Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of PhysiciansFREE
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations based on the comparative effectiveness of risk assessment scales and preventive interventions for pressure ulcers.
This guideline is based on published literature on this topic that was identified by using MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists. Searches were limited to English-language publications. The outcomes evaluated for this guideline include pressure ulcer incidence and severity, resource use, diagnostic accuracy, measures of risk, and harms. This guideline grades the quality of evidence and strength of recommendations by using ACP's clinical practice guidelines grading system. The target audience for this guideline includes all clinicians, and the target patient population is patients at risk for pressure ulcers.
ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. (Grade: weak recommendation, low-quality evidence)
ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence)
ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: weak recommendation, moderate-quality evidence)
Pressure ulcers are defined as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure alone or in combination with shear (1). They commonly occur in patients with limited mobility, such as those in hospitals or long-term care settings. It is estimated that up to 3 million adults in the United States are affected by pressure ulcers (2). The prevalence in the United States is estimated to range from 0.4% to 38% in acute care hospitals, 2% to 24% in long-term care nursing facilities, and 0% to 17% in home care settings (2–4). Between 1990 and 2001, pressure ulcers were reported as a cause of death in nearly 115 000 persons and were listed as the underlying cause of death in more than 21 000 (5). The estimated cost of treating each case of pressure ulcers ranges from $37 800 to $70 000, and up to $11 billion is spent annually in the United States to treat pressure ulcers (2, 6, 7). A growing industry has developed to market various products for pressure ulcer prevention.
Risk factors for pressure ulcers include older age; black race or Hispanic ethnicity; lower body weight; cognitive impairment; physical impairments; and other comorbid conditions that affect soft tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition (8–11). Various risk assessment instruments have been developed, including the Braden, Cubbin and Jackson, Norton, Ramstadius, and Waterlow scales.
Prevention strategies for pressure ulcers begin with identification of high-risk persons. Many interventions designed to prevent pressure ulcers and reduce friction and shear are available, and categories include various support surfaces (such as mattresses, integrated bed systems, overlays, and cushions), repositioning, nutritional supplementation, skin care (for example, dressing and management of incontinence), and topical creams (Table 1). Studies have suggested that prevention of hospital-acquired pressure ulcers is more effective than standard care (12). Although this guideline focuses on a comparative effectiveness review of individual interventions, we understand that care teams often implement multicomponent interventions or bundled approaches to preventing pressure ulcers and that pressure ulcer care involves physicians, nurses, and other members of the care team.
The purpose of this American College of Physicians (ACP) guideline is to present the available evidence on the comparative effectiveness of various risk assessment instruments and benefits and harms of strategies to prevent pressure ulcers. The target audience for this guideline is all clinicians, including physicians, nurses, dieticians, and physical therapists. The target patient population comprises all adults at risk for pressure ulcers. For recommendations on the treatment of pressure ulcers, please refer to the accompanying ACP guideline (13).
This guideline is based on a systematic evidence review (14), an update of the literature (Supplement), and an evidence report sponsored by the Agency for Healthcare Research and Quality (AHRQ) (17) that addressed the following key questions:
1. Is the use of risk assessment tools effective in reducing the incidence or severity of pressure ulcers, and how does effectiveness vary according to setting and patient characteristics?
2. How do various risk assessment tools compare with one another in their ability to predict the incidence of pressure ulcers?
3. In patients at increased risk for pressure ulcers, what is the effectiveness and comparative effectiveness of preventive interventions in reducing the incidence or severity of pressure ulcers, and how does effectiveness vary according to assessed risk level, setting, or patient characteristics?
4. What are the harms of interventions for preventing pressure ulcers? Do harms differ according to the type of intervention, setting, or patient characteristics?
We searched MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists to identify trials published in English. The outcomes evaluated for this guideline include pressure ulcer incidence and severity; resource use (including duration of hospital stay or cost); diagnostic accuracy (sensitivity, specificity, and positive and negative likelihood ratios); measures of risk (hazard ratios, odds ratios, and relative risks); discrimination (area under the receiver-operating characteristic curve); and harms, such as dermatologic reactions, discomfort, and infection.
