AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) Contents Introduction.................................. 3 Risk Assessment Tools and Risk Factors............. 3 Skin Care and Early Treatment.................... 4 Mechanical Loading and Support Surfaces.......... 6 Education.................................... 7 Assessment................................... 7 Assessing the Pressure Ulcer............................. 7 Assessing the Individual with a Pressure Ulcer............... 8 Assessing Complications................................ 8 Nutritional Assessment and Management.................. 8 Pain Assessment and Management........................ 9 Psychosocial Assessment and Management................. 9 1

Contents (continued) Managing Tissue Loads........................ 10 While in Bed........................................ 10 While Sitting........................................ 12 Ulcer Care................................... 12 Debridement........................................ 13 Wound Cleansing.................................... 13 Dressings........................................... 14 Adjunctive Therapies.................................. 15 Education and Quality Improvement............. 15 Prevention and Treatment.............................. 15 Assessing Tissue Damage............................... 16 Monitoring Outcomes................................. 17 Quality Improvement................................. 17 2

Introduction This Clinical Practice Guideline makes recommendations for the prediction, prevention, and early treatment of pressure ulcers in adults; it also provides a synopsis of supporting evidence for each recommendation. The guideline alone, without supporting rationale, can be found in the Quick Reference Guide for Clinicians. A more complete discussion of relevant research and summary evidence tables can be found in the full Guideline Report. This guideline reflects the state of current knowledge, as set out in the health care literature, regarding the effectiveness and appropriateness of procedures and practices designed to predict and prevent pressure ulcers. The guideline can also be used to treat Stage I pressure ulcers. When panel members analyzed the strength of the evidence supporting each recommendation, they used the following criteria: A. There is good research-based evidence to support the recommendation. B. There is fair research-based evidence to support the recommendation. C. The recommendation is based on expert opinion and panel consensus. This approach was adapted from Guide to Clinical Preventive Services by the Preventive Services Task Force (1989). Evidence ratings are based on the number of studies (quantity), quality of research, number of replications, and consistency of findings. Risk Assessment Tools and Risk Factors Goal: Identify at-risk individuals needing prevention and the specific factors placing them at risk. i. Bed- and chair-bound individuals or those with impaired ability to reposition should be assessed for additional factors that increase risk for developing pressure ulcers. These factors include immobility, incon- 3

tinence, nutritional factors such as inadequate dietary intake and impaired nutritional status, and altered level of consciousness. Individuals should be assessed on admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities. A systematic risk assessment can be accomplished by using a validated risk assessment tool such as the Braden Scale or Norton Scale. Pressure ulcer risk should be reassessed at periodic intervals. (Strength of Evidence = A.) All assessments of risk should be documented. (Strength of Evidence = C.) Skin Care and Early Treatment Worth remembering... The goal of skin care and early treatment is to maintain and improve tissue tolerance to pressure in order to prevent injury. Goal: Maintain and improve tissue tolerance to pressure in order to prevent injury. i. All individuals at risk should have a systematic skin inspection at least once a day, paying particular attention to the bony prominences. Results of skin inspection should be documented. (Strength of Evidence = C.) ii. Skin cleansing should occur at the time of soiling and at routine intervals. The frequency of skin cleansing should be individualized according to need and/or patient preference. Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness of the skin. During the cleansing process, care should be utilized to minimize the force and friction applied to the skin. (Strength of Evidence = C.) iii. iv. Minimize environmental factors leading to skin drying, such as low humidity (less than 40 percent) and exposure to cold. Dry skin should be treated with moisturizers. (Strength of Evidence = C.) Avoid massage over bony prominences. (Strength of Evidence = B.) v. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. When these sources of moisture cannot be controlled, underpads or briefs can be used that are made of materials that ab- 4

TIPS! Skin injury due to friction and shear forces should be minimized. vi. sorb moisture and present a quick-drying surface to the skin. For information about assessing and managing urinary incontinence, refer to Urinary Incontinence in Adults: Clinical Practice Guideline (available from AHRQ). Topical agents that act as barriers to moisture can also be used. (Strength of Evidence = C.) Skin injury due to friction and shear forces should be minimized through proper positioning, transferring, and turning techniques. In addition, friction injuries may be reduced by the use of lubricants (such as corn starch and creams), protective films (such as transparent film dressings and skin sealants), protective dressings (such as hydrocolloids), and protective padding. (Strength of Evidence = C.) vii. When apparently well-nourished individuals develop an inadequate dietary intake of protein or calories, caregivers should first attempt to discover the factors compromising intake and offer support with eating. Other nutritional supplements or support may be needed. If dietary intake remains inadequate and if consistent with overall goals of therapy, more aggressive nutritional intervention such as enteral or parenteral feedings should be considered. (Strength of Evidence = C.) For nutritionally compromised individuals, a plan of nutritional support and/or supplementation should be implemented that meets individual needs and is consistent with the overall goals of therapy. (Strength of Evidence = C.) viii. If potential for improving mobility and activity status exists, rehabilitation efforts should be instituted if consistent with the overall goals of therapy. Maintaining current activity level, mobility, and range of motion is an appropriate goal for most individuals. (Strength of Evidence = C. ix. Interventions and outcomes should be monitored and documented. (Strength of Evidence = C.) 5

