas of agreement and areas of differences among the guidelines is presented following the content comparison tables.
Abbreviations used in the text and table:
TABLE 3: COMPARISON OF RECOMMENDATIONS FOR MANAGEMENT OF PRESSURE ULCERS | |
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ASSESSMENT | |
CSCM (2000 reviewed 2005) |
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:
(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:
(Scientific evidence: I, II, V; Grade of recommendation: A, B, C; Strength of panel opinion: Strong) |
RNAO (2007) |
Assessment Recommendation 1.1 Conduct a history and focused physical assessment. (Level of Evidence = IV) Discussion of Evidence Pressure ulcers should be assessed in the context of the patient's overall physical and psychological health. A focused physical assessment includes a risk assessment for pressure ulcer development - Appendix C in the original guideline document provides a description of the Braden Scale for Predicting Pressure Sore Risk. A French translation of this scale has recently been shown to be reliable and valid in clinical practice. The guideline development panel strongly supports consultation with interdisciplinary team members in the assessment process; in particular, the involvement of members who have wound care expertise. Recommendation 1.2 Conduct a psychosocial assessment to determine the client's goals and their ability and motivation to comprehend and adhere to the treatment plan of care options. (Level of Evidence = IV) Recommendation 1.3 Assess quality of life from the client's perspective. (Level of Evidence = IV) Recommendation 1.6 Assess all patients for pain related to the pressure ulcer or its treatment. (Level of Evidence = IV) Recommendation 1.7 Assess location, frequency, and intensity of pain to determine the presence of underlying disease, the exposure of nerve endings, efficacy of local wound care, and psychological need. (Level of Evidence = IIb) Recommendation 1.8 Assess all patients with EXISTING PRESSURE ULCERS to determine their risk for developing additional pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. (Level of Evidence = IV) Recommendation 1.10 Vascular assessment (e.g., clinical assessment, palpable pedal pulses, capillary refill, ankle/brachial pressure index and toe pressure) is recommended for ulcers in lower extremities to rule out vascular compromise. (Level of Evidence = IV) Discussion of Evidence The guideline development panel recommends that vascular assessments, including Ankle/Brachial Pressure Index (ABPI) measurements, be used to rule out arterial disease and to determine appropriate therapy for those individuals with pressure ulcers on their lower extremities. It is cautioned, however, that ABPI readings may be unreliable and falsely elevated due to calcification of vessels in patients who have diabetes. Furthermore, research evidence indicates that Doppler ultrasound measurements of ABPI can be also unreliable if operators have not undergone training, adding that reliability can be considerably improved if operators have received appropriate education to undertake this measure. |
TREATMENT | |
Care Plans | |
CSCM (2000 reviewed 2005) |
A comprehensive treatment plan includes assessment of risk, health status of the individual, and status of the pressure ulcer. The elements of a treatment plan include cleansing, debridement, dressings, surgery, nutrition and management of tissue loads. These elements represent standard treatment procedures as reflected in current literature and practice. However, new research and innovative approaches are being developed in the areas of adaptive therapies. |
RNAO (2007) |
Assessment Recommendation 1.2 Conduct a psychosocial assessment to determine the client's goals and their ability and motivation to comprehend and adhere to the treatment plan of care options. (Level of Evidence = IV) Discussion of Evidence The goal of a psychosocial assessment is to collect the information necessary to develop a plan of care with the client that is consistent with individual and family preferences, goals and resources (personal, financial, etc.). The findings regarding an individual's psychological health and the impact on pressure ulcer development is mixed; however, it is evident that many of the recommendations for prevention and management of existing ulcers require the understanding, cooperation and initiative of clients and their caregivers. These complex behaviours suggest that a psychosocial assessment should be conducted to identify factors for consideration in developing prevention and management strategies. A complete psychosocial assessment should include, but not be limited to, the following:
The treatment plan should include interventions to address identified psychosocial needs and goals. Follow-up should be planned in cooperation with the individual and caregiver, in consultation with appropriate interdisciplinary team members. |
Wound Care | |
CSCM (2000 reviewed 2005) |
Cleansing Cleanse pressure ulcers at each dressing change.
(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.
(Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong) Refer to Table 7 in the original guideline document for a comparison of debridement methods. Dressings Use dressings that will keep the ulcer bed continuously moist and the surrounding intact skin dry.
