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Wound care teams have a new set of tools to improve outcomes.
Alvin Cunningham, 74, has been undergoing hemodialysis three times weekly for the past four months. His medical history includes type 2 diabetes, cardiovascular disease, a hemorrhagic cerebrovascular accident one year previously, and chronic renal failure. (This case is a composite based on our experience.) The cerebrovascular accident Mr. Cunningham experienced resulted in residual left hemiplegia necessitating assistance with personal care, repositioning, and transfer. His 6-ft., 230-lb. stature makes it impossible for his frail wife to manage his care at home, and he resides in a long-term care facility. His medications include sliding scale recombinant human insulin (Humulin R), calcium, and vitamin D supplements. His meal intake is consistently 90% to 100% of all servings, and he adheres to the prescribed 1,800-calorie renal diet.
He has recently developed depression related to the development of a new pressure ulcer. Four weeks earlier, redness was noted in the sacrococcygeal region, and it has since progressed into a full-thickness tissue injury (a stage III pressure ulcer), despite Mr. Cunningham's adherence to his repositioning regimen. Wound records from the past two weeks show that the ulcer has increased in area and depth, from 2 x 3 x 0.2 cm to 3 x 4 x 0.8 cm, while vacillating between signs of improvement ("healthy pink granulation") and reinjury ("yellow slough in the wound").
On examination there are no signs of infection. The pressure ulcer extends into the subcutaneous tissue. Its surface is 80% viable with scattered yellow slough, and the wound exudes small-to-moderate amounts of serous tan fluid. The skin perimeter is dusky but intact. The dressing regimen consists of wound irrigation with saline three times weekly and the application of a self-adherent foam dressing. At the onset of his sacrococcygeal erythema, Mr. Cunningham's pressure-redistributing foam mattress was replaced with a low-air-loss mattress. Before a recently noticed change in wheelchair activities, he spent an average of four to six hours a day positioned upright in the wheelchair, supported by a low-profile air cushion.
Pressure ulcers add a heavy personal and medical burden to medical care, causing patients mental anguish and pain, limiting normal activities, extending hospital stays, and increasing the risks of infection and death.1-3 More than 90% of pressure ulcers are caused by medical error, and at a cost of more than $3.8 billion per year (according to 2008 statistics), they rank among the most costly U.S. medical errors reported.4
A 2009 systematic review of 31 studies shows that when patient and caregiver education provided by competent wound care professionals includes information on how pressure ulcers develop and heal, personal burden becomes lighter and the quality of the patient's life improves.1 The use of evidence-based practice also improves pressure ulcer prevention and healing outcomes.5-8
A review of globally recognized pressure ulcer guidelines revealed many inconsistencies in definitions and recommendations from guideline to guideline. A multidisciplinary group of volunteers authorized by the Association for the Advancement of Wound Care (AAWC) first met in January 2008 to compile and condense the recommendations from 12 major pressure ulcer guidelines into a single, clinically relevant document (for a list of these guidelines, see Source Guidelines for the AAWC Pressure Ulcer Guideline). Among the volunteers contributing to the AAWC initiative were five certified wound ostomy continence nurses, including one who was also an advanced practice RN; a physician with a specialty in general surgery; two physical therapists, one with a PhD who is also a pressure ulcer patient and one holding a doctor of physical therapy degree and qualified as a clinical wound specialist; and two others holding PhDs, one of whom was a patient advocate.
According to the Institute of Medicine, guidelines one can trust should have clearly stated criteria for both strength of evidence and strength of recommendation.9 The Agency for Healthcare Research and Quality, formerly the Agency for Health Care Policy and Research (AHCPR), lists the highest level of evidence assigned to recommendations in guidelines as A. As stated in the AAWC pressure ulcer guideline evidence table, A-level criteria are met when "[r]esults of a meta-analysis or two or more [pressure ulcer-related] randomized controlled trials (RCT) on humans provide support (or for diagnostics or risk assessment: prospective cohort (CO) studies and/or controlled studies reporting diagnostic or predictive validity measures)." Recommendations in the source guidelines qualified for inclusion in the AAWC pressure ulcer guideline if they were supported by A-level evidence, were strongly recommended (had a "content validity index" of at least 0.75, as described below), or both. The AAWC Guideline Task Force summarized the strongest available evidence found in the MEDLINE and CINAHL databases; keywords from each recommendation were used to conduct the literature searches. A-level evidence criteria were adapted from the original AHCPR pressure ulcer treatment guidelines.10 Evidence meeting these criteria firmly supports clinical decisions in the face of all challenges long after consensus-based opinions change.