We also supplemented the AHRQ evidence review with another systematic evidence review of multicomponent strategies for preventing pressure ulcers that examined the importance of contextual aspects of programs that aim to reduce facility-acquired pressure ulcers (16). This review included implementation studies (from 2000 to September 2012) of multicomponent initiatives to prevent pressure ulcers in adults in U.S. acute and long-term care settings. Studies were limited to those that reported pressure ulcer rates at least 6 months after implementation of the intervention.
Further details about the methods and inclusion and exclusion criteria applied in the evidence review are available in the full AHRQ report (15) and the Supplement. This guideline rates the quality of evidence and strength of recommendations by using ACP's guideline grading system (Table 2). Details of the ACP guideline development process can be found in ACP's methods paper (17).
Comparative Effectiveness of Risk Assessment Tools for Reducing the Incidence or Severity of Pressure Ulcers
Low-quality evidence from 1 good-quality study showed no difference among the Waterlow scale, the Ramstadius tool (an unvalidated combination risk assessment and intervention protocol), and nurses' clinical judgment alone in reducing the risk for pressure ulcers or length of stay in patients (18). A recent Cochrane review supported this conclusion, citing lack of evidence to conclusively show a difference between the risk assessment tools and clinical judgment in reducing pressure ulcer incidence (19). No study evaluated the effectiveness of risk assessment tools across care settings or patient subgroups.
Comparative Diagnostic Accuracy of Risk Assessment Tools for Predicting the Incidence of Pressure Ulcers
Moderate-quality evidence showed that the Braden, Cubbin and Jackson, Norton, and Waterlow scales had low sensitivity and specificity to identify patients at risk for pressure ulcers. In addition, moderate-quality evidence showed that diagnostic accuracy did not differ substantially among the scales (15). Low-quality evidence showed no clear differences in diagnostic accuracy of the Braden scale according to patient characteristics or settings, with lower optimal cutoffs for surgical or acute care patients. Moderate-quality evidence showed no clear differences in diagnostic accuracy of the Braden scale according to baseline pressure ulcer risk. Although the Cubbin and Jackson scale was initially developed for patients in intensive care units, low-quality evidence showed that it had a similar diagnostic accuracy to the Braden and Waterlow scales in this setting (20, 21). Tables 3 and 4 provide descriptions of the scales as well as sensitivities and specificities; more details are available in the full evidence report (15).
Evidence Related to Individual Interventions
Effectiveness and Comparative Effectiveness of Preventive Interventions to Reduce the Incidence or Severity of Pressure Ulcers
Many interventions were studied by only 1 trial each, and pooling of studies was not practical because of methodological limitations and clinical diversity of the studies. Table 5 summarizes the evidence for the various preventive interventions. Static (moderate-quality evidence) (55–59) and alternating-air (low-quality evidence) (74–76) mattresses or overlays reduced pressure ulcer incidence compared with standard hospital mattresses. Evidence was mixed or showed no statistically significant difference for comparisons of other support surfaces (61–69, 71–83). Low-quality evidence showed no difference in risk for pressure ulcers or mixed results for heel supports or boots (84, 85), different wheelchair cushions (86–89), nutritional supplementation (90–95), various dressings (101, 102), intraoperative warming (103), and various repositioning intervals (low- to moderate-quality evidence) (96–100, 108, 109). Low-quality evidence showed that a skin cream containing fatty acid and a skin cleanser other than soap decreased risk for pressure ulcers (60, 110, 111).
Harms of Interventions to Prevent Pressure Ulcers
A total of 16 trials reported harms for interventions to prevent pressure ulcers. Although details on specific harms were sparse, no serious treatment-related harms were reported. In summary, evidence was insufficient to determine how harms of preventive interventions vary according to the type of intervention, care setting, or patient characteristics.
Mattresses, Overlays, and Other Support Systems
Low-quality evidence from 9 studies of support surfaces reported harms. Heat-related discomfort was reported in 3 trials of sheepskin overlays, which also led to withdrawals (56, 57, 60). One trial reported differences in pain and sleep disturbances between different dynamic mattresses (110). A study comparing a multicell pulsating dynamic mattress with a static gel overlay found no differences in risk for adverse events (111). One study reported no increased risk for adverse events with the Heelift Suspension Boot (DM Systems) compared with standard care (84). One study reported an increased risk for withdrawal due to discomfort with the Jay cushion compared with standard wheelchair cushions (88).
Low-quality evidence from 1 study reported that tube feeds were poorly tolerated (54% removed within 1 week and 67% removed within 2 weeks) (93).
