International Guideline - National Pressure Ulcer Advisory Panel

169 Pages·2012·1.87 MB·English

International
Guideline
Pressure Ulcer Treatment
Technical Report

©National Pressure Ulcer Advisory Panel & European Pressure
Ulcer Advisory Panel

2009
Treatment Technical Report

Table of Contents

Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Suggest Citation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Limitations and Appropriate Use of This Guideline . . . . . . . .. . . . . . . . . . . 3
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Guideline Developers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Methodology for Guideline Development. . . . . . . . . . . . . . . . . . . . . . . . .. 20
International NPUAP-EPUAP Pressure Ulcer Classification System . . . . 29

Pressure Ulcer Treatment Tables
Classification of Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Assessment and Monitoring of Healing . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Role of Nutrition in Pressure Ulcer Healing . . . . . . . . . . . . . . . . . . . . . . . 50
Pain Assessment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Support Surfaces for Treatment of Pressure Ulcers . . . . . . . . . . . . . . . . . 74
Cleansing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
Assessment and Treatment of Infection . . . . . . . . . . . . . . . . . . . . . . . . ..117
Biophysical Agents in Pressure Ulcer Management . . . . . . . . . . . . . . . . 124
Growth Factors for Pressure Ulcer Treatment . . . . . . . . . . . . . . . . . . . . 134
Surgery for Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140
Pressure Ulcer Management in Individuals Receiving Palliative Care . 160

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Treatment Technical Report

Foreword
The International Pressure Ulcer Guideline summarizes recommendations and
supporting evidence for pressure ulcer prevention and treatment. It was
developed as a 4-year collaborative effort between the European Pressure
Ulcer Advisory Panel (EPUAP) and American National Pressure Ulcer Advisory
Panel (NPUAP). It provides a detailed analysis and discussion of available
research, critical evaluations of the assumptions and knowledge of the field, a
description of the methodology used to develop the guideline, and the
acknowledgments of editors, authors, and other contributors.

The Clinical Practice Guideline is intended for professionals interested in both
the recommendations for pressure ulcer care and the scientific evidence
supporting those recommendations. A Quick Reference Guide version is also
available that contains excerpts from the Clinical Practice Guideline. The Quick
Reference Guide version is intended for busy clinicians who need a “quick”
reference in caring for individuals with pressure ulcers and/or who are at risk
for developing pressure ulcers. Users should not rely on these excerpts alone.

This Pressure Ulcer Treatment Technical Report includes the evidence tables
used as a basis for guideline development. It is intended for researchers,
educators and clinicians who wish to more fully explore the research
supporting the treatment recommendations and evidence summaries
presented in the Clinical Practice Guideline.

Printed copies of the English editions of the Clinical Practice Guideline and
Quick Reference Guide are available through the NPUAP website
(www.npuap.org). The Quick Reference Guide has been translated into several
languages; translations are available on the EPUAP website (www.epuap.org).
The Prevention Technical Report and Treatment Technical Report are only
available in electronic version from NPUAP (www.npuap.org) and EPUAP.

The goal of this international collaboration was to develop evidence-based
recommendations for the prevention and treatment of pressure ulcers that
could be used by health care 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.
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Guideline recommendations were made available to 903 individuals and 146
societies/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.

Suggested Citation
The EPUAP and NPUAP welcome the use and adaptation of this guideline at a
national and local level. However, we request citation as to the source, using
the following format:

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory
Panel. Pressure Ulcer Treatment: Technical Report. Washington DC: National
Pressure Ulcer Advisory Panel; 2009. Available at www.npuap.org.