Content validity represented "strength of recommendation" in the AAWC pressure ulcer guideline and is a clear, unbiased measure of how clinically relevant the wound care professionals believed each recommendation to be. When insufficient evidence exists to support the use of a particular procedure, it is possible to validate its use through consensus and expert opinion, although it's important that this be done using a quantitative approach in which each respondent's opinion carries equal weight. In the case of the AAWC guideline, the content validity of all 368 recommendations collected was first determined by surveying a multidisciplinary group of 31 wound care professionals who responded to the survey online. Each respondent independently rated every recommendation's clinical relevance: 1 = not relevant; 2 = confusing or unable to assess relevance without more information; 3 = relevant but needs minor improvements; 4 = very relevant and succinct.
A recommendation met the strength-of-recommendation standard for inclusion in the AAWC guideline if its content validity index was at least 0.75; that is, 75% of survey respondents rated the recommendation as either 3 or 4. Because each survey respondent's rating carried equal weight, meaning that no participant could sway the consensus more than any other, this method quantified "strength of opinion" or "clinical wisdom" more rigorously than consensus procedures could.
Those recommendations backed only by content validity-reflecting a general belief among the surveyed clinicians of their relevance but lacking sufficient evidence to be called evidence based-represent opportunities for research, as was detailed by the AAWC Guideline Task Force in collaboration with La Asociacion Mexicana para el Cuidado Integral y Cicatrizacion de Heridas AC, the Canadian Association of Enterostomal Therapy, the Canadian Association of Wound Care, the National Pressure Ulcer Advisory Panel, and the Wound Healing Society.11
Recommendations that met neither content validity nor A-level evidence criteria were omitted from the final AAWC guideline.
The result of this process was the first comprehensive, evidence-based, and content-validated pressure ulcer guideline, the Association for the Advancement of Wound Care Guideline of Pressure Ulcer Guidelines. It was published as a guideline summary by the National Guideline Clearinghouse, part of the Agency for Healthcare Research and Quality, in April 2011 as Guideline Summary NGC-8120. It can be accessed at http://1.usa.gov/12hif2w. A more complete version, with information on the background, evidence, and methods used in developing the guideline; patient education materials; and the one-page reference brochure, AAWC Pressure Ulcer Guideline: A Quick Reference Guide for Pressure Ulcer Prevention and Treatment, is available from the AAWC at http://aawconline.org/professional-resources/resources (to access just the guideline itself on this site, click on "AAWC Pressure Ulcer Guidelines 8.11"). Articles describing pressure ulcer research and educational opportunities from these guidelines are also available on the Web site, as well as teaching slides and a pressure ulcer management checklist.
An algorithm for care. Also unique to the version on the AAWC Web site is an algorithm, on the last page of the guideline-adapted with the AAWC's permission in Figure 1, with A-level evidence-based recommendations in bold-that translates the guideline into clear, practical actions to aid clinicians in the assessment, diagnosis, prevention, and treatment of pressure ulcers and decrease patients' risk of developing them. Like the full guideline, the algorithm reflects practice supported by strong evidence, general clinical wisdom, or both; different type styles are used to help readers identify which practices were based on research evidence, which were based on strong opinion (content validity), and which were based on both. A clinician choosing to counter any recommendation shown in the algorithm to be based on A-level evidence should ideally provide a statement of clinical justification specific to the particular patient.