Mechanical Loading and Support Surfaces Goal: Protect against the adverse effects of external mechanical forces: pressure, friction, and shear. TIPS! The goal of support surfaces is to protect against the adverse effects of external mechanical forces: pressure, friction, and shear. i. Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours if consistent with overall patient goals. A written schedule for systematically turning and repositioning the individual should be used. (Strength of Evidence = B.) ii. For individuals in bed, positioning devices such as pillows or foam wedges should be used to keep bony prominences (for example, knees or ankles) from direct contact with one another, according to a written plan. (Strength of Evidence = C.) iii. iv. Individuals in bed who are completely immobile should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off the bed. Do not use donut-type devices. (Strength of Evidence = C.) When the side-lying position is used in bed, avoid positioning directly on the trochanter. (Strength of Evidence = C.) v. Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Limit the amount of time the head of the bed is elevated. (Strength of Evidence = C.) vi. Use lifting devices such as a trapeze or bed linen to move (rather than drag) individuals in bed who cannot assist during transfers and position changes. (Strength of Evidence = C.) vii. Any individual assessed to be at risk for developing pressure ulcers should be placed when lying in bed on a pressure-reducing device, such as foam, static air, alternating air, gel, or water mattresses. (Strength of Evidence = B.) 6

viii. Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in a chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if consistent with overall patient management goals. Individuals who are able should be taught to shift weight every 15 minutes. (Strength of Evidence = C.) ix. For chair-bound individuals, the use of a pressure-reducing device such as those made of foam, gel, air, or a combination is indicated. Do not use donut-type devices. (Strength of Evidence = C.) x. Positioning of chair-bound individuals in chairs or wheelchairs should include consideration of postural alignment, distribution of weight, balance and stability, and pressure relief. (Strength of Evidence = C.) xi. Education A written plan for the use of positioning devices and schedules may be helpful for chair-bound individuals. (Strength of Evidence = C.) Goal: Reduce the incidence of pressure ulcers through educational programs. i. Educational programs for the prevention of pressure ulcers should be structured, organized, and comprehensive and directed at all levels of health care providers, patients, and family or caregivers. (Strength of Evidence = A.) ii. The educational program for prevention of pressure ulcers should include information on the following items (Strength of Evidence = B): Etiology and risk factors for pressure ulcers. Risk assessment tools and their application. Skin assessment. Selection and/or use of support surfaces. Development and implementation of an individualized program of skin care. 7

Demonstration of positioning to decrease risk of tissue breakdown. Instruction on accurate documentation of pertinent data. iii. iv. The educational program should identify those responsible for pressure ulcer prevention, describe each person s role, and be appropriate to the audience in terms of level of information presented and expected participation. The educational program should be updated on a regular basis to incorporate new and existing techniques or technologies. (Strength of Evidence = C.) Educational programs should be developed, implemented, and evaluated using principles of adult learning. (Strength of Evidence = C.) Assessment Assessment is the starting point in preparing to treat or manage an individual with a pressure ulcer. Assessment involves the entire person, not just the ulcer, and is the basis for planning treatment and evaluating its effects. This section provides recommendations for assessing both the pressure ulcer and the individual. Assessment of the individual addresses physical health, common complications, nutritional status, pain level, and psychosocial health. A. Assessing the Pressure Ulcer i. Assess the pressure ulcer(s) initially for location, stage (NPUAP, 1989), size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and epithelialization. (Strength of Evidence = C.) ii. Reassess pressure ulcers at least weekly. If the condition of the patient or of the wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted. (Strength of Evidence = C.) 8

Worth remembering... Assessment is the starting point in preparing to treat or manage an individual with a pressure ulcer. iii. A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. (Strength of Evidence = C.) B. Assessing the Individual with a Pressure Ulcer History and Physical Examination i. Perform a complete history and physical examination, because a pressure ulcer should be assessed in the context of the patient s overall physical and psychosocial health. (Strength of Evidence = C.) C. Assessing Complications i. Clinicians should be alert to the potential complications associated with pressure ulcers. (Strength of Evidence = C.) D. Nutritional Assessment and Management i. Ensure adequate dietary intake to prevent malnutrition to the extent that this is compatible with the individual s wishes. (Strength of Evidence = B.) 9 ii. iii. Perform an abbreviated nutritional assessment, as defined by the Nutrition Screening Initiative, at least every 3 months for individuals at risk for malnutrition. These include individuals who are unable to take food by mouth or who experience an involuntary change in weight. (Strength of Evidence = C.) Encourage dietary intake or supplementation if an individual with a pressure ulcer is malnourished. If dietary intake continues to be inadequate, impractical, or impossible, nutritional support (usually tube feeding) should be used to place the patient into positive nitrogen balance (approximately 30 to 35 calories/kg/ day and 1.25 to 1.50 grams of protein/kg/day) according to the goals of care. (Strength of Evidence = C.)