(Scientific evidence: I, II; Grade of recommendation: A, B; Strength of panel opinion: Strong) Refer to Table 8 in the original guideline document for a comparison of major dressing categories. |
RNAO (2007) |
Local Wound Care Assessment Recommendation 3.1a To plan treatment and evaluate its effectiveness, assess the pressure ulcer(s) initially for:
(Level of Evidence = IV) Discussion of Evidence There are several classification systems to describe wound stages; however, the NPUAP system is the method most widely accepted. Refer to Appendix H in the original guideline document for a description of the NPUAP classification system. Appendix I - Wound Measurement (see the original guideline document), provides a diagram of the recommended technique for measuring pressure ulcer surface area and undermining. Combining multiple measurement techniques may help to more accurately monitor and evaluate pressure ulcers. This clinical measurement can be achieved by using a ruler (width/length/depth), other measurement devices, transparency tracings or photography. Length is measured as the longest axis of the wound. Width is measured at 90 degrees to the length at the next longest axis. Sibbald, Orsted et al. (2006) suggest that the MEASURE mnemonic can be used to guide a consistent approach to local wound assessment, though it is also emphasized that assessment must occur within the context of a global assessment of the particular client and environment. Refer to Appendix J in the original guideline document for a description of MEASURE. Numerous tools have been developed for documenting wound assessment. These assessment tools include, but are not limited to: the Pressure Sore Status Tool (PSST); the NPUAP, Pressure Ulcer Scale for Healing (PUSH), the Wound Healing Scale (WHS), and the Sussman Wound Healing Tool (SWHT). Appendix K — Documentation: Wound Assessment Tools (see the original guideline document) provides examples of tools for systematic assessment and documentation. A clean pressure ulcer with adequate vascular supply receiving adequate treatment should show signs of healing within two to four weeks. If the condition of the patient or of the wound deteriorates, or if the goal of care is healing and no progress can be demonstrated, re-evaluate the treatment plan and/or the presence of complications. Some wounds, however, will not heal. In this case, the goal of healing may be revised to prevent infection, to prevent further deterioration, and to provide comfort so that quality of life and dignity is maintained. Recommendation 3.1b Conduct a comprehensive reassessment weekly to determine wound progress and the effectiveness of the treatment plan. Monitor for variances from assessment with each dressing change. Identification of variances indicates need for reassessment. (Level of Evidence = IV) Debridement Recommendation 3.2a Lower extremity ulcers or wounds in patients who are gravely palliative with dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement. (Level of Evidence = IV) Recommendation 3.2b Prior to debridement on ulcers on the lower extremities, complete a vascular assessment (e.g., clinical assessment, palpable pedal pulses, capillary refill, ankle/brachial pressure index, and toe pressure) to rule out vascular compromise. (Level of Evidence = IV) Recommendation 3.2c Determine if debridement is appropriate for the patient and the wound. (Level of Evidence = IV) Discussion of Evidence Given the risk and patient safety concerns associated with debridement procedures, the panel strongly emphasizes the need for caution in selecting debridement as an appropriate intervention. In some instances debridement may not be appropriate. Situations of this nature would include a limb or digit that is ischemic, and amputation is not possible - these wounds will not heal. In these cases, the necrotic tissue should be kept as dry as possible to prevent odour and infection. The eschar provides a barrier to external contamination in a non-healing wound. The topical application of a drying, antimicrobial agent, such as betadine, may be beneficial. In addition, for some wounds the removal of eschar is not necessary (e.g., small areas on heels and toes). Vascular assessment is essential to ensure patient safety and to determine appropriate treatment options. Although it is recognized that false positive results are possible with palpable pedal pulses and capillary refill assessment, in cases where diagnostic tests are unavailable, these assessments are recognized as useful to support decision making. Recommendation 3.2d If debridement is indicated, select the appropriate method of debridement considering:
(Level of Evidence = IV) Recommendation 3.2e Sharp debridement should be selected when the need is urgent, such as with advancing cellulitis or sepsis, increased pain, exudate, and odour. Sharp debridement must be conducted by a qualified person. (Level of Evidence = IV) Recommendation 3.2f Use sterile instruments to debride pressure ulcers. (Level of Evidence = IV) Discussion of Evidence The general categories of debridement are: sharp (or surgical), enzymatic, autolytic, biologic and mechanical. Refer to Appendix L in the original guideline document for a description of key factors in deciding on a method of debridement. NGC Note: Refer to p. 36 of the original guideline document for additional discussion of the debridement methods mentioned above. Wound Cleansing Recommendation 3.4a Do not use skin cleansers or antiseptic agents (e.g., povidone iodine, iodophor, sodium hypochlorite solution, hydrogen peroxide, acetic acid) to clean ulcer wounds. (Level of Evidence = III) Recommendation 3.4b Use normal saline, Ringer's lactate, sterile water, or non-cytotoxic wound cleansers for wound cleansing. (Level of Evidence = IV) Recommendation 3.4c Fluid used for cleansing should be warmed at least to room temperature. (Level of Evidence = III) Recommendation 3.4d Cleanse wounds at each dressing change. (Level of Evidence = IV) Recommendation 3.4e To reduce surface bacteria and tissue trauma, the wound should be gently irrigated with 100 to 150 milliliters of solution. (Level of Evidence = IV) Recommendation 3.4f Use enough irrigation pressure to enhance wound cleansing without causing trauma to the wound bed. Safe and effective ulcer irrigation pressures range from 4 to 15 pounds per square inch (psi). Pressure of 4 to 15 psi is achieved by using:
(Level of Evidence = IIa) Appendix P in the original guideline document provides a summary of the various wound care cleansers, indications and considerations. Management Approaches Recommendation 3.5a For comprehensive wound management options, consider the following:
(Level of Evidence = IV) Recommendation 3.5b Moisture-retentive dressings optimize the local wound environment and promote healing. (Level of Evidence = Ia) Recommendation 3.5c Consider caregiver time when selecting a dressing. (Level of Evidence = Ib) Recommendation 3.5d Consider the following criteria when selecting an interactive dressing:
Recommendation 3.5e Monitor dressings applied near the anus, since they are difficult to keep intact. Consider use of special sacral-shaped dressings. (Level of Evidence = Ib) Appendix Q in the original guideline document provides a summary of various categories of wound dressings, indications and considerations. |
Infection Management | |
CSCM (2000 reviewed 2005) |
Treatment Nonsurgical Topical antibiotics may be used if routine measures do not result in wound healing after several weeks. Broad spectrum agents, such as 1 percent silver sulfadiazine cream, may be used, although cross-sensitivity to other sulfonamides may occur. Mupirocin calcium cream 2 percent may be applied for pressure ulcers infected with Staphylococcus aureus and Streptococcus pyogenes. Prolonged use may result in overgrowth of nonsusceptible microorganisms, including fungi. Preoperative Care
(Scientific evidence: II, III, V; Grade of recommendation: C; Strength of panel opinion: Strong) Complications of Pressure Ulcers Nonsurgical
(Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong)
Surgical
(Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong) |
RNAO (2007) |
Control Bacteria/Infection Recommendation 3.3a The treatment of infection is managed by wound cleansing, systemic antibiotics, and debridement, as needed. (Level of Evidence = Ib) Recommendation 3.3b Protect pressure ulcers from sources of contamination, e.g., fecal matter (Level of Evidence = IIa) Recommendation 3.3c Follow Body Substance Precautions (BSP) or an equivalent protocol appropriate for the healthcare setting and the client's condition when treating pressure ulcers. (Level of Evidence = IV) Recommendation 3.3d Medical management may include initiating a two-week trial of topical antibiotics for clean pressure ulcers that are not healing or are continuing to produce exudate after two to four weeks of optimal patient care. The antibiotic should be effective against gram-negative, gram-positive and anaerobic organisms. (Level of Evidence = Ib) Recommendation 3.3e Medical management may include appropriate systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis or osteomyelitis. (Level of Evidence = Ib) Recommendation 3.3f To obtain a wound culture, cleanse wound with normal saline first. Swab wound bed, not eschar, slough, exudate, or edges. (Level of Evidence = IV) Recommendation 3.3g The use of cytotoxic antiseptics to reduce bacteria in wound tissue is not usually recommended. (Level of Evidence = IIb) Discussion of Evidence Refer to Appendix M in the original guideline document for a description of the clinical signs and symptoms of wound infection. Please refer to Appendix N in the original guideline document for a listing of commonly used topical antimicrobial agents. The development panel supports the use of sterile dressings in all care settings, whenever possible, in order to decrease the bioburden within pressure ulcers. Proper technique in obtaining a wound culture is critical, and a standardized quantitative swab technique can accurately document the bioburden in pressure ulcers. Though there remains much debate surrounding approaches to wound culture sampling, the panel supports the Levine method as it has recently emerged in the literature and current practice as the best approach for obtaining semi-quantitative wound culture swabs. This represents a change from the previously recommended zig-zag method. Most wounds need some form of preparation prior to the culture in order to reduce the risk of introducing extraneous microorganisms into the specimen. The exudate that accumulates on the surface of the wound and under dressings contains bacteria that are not the same as those causing infection in the wound. Irrigate wounds with normal saline until all visible debris has been washed away. Successful culturing also involves culturing viable tissue, therefore never swab eschar or yellow fibrous slough. Ensure that the swab is moist or alternatively, add normal saline to the wound bed and/or swab. Rotate the swab tip in a 1 cm2 area of the cleanest and deepest part of the wound and/or area of granulation, using enough pressure to release tissue exudate for a period of five seconds. This may be painful so warn the patient of the possibility of pain. Ensure adequate pain management and pre-medicate (e.g., topical wound analgesia) if possible. For a diagram of swabbing technique for accurate wound culture results, refer to Appendix O — Wound Cultures: Swabbing Techniques (see the original guideline document). |