Low-quality evidence from 2 studies reported increased nonadherence due to intolerability of repositioning at a 30-degree tilt position compared with standard positioning (108, 109).
Low-quality evidence from 1 study showed that application of the Remois Pad (Alcare) resulted in pruritus in 1 patient out of 37 total (112).
Creams, Lotions, and Cleansers
Low-quality evidence from 3 studies reported harms for lotions or creams. Two studies reported 1 case each of a wet sore or rash, and 1 study showed no differences in rash between various creams studied (106, 113, 114).
Interventions to Facilitate Implementation of Pressure Ulcer Prevention Protocols or Guidelines
Low-quality evidence from 1 study showed no difference in incident stage 2 to 4 ulcers between a multicomponent electronic clinical decision-support system or provision of guidelines (1.8% vs. 2.1%; relative risk, 0.85 [95% CI, 0.23 to 3.10]) (107). Evidence from 1 poor-quality study showed that immediate implementation of musical cues was associated with lower risk for incident ulcers in nursing home residents (6.0% vs. 9.4%; relative risk, 0.64 [CI, 0.45 to 0.90]) (115).
Evidence Related to Multicomponent Interventions
Multicomponent interventions are increasingly becoming the standard of care for prevention of pressure ulcers. Bundling care practices and organizing a team approach to care have been shown to be effective at improving patient outcomes.
Moderate-quality evidence from a review of 26 implementation studies showed that multicomponent interventions can improve skin care and reduce pressure ulcer rates in both acute and long-term care settings (16). The review found that key components of successful interventions include simplification and standardization of pressure ulcer–specific interventions and documentation, involvement of multidisciplinary teams and leadership (including ostomy, continence, and other nurses and personnel), designated skin champions who educate staff about skin care and ulcer prevention, ongoing staff education (including team meetings and motivational campaigns), and sustained audit and feedback (including weekly prevalence reports, formal and informal feedback, and all-facility meetings) (16). Successful interventions also incorporated evidence-based guidelines into their practices.
The systematic review found no harms reported for the multicomponent strategies that were used to prevent pressure ulcers (16).
The systematic review identified 4 studies (116–120) that reported significant cost savings with the multicomponent approach. In 2008, a 2-hospital system (548 beds in Naples, Florida) estimated annual cost savings of approximately $11.5 million as a result of statistically significant reductions in pressure ulcer prevalence (117).
Low-quality evidence showed that risk assessment tools (the Waterlow and Ramstadius scales) were equivalent to clinical judgment alone for reducing pressure ulcer incidence. Evidence on the diagnostic accuracy of the commonly used risk assessment instruments showed that these tools can help in the identification of patients who are at an increased risk for pressure ulcers, although the sensitivities and specificities were low. Diagnostic accuracy did not differ substantially among the various risk assessment instruments, and studies of direct comparisons were limited.
Most of the evidence on preventive interventions came from studies assessing support surfaces. Moderate-quality evidence showed that advanced static mattresses and overlays were associated with a lower risk for pressure ulcers compared with standard mattresses in higher-risk patients. Evidence on other preventive interventions, including nutritional supplementation, lotions, cleansers, and dressings, was limited and inconclusive because most were assessed by few studies.
Little evidence was available on harms of preventive interventions, although no serious harms were reported. Evidence was also insufficient to draw a conclusion about harms based on the type of intervention, care setting, or patient characteristics.
All of the preventive interventions reviewed in this guideline were assessed individually, but they can be bundled to provide optimum care. Evidence shows that multicomponent strategies can improve clinical outcomes. Key components of successful implementation efforts include simplification and standardization of pressure ulcer–specific interventions and documentation, involvement of multidisciplinary teams and leadership, designated skin champions, ongoing staff education, and sustained audit and feedback. The Figure summarizes the recommendations and clinical considerations.
Recommendation 1: ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. (Grade: weak recommendation, low-quality evidence)
Risk assessment is often part of bundled care and multicomponent interventions for preventing pressure ulcers. Risk factors for pressure ulcers include older age; black race or Hispanic ethnicity; lower body weight; cognitive impairment; physical impairments; and other comorbid conditions that affect soft tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition. Clinicians should make individualized decisions based on risk assessment on whether to use a single or multicomponent intervention to prevent pressure ulcers in patients.