The studies used in the guidelines from which the AAWC recommendations were created have shown those practices to decrease pressure ulcer incidence, time to healing, infection rates, and costs of management across the continuum of care.6, 7, 10, 12, 13
At week 5, a community wound care specialist nurse was consulted on Mr. Cunningham's case because of the lack of progress toward healing over the previous four weeks. To ensure that AAWC guideline recommendations had been followed, the multidisciplinary wound care team reviewed all interventions (discussed below) that had already been in place or had been implemented since skin changes were noted.
Use of the Braden Scale had been initiated on admission to the facility, one year earlier, and continued, revealing that Mr. Cunningham was at moderate risk for pressure ulcer development. A Braden scale score of 14 was established because of the patient's loss of sensory perception, occasional skin wetness, chairfast status and limited mobility, dietary protein restrictions, and dependence regarding activities of daily living; that score, along with his age and renal and cardiac status, supported the clinicians' judgment that the tissue's tolerance to pressure and shear forces was low. Guideline-recommended weekly head-to-toe skin inspection had been carried out by the facility staff since admission, which had revealed the sacrococcygeal tissue injury three months after the initiation of hemodialysis.
Referring to the guideline for preventive interventions, the staff had placed a low-profile (3-in.) air cushion in Mr. Cunningham's wheelchair on admission to the facility to redistribute pressure when he was sitting, as well as a pressure-redistributing foam mattress on his bed. In addition, he was repositioned hourly when sitting and every two to four hours when in bed. Sitting intervals were limited to four hours to prevent prolonged pressure, and the head-of-bed elevation was limited to less than 30[degrees] to reduce tissue shear. Mr. Cunningham was encouraged to perform minor, self-directed position adjustments as much as he was able to. The nutrition staff monitored all meals to ensure consistent intake, and his body weight was recorded weekly. A toileting program was established for bowel management to limit excess skin moisture. Despite all these early interventions, the integumentary status changed, and he wasn't progressing toward healing.
After pressure ulcer onset. Weekly monitoring, performed according to guideline recommendations, showed that the sacrococcygeal ulcer wasn't decreasing in size. The nursing staff documented all changes in pressure ulcer length, width, and depth; wound bed color; devitalized tissue; surrounding skin color and condition; and the color, amount, and odor of drainage. The wound care team reviewed Mr. Cunningham's plan of care every 14 days and because of the lack of healing revised his care according to the guideline's recommendations. The dietitian recommended vitamin supplements and pursued physician input to optimize his nutritional status at week 3. The bed support had been changed to a low-air-loss mattress when skin changes were first observed, and the mattress setting was maintained at a level of inflation designated by the manufacturer's weight scale for gentle immersion in the surface; furthermore, no hammocking or bottoming out was observed. When the facility's revised care plan failed to improve Mr. Cunningham's pressure ulcer after four weeks, however, the staff brought the community wound care specialist nurse onto the multidisciplinary team to help restructure his plan of care.
The expanded team reevaluated Mr. Cunningham's care, looking for reasons his pressure ulcer had failed to improve over four weeks. They used the AAWC algorithm, which reaffirmed that their in-house program was consistent with care standards. They encouraged Mr. Cunningham to describe exactly when his wound pain was aggravated, which revealed that the only times his wound hurt were during transport to the dialysis center on the "hard stretcher" and after being confined in a recliner for the four-hour hemodialysis procedure. No cushions were employed during his dialysis stay, and he reports, "It gets uncomfortable by the time I'm ready to go." This led the team to consider factors outside their care environment that might have placed the patient at risk. The dialysis staff and transport agency were unaware that Mr. Cunningham had a pressure-induced injury and reported that they didn't have pressure-redistribution surfaces or cushions in their short-stay environments.
The wound care consultant, who was trained in selecting and evaluating pressure-redistribution devices, evaluated the transport and dialysis environments and determined ways in which pressure and weight distribution could be improved during these periods of confinement and provided information on suitable pressure-redistribution devices.
Mr. Cunningham and his family reviewed the guideline-based patient brochure and agreed to the use of an air overlay that would fit both the transport stretcher and the dialysis recliner, providing pressure redistribution during all off-site activity. Both inpatient and outpatient services were informed regarding use and maintenance of the overlay device. Fourteen days after implementation of the air overlay, Mr. Cunningham experienced a 50% reduction in wound size, resolution of all slough in the wound bed, and resolution of wound pain. Over the next 21 days the wound size and depth continued to decrease to the point of closure.