Management of Tissue Load | |
CSCM (2000 reviewed 2005) |
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.
(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.
(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.
(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.
(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.
(Scientific evidence: II, V; Grade of recommendation: B, C; Strength of panel opinion: Strong) |
RNAO (2007) |
Assessment Recommendation 1.9 If the patient remains at risk for other pressure ulcers, a high specification foam mattress instead of a standard hospital mattress should be used to prevent pressure ulcers in moderate to high risk patients. (Level of Evidence = Ia) Clients identified at risk of developing a pressure ulcer should receive care on a low interface pressure mattress. Discussion of Evidence Even when using a high specification foam mattress, other pressure management devices, such as overlays, can be used in combination as needed. Importantly, despite the use of any pressure management device, repositioning should also be used to prevent further pressure ulcers. Additional strategies, particularly for special needs pediatric and geriatric populations, can be designed in consultation with the interdisciplinary team. For further discussion of prevention strategies, the reader is encouraged to consult the RNAO Nursing Best Practice Guideline Risk Assessment and Prevention of Pressure Ulcers (Revised) (2005) (See the NGC summary). Management of Causative/Contributing Factors Recommendation 2.1 Choose the support surface which best fits with the overall care plan for the client considering the goals of treatment, client bed mobility, transfers, caregiver impacts, ease of use, cost/benefit, etc. Ensure ongoing monitoring and evaluation to ensure that the support surface continues to meet the client's needs and that the surface is used appropriately and is properly maintained. If the wound is not healing, consider the total care plan for the client before replacing the surface. (Level of Evidence = IV) Recommendation 2.2 Pressure management of the heels while in bed should be considered independently of the support surface. (Level of Evidence = III) Recommendation 2.4 Obtain a seating assessment if a client has a pressure ulcer on a sitting surface. (Level of Evidence = IV) Recommendation 2.5 Refer patients at RISK to appropriate interdisciplinary team members (Occupational Therapist, Physiotherapist, Enterostomal Therapist, etc). Utilize those with expertise in seating, postural alignment, distribution of weight, balance, stability, and pressure management when determining positioning for sitting individuals. Ensure support surfaces are used appropriately and are properly maintained. (Strength of Evidence = IV) Recommendation 2.6 A client with a pressure ulcer on the buttocks and or trochanter should optimize mobilization. If pressure on the ulcer can be managed, encourage sitting as tolerated. (Strength of Evidence = IV) Discussion of Evidence Pressure is the major causative factor in pressure ulcer formation. Therefore, pressure ulcers will not heal if the etiology of pressure, shearing and friction are not addressed. For clients at risk of developing pressure ulcers, or for those with existing pressure ulcers, institute the recommendations related to risk assessment and prevention described in the RNAO Nursing Best Practice Guideline Risk Assessment and Prevention of Pressure Ulcers (Revised) (2005), available at www.rnao.org/bestpractices. Appendix C in the original guideline document provides a sample of the Braden Scale for Predicting Pressure Sore Risk. Importantly, the panel recognizes that the use of support surfaces may be limited by the availability of resources. As there are many factors which may result in the poor healing of pressure ulcers, the panel suggests an exploration of alternative measures to support healing prior to proceeding to a powered support surface (e.g., nutrition, transferring strategies). All surfaces should be checked to ensure they are not "bottoming out". The condition of "bottoming out" occurs when a mattress overlay, support or wheelchair cushion is compressed by high pressure. A subjective estimate of the amount of compression can be achieved by palpation of the support thickness at the bony prominence. To determine if a patient has bottomed out, the caregiver should place an outstretched hand (palm up) under the mattress overlay below the part of the body at risk for ulcer formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient has bottomed out. Bottoming out should be checked at various anatomical sites and while the patient assumes various body positions. |
Pain Management | |