iv. Give vitamin and mineral supplements if deficiencies are confirmed or suspected. (Strength of Evidence = C.) Worth remembering... Assess all patients for pain related to the pressure ulcer or its treatment. E. Pain Assessment and Management i. Assess all patients for pain related to the pressure ulcer or its treatment. (Strength of Evidence = C.) ii. Manage pain by eliminating or controlling the source of pain (e.g., covering wounds, adjusting support surfaces, repositioning). Provide analgesia as needed and appropriate. (Strength of Evidence = C.) F. Psychosocial Assessment and Management i. All individuals being treated for pressure ulcers should undergo a psychosocial assessment to determine their ability and motivation to comprehend and adhere to the treatment program. The assessment should include but not be limited to the following: Mental status, learning ability, depression. Social support. Polypharmacy or overmedication. Alcohol and/or drug abuse. Goals, values, and lifestyle. Sexuality. Culture and ethnicity. Stressors. ii. iii. iv. Periodic reassessment is recommended. (Strength of Evidence = C.) Assess resources (e.g., availability and skill of caregivers, finances, equipment) of individuals being treated for pressure ulcers in the home. (Strength of Evidence = C.) Set treatment goals consistent with the values and lifestyle of the individual, family, and caregiver. (Strength of Evidence = C.) 10

v. Arrange interventions to meet identified psychosocial needs and goals. Follow-up should be planned in cooperation with the individual and caregiver. (Strength of Evidence = C.) Managing Tissue Loads The goal of the following recommendations is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer(s). The term tissue load refers to the distribution of pressure, friction, and shear on the tissue. The interventions are designed to decrease the magnitude of tissue loads and to provide levels of moisture and temperature that support tissue health and growth. While in Bed Positioning techniques and support surfaces for patients in bed are important factors in the management of tissue loads. A. Positioning Techniques i. Avoid positioning patients on a pressure ulcer. (Strength of Evidence = C.) ii. iii. iv. Use positioning devices to raise a pressure ulcer off the support surface. If the patient is no longer at risk for developing pressure ulcers, these devices may reduce the need for pressure-reducing overlays, mattresses and beds. Avoid using donut-type devices. (Strength of Evidence = C.) Establish a written repositioning schedule. (Strength of Evidence = C.) Assess all patients with existing pressure ulcers to determine their risk for developing additional pressure ulcers. For those individuals who remain at risk, institute the measures recommended in Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, No. 3: 11

Avoid positioning immobile individuals directly on their trochanters and use devices such as pillows and foam wedges that totally relieve pressure on the heels, most commonly by raising the heels off the bed. (Strength of Evidence = C.) Use positioning devices such as pillows or foam to prevent direct contact between bony prominences (such as knees or ankles). (Strength of Evidence = C.) Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Limit the amount of time the head of the bed is elevated. (Strength of Evidence = C.) B. Support Surfaces i. Assess all patients with existing pressure ulcers to determine their risk for developing additional pressure ulcers. If the patient remains at risk, use a pressure-reducing surface. (Strength of Evidence = C.) ii. iii. iv. Use a static support surface if a patient can assume a variety of positions without bearing weight on a pressure ulcer and without bottoming out. (Strength of Evidence = B.) Use a dynamic support surface if the patient cannot assume a variety of positions without bearing weight on a pressure ulcer, if the patient fully compresses the static support surface, or if the pressure ulcer does not show evidence of healing. (Strength of Evidence = B.) If a patient has large Stage III or Stage IV pressure ulcers on multiple turning surfaces, a low-air-loss bed or an air-fluidized bed may be indicated. (Strength of Evidence = C.) v. When excess moisture on intact skin is a potential source of maceration and skin breakdown, a support surface that provides airflow can be important in drying the skin and preventing additional pressure ulcers. (Strength of Evidence = C.) 12

While Sitting Positioning techniques and support surfaces for patients who are sitting are important factors in the management of tissue loads. A. Positioning Techniques i. A patient who has a pressure ulcer on a sitting surface should avoid sitting. If pressure on the ulcer can be relieved, limited sitting may be allowed. (Strength of Evidence = C.) ii. iii. Consider postural alignment, distribution of weight, balance, stability, and pressure relief when positioning sitting individuals. (Strength of Evidence = C.) Reposition the sitting individual so the points under pressure are shifted at least every hour. If this schedule cannot be kept or is inconsistent with overall treatment goals, return the patient to bed. Individuals who are able should be taught to shift their weight every 15 minutes. (Strength of Evidence = C.) B. Support Surfaces i. Select a cushion based on the specific needs of the individual who requires pressure reduction in a sitting position. Avoid donut-type devices. (Strength of Evidence = C.) ii. Develop a written plan for the use of positioning devices. (Strength of Evidence = C.) Ulcer Care Initial care of the pressure ulcer involves debridement, wound cleansing, the application of dressings, and possibly adjunctive therapy. In some cases, operative repair will be required. In all cases, specific wound care strategies should be consistent with overall patient goals. 13