Limitations and Appropriate Use of This Guideline
• Guidelines are systematically developed statements to assist practitioner
and patient decisions about appropriate health care for specific clinical
conditions. The recommendations may not be appropriate for use in all
circumstances.
• The decision to adopt any particular recommendation must be made by the
health care professional in light of available resources and circumstances
presented by the individual patient. Nothing contained in this guideline is to
be considered medical advice for specific cases.
• Because of the rigorous methodology used to develop this guideline, the
NPUAP and EPUAP believe that the research supporting these
recommendations is reliable and accurate. However, we do not guarantee the
reliability and accuracy of individual studies referenced in this document.
• This guideline and any recommendations herein are intended for
educational and informational purposes only.
• This guideline contains information that was accurate at the time of
publication. Research and technology change rapidly and the
recommendations contained in this guideline may be inconsistent with future
advances. The health care professional is responsible for maintaining a
working knowledge of the research and technological advances that may
affect his/her practice decisions.
• Generic names of products are provided. Nothing in this guideline is
intended as an endorsement of a specific product.
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• Nothing in this guideline is intended as advice regarding coding standards or
reimbursement regulations.

Abstract
This guideline is the result of a collaborative effort between the American
National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer
Advisory Panel (EPUAP). A comprehensive literature review was conducted on
pressure ulcer prevention and treatment. A rigorous scientific methodology
was used to analyze available research and to make evidence-based
recommendations for the prevention and treatment of pressure ulcers. Drafts
of the guideline were made available to 903 individuals and 146
societies/organizations registered as stakeholders in 63 countries on 6
continents. All stakeholder comments were carefully considered by guideline
developers. Explicit recommendations and summaries of supporting evidence
are provided for the following aspects of pressure ulcer prevention: etiology,
risk assessment, skin assessment, nutrition, repositioning, support surfaces,
and special pressure ulcer preventive needs of patients in the operating room.
Recommendations and research were also summarized for a wide variety of
topics related to pressure ulcer treatment: classification of pressure ulcers,
assessment and monitoring of healing, the role of nutrition in healing, pain
assessment and management, support surfaces, principles of wound bed
preparation (i.e., cleansing, debridement, dressing selection, assessment and
treatment of infection), biophysical agents (e.g., electrical stimulation,
negative pressure wound therapy), surgery, and management in individuals
receiving palliative care. The NPUAP and EPUAP also agreed on an
international classification system for pressure ulcers with the hope that it
will be adopted internationally and therefore help reduce discrepancies in
international reporting of pressure ulcer incidence and prevalence.

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Guideline Development Group

EPUAP
Carol Dealey, PhD, RN (EPUAP Chair)
Research Development Team,
University Hospital Birmingham, NHS Foundation Trust,
Birmingham, United Kingdom

Michael Clark, PhD
Wound Healing Research Unit, Cardiff University,
Cardiff, United Kingdom

Tom Defloor, PhD, RN
Nursing Science, Ghent University, Ghent, Belgium

Lisette Schoonhoven, PhD, RN
Nursing Science, St Radboud University,
Nijmegen, The Netherlands

Katrien Vanderwee, PhD, RN
Nursing Science, Ghent University, Ghent, Belgium

Anne Witherow, RN
Associate Director of Nursing, Western Health and Social
Care Trust, Northern Ireland

NPUAP
Janet Cuddigan, PhD, RN CWCN
(NPUAP Co-Chair & Editor-in-Chief)
University of Nebraska Medical Center, Omaha, NE, USA

Diane K. Langemo, PhD, RN, FAAN
(NPUAP Co-Chair)
University of North Dakota, Grand Forks, ND, USA

Mona M. Baharestani, PhD, ANP, CWON, CWS
East Tennessee State University, Johnson City, TN, USA
James H. Quillen
Veterans Affairs Medical Center, Johnson City, TN, USA

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Joyce Black, PhD, RN, CWCN, CPSN
University of Nebraska Medical Center, Omaha, NE, USA

Evan Call, MS
Weber State University, Centerville, UT, USA

Mary Ellen Posthauer, RD, CD, LD
Supreme Care West, LLC, Evansville, IN, USA

Consultants
Steven Black, MD, FACS served as a medical consultant to the Guideline Development
Group. Dr. Black is a plastic surgeon at The Nebraska Medical Center, Omaha, NE, USA.
Phillip Smith, MD served as a consultant on the assessment and management of
infection. Dr. Smith is a Professor in Internal Medicine and Chief of the Infectious
Diseases Section at the University of Nebraska Medical Center in Omaha, NE, USA. He
is a Fellow of the American College of Physicians and the Infectious Diseases Society of
America.