CSCM (2000 reviewed 2005) |
No recommendations offered. |
RNAO (2007) |
Recommendation 1.6 Assess all patients for pain related to the pressure ulcer or its treatment. (Level of Evidence = IV) Recommendation 1.7 Assess location, frequency, and intensity of pain to determine the presence of underlying disease, the exposure of nerve endings, efficacy of local wound care, and psychological need. (Level of Evidence = IIb) Discussion of Evidence Pain should be assessed routinely and regularly using the same validated tool each time. Assessment tools should be appropriate for the cognitive ability of the patient, and should be easy to use. Although there are a number of validated tools, some of which are adapted for specific patient populations, there are no validated pain assessment tools for use specifically with clients experiencing pressure ulcer pain. However, recent studies have supported the use of the McGill Pain Questionnaire, the Modified Functional Independence Measure (FIM) in combination with the Visual Analogue scale, and the Faces Rating Scale, particularly with cognitively and sensory impaired elderly, to assess pain related to pressure ulcers or associated treatment. For sample assessment tools that have been tested for validity and reliability in adults, please refer to Appendix E in the original guideline document - Tools for Assessment of Pain. The AHCPR (1994) recommends that the management of pressure ulcer pain should include eliminating or controlling the source of pain (i.e., covering wounds, adjusting support surfaces, and repositioning), as well as providing analgesia to treat procedure-related and wound pain. Case and pilot studies indicate topical analgesia may be useful in treating pressure ulcer pain. Overall, however, the successful management of pain is a complex interdisciplinary effort requiring a multifaceted treatment plan, the discussion of which is beyond the scope of this guideline. Accurate assessment and diagnosis of the type of pain, its intensity and its effect on the person, are necessary to plan appropriate interventions or treatments and are an integral part of an overall clinical assessment. For comprehensive recommendations on the assessment and management of pain, and a discussion of the evidence, please refer to the RNAO Nursing Best Practice Guideline Assessment and Management of Pain (Revised) (2007) (see the NGC Summary). Recommendation 3.2g Prevent or manage pain associated with debridement. Consult with a member of the healthcare team with expertise in pain management. Refer to the Registered Nurses' Association of Ontario (RNAO) Best Practice Guideline Assessment and Management of Pain (Revised) (2007). (Level of Evidence = IV) |
Nutrition and Hydration | |
CSCM (2000 reviewed 2005) |
Nutrition
(Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong)
(Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong)
(Scientific evidence: II; Grade of recommendation: B; Strength of panel opinion: Strong) |
RNAO (2007) |
Recommendation 1.4 Ensure adequate dietary intake to prevent malnutrition or replace existing deficiencies to the extent that this is compatible with the individual's wishes. (Level of Evidence = III) Recommendation 1.5 Prevent clinical nutrient deficiencies by ensuring that the patient is provided with optimal nutritional support through one or more of the following:
Discussion of Evidence Nutritional management should address four rules: determine the nutritional status; ensure adequate nutritional intake; initiate additional nutrient intake and supplementation; and determine vitamin, mineral and trace element deficits and correct them. A screening tool may be used by nurses to identify those at nutritional risk; however, referral to those with expertise in nutritional interventions is necessary to establish an appropriate treatment plan. For a sample tool focusing on nutritional screening and assessment, refer to Appendix D in the original guideline document which includes the Mini Nutritional Assessment (MNA). The Mini Nutritional Assessment has been validated for use with adults over the age of 55. Body Mass Index (BMI) is another nutritional screening tool, which is a valid measurement of weight in relation to health. It is not recommended, however, for use as the sole measurement of either body composition or level of fitness. The BMI is available on the Health Canada Web site. Early identification and intervention to correct malnutrition can alter the healing trajectory in patients with wounds. A nutritional plan should be comprehensive and individualized, and therefore requires a multidisciplinary approach. The involvement of the interdisciplinary team and the patient in addressing nutritional goals is essential for successful outcomes. Nutritional interventions should be staged to meet the nutritional needs of the individual and move from screening, monitoring of intake and supplementation (when necessary) to more intensive interventions, including enteral or parenteral feeding. |
Surgical Intervention | |
CSCM (2000 reviewed 2005) |
Reassessment 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:
(Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong) Preoperative Care Assess, treat and optimize the following factors preoperatively:
(Scientific evidence: II, III, V; Grade of recommendation: B, C; Strength of panel opinion: Strong) Postoperative Care Be cognizant of postoperative care procedures.
(Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong) Complications of Pressure Ulcers Surgical Identify potential complications of surgical intervention, including:
(Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong) |
RNAO (2007) |
Surgical Intervention Recommendation 3.7 Possible candidates for operative repair are medically stable, adequately nourished and are able to tolerate operative blood loss and postoperative immobility. (Level of Evidence = IV) Discussion of Evidence Operative repair of pressure ulcers is an option for clean Stage III or Stage IV pressure ulcers that do not respond to optimal wound care. The high recurrence rate and long duration to achieve complete healing are often given as reasons for surgical closure as an appropriate option. Surgical procedures used to repair pressure ulcers include one or more of the following: direct closure, skin grafting, skin flaps, musculocutaneous flaps and free flaps. The decision for surgery is determined in collaboration with the interdisciplinary team and the client. Factors to consider prior to operative repair include: the patient's medical stability, nutritional status, ability to tolerate the recovery period as well as the likelihood that surgery will improve the patient's functional status. |
Adjuvant Therapy | |
CSCM (2000 reviewed 2005) |
Treatment Nonsurgical 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) Adjunctive Therapies Literature reviews were done for several adjunctive wound therapies, including those that used physical forms of energy, such as ultraviolet radiation, low-energy laser radiation, normothermia, ultrasound, subatmospheric pressure therapy, hyperbaric oxygen, topical agents, cytokine growth factors, and nonantibiotic systemic drugs. These reviews did not provide sufficient supporting evidence to justify recommending them for the treatment of pressure ulcers in individuals with spinal cord injury. |
RNAO (2007) |
Adjunctive Therapies Recommendation 3.6a Refer to physiotherapy for a course of treatment with electrotherapy for Stage III and IV pressure ulcers that have proved unresponsive to conventional therapy. Electrical stimulation may also be useful for recalcitrant Stage II ulcers. (Level of Evidence = Ib) Recommendation 3.6b Chronic pressure ulcers may be treated by:
Discussion of Evidence Candidates for adjunctive therapies include individuals with chronic wounds who have failed to respond to optimal standard wound care, those with pre-existing medical conditions that delay wound healing and/or who prefer a non-surgical, conservative option to facilitate wound healing. Prior to initiating an adjunctive therapy, the health care provider must ensure that the patient does not have any contraindications for that treatment modality. |
Reassessment and Ongoing Care | |
CSCM (2000 reviewed 2005) |
Reassessment Monitor and assess the pressure ulcer on a consistent, ongoing basis to determine the adequacy of the plan of care.
(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.