A. Debridement i. Remove devitalized tissue in pressure ulcers when appropriate for the patient s condition and consistent with patient goals. (Strength of Evidence = C.) ii. iii. iv. Select the method of debridement most appropriate to the patient s condition and goals. Sharp, mechanical, enzymatic, and/or autolytic debridement techniques may be used when there is no urgent clinical need for drainage or removal of devitalized tissue. If there is urgent need for debridement, as with advancing cellulitis or sepsis, sharp debridement should be used. (Strength of Evidence = C.) Use clean, dry dressings for 8 to 24 hours after sharp debridement associated with bleeding; then reinstitute moist dressings. Clean dressings may be used in conjunction with mechanical or enzymatic debridement techniques. (Strength of Evidence = C.) Heel ulcers 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 (e.g., edema, erythema, fluctuance, drainage). (Strength of Evidence = C.) V. Prevent or manage pain associated with debridement as needed. (Strength of Evidence = C.) B. Wound Cleansing i. Cleanse wounds initially and at each dressing change. (Strength of Evidence = C.) ii. iii. Use minimal mechanical force when cleansing the ulcer with gauze, cloth, or sponges. (Strength of Evidence = C.) Do not clean ulcer wounds with skin cleansers or antiseptic agents (e.g., povidone iodine, iodophor, sodium hypochlorite solution [Dakin s solution], hydrogen peroxide, acetic acid). (Strength of Evidence = B.) 14

iv. Use normal saline for cleansing most pressure ulcers. (Strength of Evidence = C.) DID YOU KNOW Safe and effective ulcer irrigation pressures range from 4 to 15 psi. v. 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 psi. (Strength of Evidence = B.) vi. Consider whirlpool treatment for cleansing pressure ulcers that contain thick exudate, slough, or necrotic tissue. Discontinue whirlpool when the ulcer is clean. (Strength of Evidence = C.) C. Dressings i. Use a dressing that will keep the ulcer bed continuously moist. Wet-to-dry dressings should be used only for debridement and are not considered continuously moist saline dressings. (Strength of Evidence = B.) ii. iii. iv. Use clinical judgment to select a type of moist wound dressing suitable for the ulcer. Studies of different types of moist wound dressings showed no differences in pressure ulcer healing outcomes. (Strength of Evidence = B.) Choose a dressing that keeps the surrounding intact (periulcer) skin dry while keeping the ulcer bed moist. (Strength of Evidence = C.) Choose a dressing that controls exudate but does not desiccate the ulcer bed. (Strength of Evidence = C.) v. Consider caregiver time when selecting a dressing. (Strength of Evidence = B.) vi. Eliminate wound dead space by loosely filling all cavities with dressing material. Avoid over-packing the wound. (Strength of Evidence = C.) vii. Monitor dressings applied near the anus, since they are difficult to keep intact. (Strength of Evidence = C.) 15

D. Adjunctive Therapies DID YOU KNOW Electrical stimulation may also be useful for recalcitrant Stage II ulcers. i. Consider 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. (Strength of Evidence = B.) ii. The therapeutic efficacy of hyperbaric oxygen; infrared, ultraviolet, and low-energy laser irradiation; and ultrasound has not been sufficiently established to permit recommendation of these therapies for the treatment of pressure ulcers. (Strength of Evidence = C.) iii. iv. The therapeutic efficacy of miscellaneous topical agents (e.g., sugar, vitamins, elements, hormones, other agents), growth factors, and skin equivalents has not yet been sufficiently established to warrant recommendation of these agents at this time. (Strength of Evidence = C.) The therapeutic efficacy of systemic agents other than antibiotics has not been sufficiently established to permit their recommendation for the treatment of pressure ulcers. (Strength of Evidence = C.) Education and Quality Improvement Education Recommendations for developing and implementing educational programs are provided in the following categories: Prevention and treatment, assessing tissue damage, and monitoring outcomes. A. Prevention and Treatment: A Continuum i. Design, develop, and implement educational programs for patients, caregivers, and health care providers that reflect a continuum of care. The program should begin with a structured, comprehensive, and organized approach to prevention and should culminate in effective 16

treatment protocols that promote healing as well as prevent recurrence. (Strength of Evidence = C.) ii. iii. iv. Develop educational programs that target appropriate health care providers, patients, family members, and caregivers. Present information at an appropriate level for the target audience to maximize retention and ensure a carryover into practice. Use principles of adult learning (e.g., explanation, demonstration, questioning, group discussion, drills). (Strength of Evidence = C.) Involve the patient and caregiver, when possible, in pressure ulcer treatment and prevention strategies and options. Include information on pain, discomfort, possible outcomes, and duration of treatment, if known. Encourage the patient to actively participate in and comply with decisions regarding pressure ulcer prevention and treatment. (Strength of Evidence = C.) Educational programs should identify those responsible for pressure ulcer treatment and describe each person s role. The information presented and the degree of participation expected should be appropriate to the audience. (Strength of Evidence = C.) B. Assessing Tissue Damage i. Educational programs should emphasize the need for accurate, consistent, and uniform assessment, description, and documentation of the extent of tissue damage. (Strength of Evidence = C.) ii. Include the following information when developing an educational program on the treatment of pressure ulcers (Strength of Evidence = C.): Etiology and pathology. Risk factors. Uniform terminology for stages of tissue damage based on specific classification. Principles of wound healing. Principles of nutritional support with regard to tissue integrity. Individualized program of skin care. Principles of cleansing and infection control. 17

