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Update on evidence-based guideline for pressure ulcers

June 1, 2010
by Catherine R. Ratliff, PHD, APRN-BC, CWOCN, CFNC and Nancy Tomaselli, MSN, RN, CS, CRNP, CWOCN, CLNC
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The Wound, Ostomy, and Continence Nurses Society (WOCN) has been a leader in the development of clinical practice guidelines for the care of patients with wounds, fecal and urinary diversions, and continence disorders since the late 1980s. In 2000, WOCN established a process to develop evidence-based guidelines for preventing and managing wounds due to pressure, venous, arterial, and diabetes/neuropathy. Four guidelines were developed and accepted by the National Guideline Clearinghouse (www.guideline.gov) and have been widely used by healthcare professionals. A level-of-evidence rating was established for the recommendations in each guideline.

The WOCN Guideline for Prevention and Management of Pressure Ulcers was originally published in 2003 and is intended for use by physicians, nurses, therapists, and other healthcare professionals. The goal of the guideline is to assist healthcare professionals to provide evidence-based care for prevention and management of pressure ulcers, serve as a guide for continued education, and provide direction for future research. To that end, the WOCN has recently updated the guideline to keep it current. The guideline task force developed the following questions to guide the evidence-based review of the literature:

  1. What factors are important to assess for pressure ulcer development?

  2. What are the major pressure ulcer prevention strategies?

  3. What support surfaces are appropriate for high-risk patients?

  4. What is the most appropriate method to diagnose the presence of infection in pressure ulcers?

  5. Are topical antibiotics, systemic antibiotics, or both, effective methods of treatment for infection in pressure ulcers?

  6. What topical dressings are most effective for treating pressure ulcers?

  7. What adjunctive therapies are most effective for treating pressure ulcers?

  8. What are the most effective support surfaces for patients with pressure ulcers?

  9. What methods or tools are used to assess healing of pressure ulcers?

  10. What is the role of surgery in treating pressure ulcers?

  11. What factors are the most influential in recidivism of pressure ulcers?

The primary authors of the guideline independently conducted searches of MEDLINE, CINAHL, and Cochrane Library databases for studies, published in English from January 2003 through October 2009. The medical subject headings used to search for research on each specific question were pressure sore, decubitus ulcer, and bedsore. The search targeted meta-analyses, randomized controlled trials, prospective clinical trials, retrospective studies, and systematic reviews. Reference lists of selected articles were also reviewed to identify relevant studies to include. After the two primary authors reviewed and rated the selected research studies, a written summary of the evidence was presented to all task force members for review, discussion, and clarification and a level-of-evidence rating was assigned to specific recommendations indicating whether there was support ranging from well conducted, randomized trials, nonrandomized studies, or case studies.

The recommendations in the guideline are divided into three areas: assessment, prevention, and treatment of pressure ulcers. The guidelines include recommendations for prevention and management strategies to address such areas as risk assessment, repositioning, pressure redistribution surfaces, skin care for incontinence, wound cleansing and debridement, use of topical and systemic antibiotics, adjunctive therapies, and patient/family education. Many of the recommendations in the guideline are based on case studies or expert opinion. Further research is needed to improve patient outcomes for prevention and treatment of pressure ulcers.

The Guideline for Prevention and Management of Pressure Ulcers will debut at the joint international conference of the Wound, Ostomy and Continence Nurses Society and World Council of Enterostomal Therapists in Phoenix, June 12 through 16, 2010. The complete guideline can also be purchased at WOCN's Web site (www.wocn.org).

Guideline Task Force

Margaret Goldberg, MSN, RN, CWOCN (Chair, Task Force)

Phyllis A. Bonham, PhD, MSN, RN, CWOCN, DPNAP, FAAN

Penny S. Crawford, RN, MSN, FNP, BC, CWOCN

Bonny G. Flemister, MSN, RN, CWOCN, ANP, GNP-BC

Jan J. Johnson, MSN, ANP-BC, CWOCN

Teresa J. Kelechi, PhD, MSN, RN, GCNS-BC, CWCN

Myra Fields Varnado, BS, RN, CDE, CWOCN

Ronald Palmer, Scribe

Catherine R. Ratliff, PhD, APRN-BC, CWOCN, CFNC, is Associate Professor at the University of Virginia School of Nursing as well as Program Director of WOC Graduate Program/Nurse Practitioner at the University of Virginia Health System. She serves as chair of WOC national wound guidelines committee, including pressure ulcer guidelines, chair of the WOC pressure ulcer guideline update, leader of several sections of NPUAP/EPUAP Pressure Ulcer Prevention and Treatment guidelines, and numerous publications and presentations on WOC issues.

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Comments

WOCN does great work. I am in the process of completing my PhD dissertation research involving development of a PU risk assessment instrument for use in hospital ancillary services units (radiology, interventional labs, etc.). I am very frustrated at the absence of consensus and quality research of PU risk factors. Will we ever slay that dragon?
M. Messer, RN, DNP, CWS

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