(Scientific evidence: I, V; Grade of recommendation: A, C; Strength of panel opinion: Strong) Complications of Pressure Ulcers Nonsurgical
(Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong)
(Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong)
(Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong) Surgical
(Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong) |
RNAO (2007) |
A clean pressure ulcer with adequate vascular supply receiving adequate treatment should show signs of healing within two to four weeks. If the condition of the patient or of the wound deteriorates, or if the goal of care is healing and no progress can be demonstrated, re-evaluate the treatment plan and/or the presence of complications. Some wounds, however, will not heal. In this case, the goal of healing may be revised to prevent infection, to prevent further deterioration, and to provide comfort so that quality of life and dignity is maintained. Management of Causative/Contributing Factors Recommendation 2.1 Choose the support surface which best fits with the overall care plan for the client considering the goals of treatment, client bed mobility, transfers, caregiver impacts, ease of use, cost/benefit, etc. Ensure ongoing monitoring and evaluation to ensure that the support surface continues to meet the client's needs and that the surface is used appropriately and is properly maintained. If the wound is not healing, consider the total care plan for the client before replacing the surface. (Level of Evidence = IV) Recommendation 3.1b Conduct a comprehensive reassessment weekly to determine wound progress and the effectiveness of the treatment plan. Monitor for variances from assessment with each dressing change. Identification of variances indicates need for reassessment. (Level of Evidence = IV) Discharge/Transfer of Care Arrangements Recommendation 4.1 Clients moving between care settings should have the following information provided:
(Level of Evidence = IV) Recommendation 4.2 Use the Registered Nurses' Association of Ontario Best Practice Guideline Risk Assessment and Prevention of Pressure Ulcers (Revised) (2005) (see the NGC summary). (Level of Evidence = IV) |
TABLE 4: BENEFITS AND HARMS | |
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Benefits | |
CSCM (2000 reviewed 2005) |
The benefits of clinical practice guidelines for the spinal cord medicine practice community are numerous. Among the more significant applications and results are the following:
Additional benefits include:
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RNAO (2007) |
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Harms | |
CSCM (2000 reviewed 2005) |
Mechanical debridement is slow, can be painful, and should be discontinued when necrotic tissue has been removed. Bleeding, the need for anesthesia and its associated risks, and possible injury to nervous or other viable tissue are the main disadvantages of sharp or surgical debridement techniques. |
RNAO (2007) |
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TABLE 5: EVIDENCE RATING SCHEMES AND REFERENCES | |
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CSCM (2000 reviewed 2005) |
Hierarchy of the Levels of Scientific Evidence:
Categories of the Strength of Evidence Associated With the Recommendations
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 2.32 Moderate: Mean agreement score of 2.33 to 3.66 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). |
RNAO (2007) |
Levels of Evidence Ia: Evidence obtained from meta-analysis or systematic review of randomized controlled trials. Ib: Evidence obtained from at least one randomized controlled trial. IIa: Evidence obtained from at least one well-designed controlled study without randomization. IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization. III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies. IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. |
The Consortium for Spinal Cord Medicine (CSCM) and the Registered Nurses' Association of Ontario (RNAO) present recommendations for treatment of pressure ulcers. Both guidelines provide explicit reasoning behind their judgments, ranking the level of evidence for each major recommendation. The CSCM guideline is somewhat broader in scope, providing recommendations for the prevention of pressure ulcers in addition to treatment. For prevention recommendations RNAO refers readers to their guideline Risk Assessment and Prevention of Pressure Ulcers. CSCM also addresses areas where more research is needed.
The content of the CSCM guideline is tailored to individuals with spinal cord injury. It considers some issues not addressed by RNAO, including the need for individualized wheelchair prescribing and additional aspects of positioning relevant to wheelchair-bound patients.
The guidelines are in general agreement that the pressure ulcer should be assessed within the context of the patient's physical and psychosocial health, including functional, nutritional, and cognitive status and comorbidities. They also agree that initial assessment of a pressure ulcer should include careful evaluation and documentation of the wound characteristics, including its location, size, and depth; existence of tunneling, undermining, and sinus tracts; color of the wound and surrounding tissue; drainage; and odor.
As a recommended initial assessment tool for characterizing ulcer stage, the NPUAP four-stage system is recommended by RNAO. They acknowledge that there are several classification systems to describe wound stages, but state that the NPUAP system is the method most widely accepted. CSCM notes that, while the NPUAP system is one of several systems developed to describe the depth of pressure ulcers and is the most commonly used, other systems use more descriptive criteria and possess good interrater reliability.
Wound Care
The guidelines agree that pressure ulcers should be carefully cleansed, debrided, and dressed. Non-cytotoxic cleansers, specifically normal saline solution, should be used rather than antiseptic solutions. There is overall agreement that irrigation pressure should be strong enough to enhance cleansing without causing trauma to the wound bed.