Worth remembering... Update educational programs on an ongoing and regular basis. Principles of postoperative care including positioning and support surfaces. Principles of prevention to reduce recurrence. Product selection (i.e., categories and uses of support surfaces, dressings, topical antibiotics, or other agents). Effects or influence of the physical and mechanical environment on the pressure ulcer, and strategies for management. Mechanisms for accurate documentation and monitoring of pertinent data, including treatment interventions and healing progress. iii. Update educational programs on an ongoing and regular basis to integrate new knowledge, techniques, or technologies. (Strength of Evidence = C.) C. Monitoring outcomes i. Evaluate the effectiveness of an educational program in terms of measurable outcomes: Implementation of guideline recommendations, healing of existing ulcers, reducing the incidence of new or recurrent ulcers, and preventing the deterioration of existing ulcers. (Strength of Evidence = C.) ii. Include a structured, comprehensive, and organized educational program as an integral part of quality improvement monitoring. Use information from quality assurance/improvement surveys to identify deficiencies, to evaluate the effectiveness of care, and to determine the need for education and policy changes. Focus in-service training on identified deficiencies. (Strength of Evidence = C.) Quality Improvement Recommendations follow on QI to facilitate comprehensive, consistent care of pressure ulcers. i. Obtain intradepartmental and interdepartmental QI support for pressure ulcer management as a major aspect of care. (Strength of Evidence = C.) ii. Convene an interdisciplinary committee of interested 18

and knowledgeable persons to address QI in pressure ulcer management. (Strength of Evidence = C.) iii. iv. Identify and monitor the occurrence of pressure ulcers to determine their incidence and prevalence. This information will serve as a baseline to the development, implementation, and evaluation of treatment protocols. (Strength of Evidence = C.) Monitor the incidence and prevalence of pressure ulcers on a regular basis. (Strength of Evidence = C.) v. Develop, implement, and evaluate educational programs based on the data obtained from QI monitoring. (Strength of Evidence = C.) Content excerpted from: 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. Department of Health and Human Services. May 1992. Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 95-0652. December 1994. 19

NATIONAL PRESSURE ULCER ADVISORY PANEL (NPUAP) Contents Statement on Pressure Ulcer Prevention............ 2 Introduction.................................. 2 Risk Assessment............................... 4 Intervention.................................. 4 Pressure Reduction............................ 5 Evaluation and Documentation................... 9 Education of Caregivers: Patients and Families....... 9 Conclusion.................................. 10 1

Statement on Pressure Ulcer Prevention (1992) Forward Millions of dollars are spent annually on pressure ulcer prevention and management. An effective national approach to pressure ulcer prevention will help to meet the National Pressure Ulcer Advisory Panel's (NPUAP) goal of reducing pressure ulcer incidence by 50% by the year 2000. This monograph is designed to assist clinicians with pressure ulcer prevention. The Agency for Health Care Policy Research, Public Health Service, U.S. Department of Health and Human Services, is developing a set of clinical practice Guidelines with the intent of assisting health care providers and patients to determine appropriate care for specific clinical conditions. The guideline on pressure ulcer prevention, Pressure Ulcers in Adults: Prediction and Prevention, was released May 18, 1992. A guideline for detecting and treating urinary incontinence was released earlier in 1992. A guideline on treatment of pressure ulcers is currently being developed. The AHCPR clinical practice guidelines are written by private-sector, multidisciplinary panels of experts. Several members of the NPUAP served on the AHCPR pressure ulcer prevention guideline panel. In March, 1991, the NPUAP also conducted the first public critique of the proposed AHCPR pressure ulcer prevention guideline. The dissemination of guidelines for the effective prevention and management of pressure ulcers is a goal of the NPUAP. The NPUAP presents this monograph as an interpretation and summary of the AHCPR Clinical Practice Guideline Pressure Ulcers in Adults: Prediction and Prevention. A concise summary of specific AHCPR recommendations for pressure ulcer prevention is presented in Table 1. Introduction Pressure Ulcers are defined as localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time. 2

