In my previous column, Checklist for Improved Wound Outcomes: Part 1, we reviewed the differentiating factors for arterial, diabetic, and venous ulcers. Now, let’s examine another wound type, pressure ulcers (PrUs), through the lens of evidence-based practice guidelines.
Evidence-based practice is the acknowledgment of uncertainty followed by assessment, appraisal, and then implementation of the new knowledge.1 In wound care, the comprehensive wound assessment follows the patient assessment. The wound assessment will define the status of the wound and begin to identify impediments to the healing process.2 Knowing these assessment parameters, your goal is to map quality improvement measures in concert with your clinical practice to improve your patient’s outcome.
It is unclear how many people in the United States have PrUs, although the Agency for Healthcare Research and Quality (AHRQ)3 reported in 2008 that hospitalizations involving patients with PrUs—developed either before or after admission—increased by nearly 80% between 1993 and 2006. AHRQ’s analysis found that of the 503,300 PrU–related hospitalizations in 2006:
* PrUs were the primary diagnosis in about 45,500 admissions—up from 35,800 in 1993.
* PrUs were a secondary diagnosis in 457,800 hospital admissions—up from 245,600 in 1993. These patients were admitted primarily for pneumonia, infections, or other medical problems.
* Among hospitalizations involving PrUs as a primary diagnosis, about 1 in 25 admissions ended in death. The death rate was higher when PrUs were a secondary diagnosis—about 1 in 8.
* PrU-related hospitalizations are longer and more expensive than many other hospitalizations. Although the overall average hospital stay is 5 days and costs about $10,000, the average PrU–related stay is 13 to 14 days and costs $16,755 to $20,430, depending on medical circumstances.
As an aid to risk assessment and management, AHRQ published 2 booklets for healthcare professionals: Pressure Ulcers in Adults: Prediction and Prevention, and Treatment of Pressure Ulcers. The agency also published a handbook for patients, available in English and Spanish, titled Preventing Pressure Ulcers: A Patient’s Guide to Treating Pressure Sores. Although these resources were published in 1992 and 1994, respectively, they continue to provide the basic guidelines needed to develop a sound program. In addition, the Wound, Ostomy, and Continence Nurses Society published guidelines for PrU care, titled Prevention and Management of Pressure Ulcers.
In 2009, the European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) developed Quick Reference Guides for the Prevention and Treatment of Pressure Ulcers as a 4-year collaborative effort. The more comprehensive Clinical Practice Guideline version of these guidelines provides a detailed analysis and discussion of available research, critical evaluations of the assumptions and knowledge of the field, description of the methodology used to develop the guideline, and acknowledgments of editors, authors, and other contributors. The Quick Reference Guide contains excerpts from the Clinical Practice Guideline, but users should not rely on these excerpts alone.
The goal of this international collaboration was to develop evidence-based recommendations for the prevention and treatment of PrUs that could be used by healthcare professionals throughout the world. An explicit scientific methodology was used to identify and evaluate available research. In the absence of definitive evidence, expert opinion (often supported by indirect evidence and other guidelines) was used to make recommendations. Guideline recommendations were made available to 903 individuals and 146 societies or organizations registered as stakeholders in 63 countries on 6 continents. The final guideline is based on the available research and the accumulated wisdom of the EPUAP, NPUAP, and international stakeholders. Both documents are available through the NPUAP website at http://www.npuap.org. The Quick Reference Guide has been translated into several languages; translations are available on the EPUAP website at http://www.epuap.org.
Source: Hess CT. Clinical Guide: Skin and Wound Care. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
1. Dawes M, Davies PT, Gray AM, Mant J, Seers K, Snowball R, eds. Evidence-Based Practice: A Primer for Health Care Professionals. Oxford, UK: Churchill Livingstone Publishers; 1999.
2. Hess CT, Kirsner RS. Orchestrating wound healing: assessing and preparing the wound bed. Adv Skin Wound Care 2003: 6: 246–57.