The guidelines are also in agreement that the method of debridement (autolytic, enzymatic, mechanical, or sharp debridement) should be selected based on the patient's condition, treatment goals, and the amount of eschar and necrotic tissue in the wound. RNAO recommends against debridement of dry, black eschar on heels that are nontender, nonfluctuant, nonerythematous and nonsuppurative.
The guidelines also agree that wound dressings should keep the ulcer bed continuously moist and the surrounding tissue dry. The type of dressing should be chosen based on wound characteristics.
Both guidelines agree that clean wounds not responding to treatment within 2 to 4 weeks can be treated with a two-week trial of topical antibiotics. RNAO notes that the topical antibiotic should be effective against gram-negative, gram-positive and anaerobic organisms. Both guidelines agree that when infection is suspected, an appropriate deep tissue culture or biopsy should be obtained. There is also overall agreement that systemic antibiotics are appropriate when there is evidence of cellulitis, osteomyelitis, or sepsis.
Both guidelines address tissue load management, including the need to protect tissue by minimizing pressure and shear. Both guidelines address positioning, use of pressure-reducing devices, and lifting and positioning aids both to aid healing of pressure ulcers and prevent development of new ulcers. The CSCM guideline, targeting care for persons with spinal cord injury, provides the most extensive recommendations concerning wheelchair positioning, including the need to prescribe wheelchairs according to individualized anthropometric, ergonomic, and functional principles and to regularly inspect wheelchair cushions.
RNAO recommends that pain be assessed routinely and regularly using the same validated tool each time. They specifically note the need for management of pain associated with debridement.
The guidelines are in general agreement that measures should be taken to assess nutritional status and ensure adequate nutrition and hydration. CSCM points out the need for optimal protein intake to promote wound healing. Both groups consider the need for nutritional supplements. RNAO also notes that there are a number of appropriate steps to take to ensure that the patient is provided with optimal nutritional support. These steps include consultation with a dietitian, consultation with a speech language pathologist for swallowing assessment, or enteral tube feeding (among others).
Both guidelines recommend that surgical intervention be considered for Stage III and IV ulcers that have not responded to conservative therapy. RNAO notes that factors to consider prior to operative repair include: the patient's medical stability, nutritional status, ability to tolerate the recovery period as well as the likelihood that surgery will improve functional status. CSCM addresses surgery in the greatest detail, including recommendations for preoperative and postoperative care and potential post-surgery complications in persons with spinal cord injury.
Both guidelines address the use of adjuvant therapies when an ulcer has not responded to conventional therapy and agree that electrical stimulation is an appropriate therapy to consider. There are differences, however, among the guidelines concerning the effectiveness of other adjuvant therapies; these differences are discussed below.
The guidelines are in general agreement that pressure ulcers should be monitored at each dressing change and reassessed at least weekly.
CSCM points out the need to identify the potential psychosocial impacts of pressure ulcers and immobility in persons with spinal cord injury and to provide referral for therapeutic interventions such as vocational rehabilitation, peer counseling, support groups, and psychotherapy.
Although there is general agreement that electrical stimulation is an appropriate therapy to consider, there is less agreement concerning other adjuvant therapies. For example, CSCM did not find sufficient evidence to recommend any adjuvant therapy except electrical stimulation, whereas RNAO states that growth factors, negative pressure therapy, as well as heat therapy can be helpful for chronic non-healing wounds. In contrast to CSCM, RNAO notes that physiotherapy, ultraviolet light C, skin equivalents, and hyperbaric oxygen may also be used to treat chronic pressure ulcers.
This synthesis was prepared by ECRI on October 31, 2006. The information was verified by UIGN on November 21, 2006, by AMDA and WOCN on December 5, 2006, and by RNAO on December 11, 2006. This synthesis was updated by ECRI Institute on July 16, 2007 following the removal of the AMDA, RNAO, and Singapore MOH guidelines from the NGC Web site. This synthesis was revised on December 12, 2007 to remove recommendations from UIGN. This synthesis was revised on May 9, 2008 to add RNAO recommendations. The information was verified by RNAO on June 18, 2008. This synthesis was revised in November 2008 to remove WOCN recommendations.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Management and treatment of pressure ulcers. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2006 Dec (revised 2008 Dec). [cited YYYY Mon DD]. Available: http://www.guideline.gov.