3 DID YOU KNOW Incidence refers to the rate at which new cases occur in a population over a given time period; prevalence refers to the number of both new and old cases at any one time in the population. These wounds have been referred to by many names, including: decubitus ulcers bedsores pressure sores dermal ulcers pressure ulcers Because pressure is the critical factor in the development of these wounds, the term "pressure ulcer" is recommended to describe these lesions. Early intervention is designed for patients at increased risk for pressure ulcer development. The principle components of early intervention are: 1. Identification of at-risk individuals who need preventive interventions and of the specific factors that place them at risk 2. Maintenance and improvement of tissue tolerance to injury 3. Protection against the adverse effects of pressure, friction, and shear 4. Reduction of the incidence of pressure ulcers through educational programs Most pressure ulcers are preventable. However, in some cases it is unrealistic, and may even be in conflict with the overall plan of care or patient directives for a terminally ill patient, to subject the patient to aggressive preventive measures. Pressure ulcers can be an indication of the multi-system failure that accompanies the terminal stages of many disease processes. In these cases, patient comfort should be the primary goal. Pressure ulcer incidence has been used as an indicator of the quality of patient care. Is important that incidence and prevalence of pressure ulcers be differentiated. Incidence refers to the rate at which new cases occur in a population over a given time period, such as the number of new cases per year among the patients at a long term care facility.

Prevalence refers to the number of both new and old cases at any one time in the population, such as the proportion of patients in a long term care facility with pressure ulcers on a specified day--a cross-sectional view of the problem. Worth remembering... Factors most commonly associated with pressure ulcer development are: Immobility Inactivity Nutritional Factors Fecal and urinary incontinence Decreased perception Because patients may develop pressure ulcers in one health care facility and then be transferred to another facility, the incidence of new pressure ulcers is a more appropriate criterion to use for quality of care assessment. Risk Assessment Pressure ulcer risk assessment requires a comprehensive approach including skin assessment and evaluation of factors most commonly reported to be associated with pressure ulcer development immobility inactivity nutritional factors fecal and urinary incontinence decreased sensory perception Individuals may have multiple conditions that increase their susceptibility to pressure ulceration. Pressure ulcer risk assessment must be done systematically. An assessment tool that is validated for a specific type of patient population is recommended. There are several published pressure ulcer risk assessment instruments including the: Braden Scale Gosnell Scale Norton Scale Patients must be assessed for pressure ulcer risk on admission to any health care agency and reassessed periodically as their condition changes. Intervention When assessment identifies pressure ulcer risk before there is overt evidence of pressure-induced injury, interventions can be implemented to reduce the risk. 4

Skin Care 1. Healthy skin is clean and well-hydrated. Dry skin is evidenced by roughness and scaling. 2. Skin should be washed with warm water, using a mild cleansing agent to minimize excessive dryness. 3. Excessive friction and scrubbing are contraindicated. 4. Cleansing must be done at each time of soiling and at intervals consistent with good hygiene. 5. Non-alcohol based moisturizing agents are recommended. Although it is important to cleanse and moisturize all skin surfaces, aggressive massage has been shown to cause tissue damage, and must be avoided. Massage over bony prominences is especially likely to cause additional injury to pressure-damaged skin. Ideally, temperature and humidity should be maintained at levels that minimize damage to the patient's skin, such as MACERATION, cracking, or decrease in blood flow to the skin. Heat lamps should be avoided because they increase local tissue temperature and metabolic demands, dry the tissue, and may be a safety hazard. It is important to prevent mechanical injury to the skin from friction and shearing forces during repositioning and transfer activity. The key is to have a sufficient number of personnel available to move patients. Assistive devices such as lift sheets, trapezes, transfer boards, or mechanical lifts may be useful adjunctive devices to minimize tissue injury. Mechanical injury from friction can be reduced with dry lubricants, such as cornstarch, or application of barrier dressings such as TRANSPARENT FILMS and HYDROCOL- LOIDS. Pressure Reduction Intervention to reduce pressure over bony prominences are of primary importance. Immobile patients need to be maintained in proper alignment. Attention must be focused on maintaining and/or Figure 1 5

DID YOU KNOW Two hours in a single position is the maximum duration of time recommended for patients with normal circulatory capacity. enhancing functional ability. If not medically contraindicated, activity regimens may include physical therapy and/ or occupational therapy. A turning schedule must be established for patients who are confined to bed. Data do not indicate how often patients should be turned to prevent ischemia of soft tissue, but two hours in a single position is the maximum duration of time recommended for patients with normal circulatory capacity. For positioning, the "rule of 30" is used. This means that the head of the bed is elevated to 30 degrees or less (Figure 1) and the body is placed in a 30-degree laterally inclined position, when repositioned to either side (Figure 2). [Figures 1 and 2 adapted from J. Maklebust. Pressure ulcer update. RN, December 1991, pages 56-61. Original illustration by Jack Tandy. Used with permission.] If the head of the bed is elevated (e.g.., for eating, watching television) beyond 30 degrees, the duration of this position needs to be limited to minimize both pressure and shear forces. In the 30 degree laterally inclined position, the patient's hips and shoulders are tilted 30 degrees from supine and pillows or foam wedges are used to keep the patient properly positioned without pressure over the trochanter or sacrum. If tolerated, the prone position may also be used. Figure 2 Basics of Wound Care Based on the patient's risk and mobility status, pressure reducing MATTRESS OVERLAYS or MAT- TRESS REPLACEMENT UNITS may need to be employed. Health care agencies must have support surface protocols that describe the specific product(s) recommended and the indications for each. Pillows and cotton blankets are simple devices that are readily available for pressure reduction. When used judiciously, they expand the weight-bearing surface by molding to the body. 6