Mr. Cunningham's mood also improved. He admitted to the nursing staff that he had viewed his pressure ulcer as "the last straw" and that he'd been ready to "give up." Team-oriented investigations and problem solving, analysis of individual clinical and environmental factors, and the evidence-based, content-validated AAWC pressure ulcer guidelines provided a positive outcome for Mr. Cunningham and improved the quality of his life.
Guidelines exist to supplement clinical wisdom, not replace it. The Association for the Advancement of Wound Care Guideline of Pressure Ulcer Guidelines is unique in its addition of content validity-in this case, the equally weighted perspective of 31 independent wound care professionals-as an objective gauge of the strength of opinion-based recommendations. However, there is no substitute for the nurse's own knowledge of an individual patient's clinical, financial, and social situation or goals and capabilities. Guidelines supplement clinical wisdom with evidence and others' insights and can improve consistency and quality of care, and outcomes. They can also limit legal liability; when clinical wisdom dictates deviation from a guideline that has been incorporated into one's institutional protocol, clinicians who clearly document the reason (or reasons) for the deviation help all members of the wound care team stand united in their efforts to achieve the patient's unique goals.
This unique evidence-based, content-validated guideline allows clinicians to add the insights and research of those who have faced the same challenges to their own clinical wisdom. Good guidelines evolve and improve with regular updates as new evidence emerges, much of it from nursing professionals, to raise the level of support for the recommendations. For example, updated wording in the algorithm (which will appear later this year on the AAWC Web site) reflects current evidence on repositioning frequency better than the original guideline did14, 15: "Reposition at least every 4 hours when on a pressure-redistributing surface if patient appropriate and feasible."
Such guidelines not only support care decisions, they also reveal areas in which stronger research or education initiatives are needed to help ensure that patients benefit from the existing science. High-quality, evidence-based pressure ulcer guidelines give nursing staff-indeed, all members of the multidisciplinary wound care team-the opportunity to expand their knowledge of the available pressure ulcer science, so that they can deliver consistent, excellent care.
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2. Graves N, et al. Effect of pressure ulcers on length of hospital stay Infect Control Hosp Epidemiol. 2005;26(3):293-7 [Context Link]
3. Redelings MD, et al. Pressure ulcers: more lethal than we thought? Adv Skin Wound Care. 2005;18(7):367-72 [Context Link]
4. Shreve J, et al. The economic measurement of medical errors. Schaumburg, IL: Society of Actuaries; 2010 Jun. http://www.soa.org/research/research-projects/health/research-econ-measurement.a. [Context Link]
5. Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. [Context Link]
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9. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine. Clinical practice guidelines we can trust. Washington, DC: Institute of Medicine of the National Academies; 2011 Mar. Report brief; http://www.iom.edu/~/media/Files/Report%20Files/2011/Clinical-Practice-Guideline. [Context Link]
10. Bergstrom N, et al. Treatment of pressure ulcers, clinical practice guideline no. 15. Rockville, MD: Agency for Health Care Policy and Research; 1994 Dec. AHCPR publication no. 95-0652. AHCPR quick reference guides; http://www.ncbi.nlm.nih.gov/books/NBK63851. [Context Link]
11. Black J, et al. Understanding pressure ulcer research and education needs: a comparison of the Association for the Advancement of Wound Care pressure ulcer guideline evidence levels and content validity scores Ostomy Wound Manage. 2011;57(11):22-35 [Context Link]
12. Kobza L, Scheurich A. The impact of telemedicine on outcomes of chronic wounds in the home care setting Ostomy Wound Manage. 2000;46(10):48-53 [Context Link]
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14. Reddy M, et al. Preventing pressure ulcers: a systematic review JAMA. 2006;296(8):974-84 [Context Link]
15. Vanderwee K, et al. Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers Age Ageing. 2005;34(3):261-7 [Context Link]
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