The current evidence does not conclusively show a difference between clinical judgment and risk assessment scales in reducing pressure ulcer incidence. However, tools may be especially useful for clinicians without expert gestalt. Moderate-quality evidence showed that the Braden, Cubbin and Jackson, Norton, and Waterlow scales can predict which patients are more likely to develop a pressure ulcer, and all of these instruments have low sensitivity and specificity. In addition, moderate-quality evidence showed that the diagnostic accuracies of the scales do not differ substantially. No study evaluated the effectiveness of risk assessment tools across care settings or patient subgroups.
Recommendation 2: ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence)
Moderate-quality evidence showed that the use of advanced static mattresses or overlays was associated with a lower risk for pressure ulcers compared with standard hospital mattresses, and no brand was shown to be superior. Advanced static mattresses and overlays are also less expensive than alternating-air or low–air-loss mattresses and can be used as part of a multicomponent approach to pressure ulcer prevention.
Recommendation 3: ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: weak recommendation, moderate-quality evidence)
The current evidence does not show a clear benefit for pressure ulcer prevention using alternating-air beds and overlays compared with static mattresses and overlays, and alternating-air beds and overlays are associated with significantly higher costs. Lower-cost support surfaces should be the preferred approach to care.
Inconclusive Areas of Evidence
Evidence is insufficient to compare various preventive interventions, such as different types of repositioning and leg elevations, relative to various kinds of usual care. Creams and lotions, dressings, repositioning, and nutritional support, in any combination, are generally regarded as usual care. Of note, the comparison group in many studies was standard care that often included repositioning, skin care, and/or nutrition. Therefore, any lack of evidence showing benefit relative to the comparison group of usual care does not mean that usual care should be abandoned.
Data on the efficacy of many of the interventions came only from single studies, and further research into comparative effectiveness of pressure ulcer prevention strategies is warranted. In addition, more research is needed on the comparative efficacy of pressure ulcer risk assessment tools and their efficacy compared with clinical judgment.
Prevention of pressure ulcers is the first important step, and advanced static mattresses and overlays were associated with a lower risk for pressure ulcers compared with standard mattresses in higher-risk patients. Many hospitals in the United States use alternating-air and low–air-loss mattresses and overlays despite the lack of evidence showing a potential benefit in the reduction of pressure ulcers in high-risk populations. Using these support systems is expensive and adds unnecessary burden on the health care system. Based on the review of the current evidence, lower-cost support services should be the preferred approach to care.
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Author, Article, and Disclosure Information
From the American College of Physicians, Philadelphia, Pennsylvania; New York University Clinical Cancer Center, New York, New York; and Carilion Clinic, Roanoke, Virginia.
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Acknowledgment: The authors thank Dr. Roger Chou for updating the evidence from the original systematic review for the development of this guideline.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1567. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Corresponding Author: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, aqaseem@acponline.
Current Author Addresses: Drs. Qaseem and Starkey: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Mir: New York University Clinical Cancer Center, 160 East 34th Street, New York, NY 10016.
Dr. Denberg: Carilion Clinic, PO Box 13727, Roanoke, VA 24036.
Author Contributions: Conception and design: A. Qaseem, T.P. Mir.
Analysis and interpretation of the data: A. Qaseem, M. Starkey, T.D. Denberg.
Drafting of the article: A. Qaseem, T.P. Mir, M. Starkey, T.D. Denberg.
Critical revision of the article for important intellectual content: A. Qaseem, M. Starkey, T.D. Denberg.
Final approval of the article: A. Qaseem, T.P. Mir, T.D. Denberg.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem, M. Starkey, T.D. Denberg.
Collection and assembly of data: A. Qaseem, M. Starkey.
* This paper, written by Amir Qaseem, MD, PhD, MHA; Tanveer P. Mir, MD; Melissa Starkey, PhD; and Thomas D. Denberg, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians. Individuals who served on the Clinical Guidelines Committee from initiation of the project until its approval were Thomas D. Denberg, MD, PhD (Chair); Michael J. Barry, MD; Molly Cooke, MD; Paul Dallas, MD; Nick Fitterman, MD; Mary Ann Forciea, MD; Russell P. Harris, MD, MPH; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schünemann, MD, PhD; J. Sanford Schwartz, MD; Paul Shekelle, MD, PhD; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 26 July 2014.