Pillows under the calf may be used to elevate the patient's heels off the bed surface. Cushioning devices should be placed between the legs/ankles to maintain alignment and prevent apposition of bony prominences. Commercially available pressure-reducing mattresses include: Worth remembering... Areas at particularly high risk in the seated person include: Ischial tuberosities Thoracic Spine Feet Heels foam static air alternating air gel water A small percentage of patients may need support surfaces with greater ability to reduce pressure, shear, friction, and moisture. These products may include: low air loss air-fluidized support surfaces Patients who are chair bound for long periods of time need appropriate seating surfaces, capable of safely reducing pressure while still providing adequate stability and support. Areas at particularly high risk in the seated person include ischial tuberosities thoracic spine feet heels Donut cushions are to be avoided because they can cause tissue ischemia. Selection of customized chair cushions requires the services of a qualified seating specialist. For those patients who are temporarily chair bound, consideration should be given to cushions that furnish maximum pressure reduction over the ischial tuberosities, adequate support, and comfort Proper body alignment is essential for chair bound patients. Patients who are able must be instructed to reposition themselves at 15-20 minute intervals. Patients who have sufficient upper body strength should be taught to do wheelchair push-ups. 7

Nutrition Nutrition is important for maintaining tissue integrity. Sufficient nutrients for individual needs must be available. Indicators of impaired nutritional status include: rapid weight loss inadequate intake decreased serum albumin/transferrin For patients with inadequate nutritional intake, strategies must be employed to increase oral intake. Patients must have diets prescribed with protein and caloric content sufficient to meet metabolic needs (this assumes that there are no medical contraindications for doing so). Dietary consultation is indicated for nutritional evaluation. The diet prescription should consider patient preferences and special needs, such as a dental soft diet for and endentuous patient. Assistance with meals may include opening food containers, elevating the head of the bed to allow the patient to eat or be fed, providing an environment conducive to eating and allowing sufficient time and assistance for optimal oral intake. When, despite these measures, patients are unable to consume adequate amounts of nutrients, tube feeding or parenteral alimentation should be considered. Patient and family preferences and the overall goals of treatment should guide these decisions. Incontinence Patients who are incontinent of urine and/or feces must have an adequate evaluation to identify whether reversible causes exist. Reversible causes include: urinary tract infection medications confusion fecal impaction polyuria due to glycosuria or hypercalcemia restricted mobility due to restraints A bowel training program must be instituted for spinal cord injury patients. Further evaluation and intervention should be considered if consistent with the patient's overall treatment goals. Preventing maceration of skin by managing excessive moisture can be 8

achieved through cleansing at appropriate intervals and the use of skin barriers and absorbent materials. Briefs, diapers, or absorbent underpads may be used if they are of the type that "wick" moisture away from the patient. Evaluation and Documentation The effectiveness of skin protection measures for high-risk patients must be evaluated as appropriate for the individual's condition and setting. Adjustments in preventive measures should be made as needed. Development of Stage I pressure ulcer(s) (NON-BLANCHABLE ERYTHEMIA) is an indication for intensifying interventions, such as: more frequent repositioning, use of topical skin management agents and/or dressings, and the use of pressure reducing devices Documentation must be done at regular intervals and should include: risk assessment skin evaluation therapies designed to maintain intact skin patient response to alterations in therapy, the rational for the alteration(s) the outcome of the skin care program Education of Caregivers: Patients and Families Responsibility for pressure ulcer prevention is shared by physicians, nurses, enterostomal therapy nurses, physical and occupational therapist, nutritionists, pharmacists, administrators, patients, and patients' families. Education of these groups is an important aspect of pressure ulcer prevention. Toward that end, appropriate educational programs that provide current research-based information should be offered at periodic intervals. Educational programs for health professionals must include: 1. Characteristics of normal, healthy skin 2. Elements of skin assessment 9