Small Working Group (SWG) Members
Prevention
Aetiology: Cees Oomens (Leader), José Verdu Soriano, Dan Bader & Amit Gefen • Risk
Assessment: Jane Nixon (Leader), Jacqui Fletcher, Alexander Heyneman, Helvi
Hietanen, Jeannie Donnely, Khryz Gebhardt, Maureen Benbow, Zena Moore & Katrien
Vanderwee • Skin Assessment: Carol Dealey (Leader), Katrien Vanderwee, Lisette
Schoonhoven, Tom Defloor • Nutrition for Pressure Ulcer Prevention: Jos Schols
(Leader), Ruud Halfens, Pam Jackson, Gero Langer, Judith Meijers & Hilde Heyman •
Repositioning for Prevention of Pressure Ulcers: Zena Moore (Leader), Trudie Young,
Anna Polak & Hilde Heyman • Support Surfaces: Lena Gunningberg (Leader), Andrea
Bellingeri, Paulo Alves, Mark Collier, Katia Furtado, Jan Weststrate & Erik de Laat •
Special Population: Patients in the Operating Room: Lisette Schoonhoven (Leader)
Lena Gunningberg (Leader), Andrea Bellingeri, Paulo Alves, Mark Collier, Katia Furtado,
Jan Weststrate & Erik de Laat

Treatment
Classification of Pressure Ulcers: Joyce Black (Leader), Janet Cuddigan, Tom Defloor &
Courtney Lyder • Assessment & Monitoring of Healing: Janet Cuddigan (Leader),
Susan Garber & Diane Langemo • Role of Nutrition in Pressure Ulcer Healing: Mary
Ellen Posthauer (Leader), Becky Dorner, David Thomas & Steven Black • Pain
Assessment & Management: Diane Langemo (Leader) & Barbara Bates-Jensen •
Support Surfaces for Treatment of Pressure Ulcers: Evan Call (Leader), Joyce Black,
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Steven Black, David Brienza, Janet Cuddigan, Kim Davis, Susan Garber, Diane Langemo
& Steven Reger • Wound Bed Preparation & Biofilms: Greg Schultz • Cleansing:
Catherine Ratliff (Leader), George Rodeheaver & Greg Schultz • Debridement: Mona
Baharestani (Leader), Steven Black & Carrie Sussman • Dressings: Joyce Black (Leader),
Laurie McNichol (Leader) & Karen Zulkowski (Leader), Sharon Baranoski, Barbara
Bates-Jensen & Joann Maklebust • Assessment & Treatment of Infection: Catherine
Ratliff (Leader), Joyce Black, Janet Cuddigan, George Rodeheaver & Greg Schultz •
Biophysical Agents in Pressure Ulcer Management: Teresa Conner-Kerr (Leader),
Carrie Sussman, Luther Kloth, Laura Edsberg & Diane Langemo • Negative Pressure
Wound Therapy: Joyce Black & Laurie McNichol • Biological Dressings & Growth
Factors: Laura Edsberg (Leader), Harold Brem, Aimee` Garcia & Greg Schultz • Surgery
for Pressure Ulcers: Steven Black (Leader), Joyce Black & Harold Brem • Pressure Ulcer
Management in Individuals Receiving Palliative Care: Diane Langemo (Leader) &
Barbara Bates-Jensen, with assistance from Steven Antokal & Nicole Hayes

Acknowledgments

The European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure
Ulcer Advisory Panel (NPUAP) gratefully acknowledge the contributions of the
following individuals and groups for financially supporting the presentation
and dissemination of the guideline. All financial contributions were made
after the guideline was developed and in no way influenced the development
of the guideline or its content. Financial contributions are being used for the
printing and dissemination of the guideline. The following companies
provided unrestricted education grants:

NPUAP Donors
Platinum Level Contributor ($20,000 or greater)
Kinetic Concepts, Inc
Gold Level Contributor ($10,000 to $19,999)
American Medical Technologies, Inc
Silver Level Contributors ($1,000 to $9,999)
Coloplast
EHOB, Incorporated
Genesis HealthCare
HCR ManorCare
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Nestlé Nutrition
Smith & Nephew
Bronze Level Contributor ($1,000 or less)
SAM Medical Products

EPUAP Donors
ArjoHuntleigh, Europe
Hill-Rom, Europe
Nutricia Advanced Medical Nutrition
Kinetic Concepts, Inc

In Kind Contributions
 McGoogan Library, University of Nebraska Medical Center, Omaha,
NE, USA (database searches by a professional librarian & interlibrary
loan services)
 College of Nursing, University of Nebraska Medical Center, Omaha,
NE, USA
 World Union of Wound Healing Societies and the University of
Toronto, Toronto, CA (initial database searches)
 The Registered Nurses of Ontario, Royal College of Nursing,
Consortium on Spinal Cord Injury Medicine, Agency for Health Care
Policy and Research (now AHRQ) provided evidence tables used to
support previous guidelines.
 Eran Ganz-Lindgren reviewed an article written in Hebrew.

Stakeholders
Special thanks go to the many stakeholders across the globe who reviewed
guideline processes and drafts. All stakeholder comments were reviewed by
the EPUAP-NPUAP Guideline Development Group. Revisions were made
based on these comments. We appreciate the investment of clinicians,
researchers, educators, and manufacturers from all over the world who took
the time to share their expertise and thoughtful critique. The guideline
recommendations are better because of you!

Special thanks go to Timothy J. Gilbert, BA his excellent work in preparing this
document and supporting the work of the Guideline Development Group.

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Executive Summary

Significance
Pressure ulcers are painful, costly, and often preventable complications that
threaten many individuals in hospitals, nursing homes, and home care. They
remain a frequently occurring health care problem throughout the world. A
European pilot survey undertaken by the European Pressure Ulcer Advisory
Panel (EPUAP), which included 5947 patients located in Belgium, Italy,
Portugal, Sweden, and the United Kingdom, found an overall prevalence of
18.1%, although there was some variation between countries (1). In 2001, The
National Pressure Ulcer Advisory Panel (NPUAP) estimated that pressure ulcer
prevalence in American hospitals was 15% and the incidence 7% (2).

More recent national studies fail to demonstrate sustained significant
declines in American hospitals or other health care settings (3, 4). Prevalence
and incidence rates are often higher in unique populations such as those
receiving palliative care in home hospice (5, 6), those with spinal cord injuries
(7), and in critical care units (8). Pressure ulcers represent a major burden of
sickness and reduced quality of life for patients and their carers (9–11).
Increased morbidity and mortality associated with pressure ulcer
development in hospitalized patients is documented in multiple studies (12–
15). Hospital lengths of stay, readmission rates, and hospital charges are
greater in patients who develop pressure ulcers than in those remaining
ulcer-free (12–14, 16). The development of a single pressure ulcer in U.S.
hospitals can increase a patient’s length of stay five-fold and increase hospital
charges by $2,000–11,000 (12). Recent European cost-models to highlight the
cost of illness associated with pressure ulcers have indicated that the total
costs may consume between 1% in the Netherlands (17) and 4% in the United
Kingdom (18) of health care expenditure.

Purpose and Scope
The goal of this guideline is to provide evidence-based recommendations for
the prevention and treatment of pressure ulcers that can be used by health
care professionals throughout the world. The purpose of the prevention
recommendations is to guide evidence-based care to prevent the
development of pressure ulcers. The prevention recommendations will apply
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