3. Characteristics of tissue deformation (tissue performance under mechanical loading) 4. Role of nutrition in pressure ulcer prevention 5. Pressure ulcer risk factors 6. Research-based risk assessment tools and their selection for specific populations 7. Etiology and staging of pressure ulcers 8. Proper techniques for turning, positioning, and repositioning 9. Indications and limitations of pressure-reducing devices/support surfaces 10. Indications and limitations of friction reducing products 11. Documentation of skin assessment and skin care program, including outcomes Programs presented for patient and/or family must include: 1. Etiology of pressure ulcers 2. Inspection of skin 3. Protection of skin 4. Proper, safe cleansing techniques and agents 5. Reduction of pressure ulcer risk 6. Role of nutrition in pressure ulcer prevention 7. Need for position changes 8. Proper/correct positioning techniques. 9. Proper use of pillows and/or other pressure reducing devices. 10. Skin and other health status changes to be reported to health care professionals. Conclusion Adherence to the principles in this monograph will help to prevent pressure ulcer development in most high-risk patients. The NPUAP believes that pressure ulcers are a major health problem, and recommends that health care professionals adopt the following: Prevention is the best solution to the pressure ulcer problem. Pressure ulcer prevention alleviates needless human suffering and unnecessary health care costs. Responsibility for pressure ulcer prevention is shared by health care professionals, bedside caregivers, patients, and families. 10

Content excerpted from: National Pressure Ulcer Advisory Panel. The Statement on Pressure Ulcer Prevention page. Available at: http://www.npuap.org/positn1.html. Accessed January 4, 2007. National Pressure Ulcer Advisory Panel. The PUSH Tool page. Available at: http://www.npuap.org/pdf/push3.pdf. Accessed January 4, 2007. Reproduction of the National Pressure Ulcer Advisory Panel (NPUAP) materials in this document does not imply endorsement by the NPUAP of any products, organizations, companies, or any statements made by any organization or company. 11

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) Contents CMS Guidance to Surveyors: Tags F309/F314........ 2 Tag F309: Quality of Care........................ 2 Definitions........................................... 2 Tag F314: Pressure Sores......................... 5 Definitions........................................... 5 Overview............................................ 8 Prevention of Pressure Ulcers............................ 9 Assessment.......................................... 10 Interventions........................................ 14 Monitoring......................................... 18 Assessment and Treatment............................. 18 Types of Ulcers....................................... 19 Ulcer Characteristics.................................. 19 Stages of Pressure Ulcers............................... 20 The Healing Pressure Ulcer............................. 22 Infections Related to Pressure Ulcers...................... 23 Pain............................................... 24 Dressings and Treatments.............................. 24 End Notes (References)................................ 25 1

CMS Manual System Pub. 100-07 State Operations Provider Certification Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 4 Date: NOVEMBER 12, 2004 SUBJECT: Guidance to Surveyors for Long Term Care Facilities I. SUMMARY OF CHANGES: Appendix PP, Tag F314, current Guidance to Surveyors, is entirely replaced by this revision which is to be inserted in the Appendix immediately after the regulatory text for F314. To complement the revision of F314, new language is being added to Tag F309 to include certain definitions of non-pressure related ulcers. Hypertext links are added for all Web sites listed in the Overview, (www.ahrq.gov, www.npuap.org, www.amda.org, www.medqic.org, www.wocn.org, and www.healthinaging.org ). Hypertext link is added in the Endnotes section to link to a CMS site (www.cms.hhs.gov/medicaid/survey-cert/siqhome.asp) for further information. NEW/REVISED MATERIAL - EFFECTIVE DATE*: November 12, 2004 IMPLEMENTATION DATE: November 12, 2004 Disclaimer for manual changes only: The revision date and transmittal number apply to the red italicized material only. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual not updated.) (R = REVISED, N = NEW, D = DELETED) (Only One Per Row.) R/N/D R R CHAPTER/SECTION/SUBSECTION/TITLE Appendix PP/483.25/Quality of Care/Tag F309 Appendix PP/483.25(c)/Pressure Sores/Tag F314 III. FUNDING: Medicare contractors shall implement these instructions within their current operating budgets. IV. ATTACHMENTS: Business Requirements x Manual Instruction Confidential Requirements One-Time Notification Recurring Update Notification *Unless otherwise specified, the effective date is the date of service. 2

F309 (Rev.4, Issued 11-12-04, Effective: 11-12-04, Implementation: 11-12-04) 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Use F309 for quality of care deficiencies not covered by 483.25(a)-(m). Intent: 483.25 The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident s right to refuse treatment, and within the limits of recognized pathology and the normal aging process. Definitions: 483.25 Highest practicable is defined as the highest level of functioning and well-being possible, limited only by the individual s presenting functional status and potential for improvement or reduced rate of functional decline. Highest practicable is determined through the comprehensive resident assessment by competently and thoroughly addressing the physical, mental or psychosocial needs of the individual. Skin Ulcer/Wound TIPS! Best practice clarification: Non-pressure ulcers need to be well documented, especially if they look like pressure ulcers. NOTE: Skin ulcer definitions are included to clarify clinical terms related to skin ulcers. At the time of the assessment and diagnosis, the clinician is expected to document the clinical basis (e.g., underlying condition contributing to the ulceration, ulcer edges and wound bed, location, shape, condition of surrounding tissues) which permit differentiating the ulcer type, especially if the ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one. o Arterial Ulcer is ulceration that occurs as the result of arterial occlusive disease when non-pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis. Inadequate blood supply to the extremity may initially present as intermittent claudication. Arterial/Ischemic ulcers may be present in 3