Understanding Pressure Ulcer Research and …...22 OSTOMY WOUND MANAGEMENT NOVEMBER 2011 AA ERE Understanding Pressure Ulcer Research and Education Needs: A Comparison of the Association

22 OSTOMY WOUND MANAGEMENT NOVEMBER 2011 www.o-wm.com

AAWC FEATURE

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 ScoresJoyce Black, PhD, RN, CPSN, CWCN, FAAN; Sue Girolami, RN, BSN, CWOCN; M. Gail Woodbury, BSc, BScPT, MSc, PhD; Mary Hill, RN, BScN, MN, CETN(C); José Contreras-Ruiz, MD; JoAnne D. Whitney, PhD, RN, CWCN, FAAN; and Laura Bolton, PhD

AbstractAlthough difficult to quantify due to methodological variations, the worldwide burden of pressure ulcers (PUs) is sub-stantial. Recognizing the importance of providing evidence-based care to help reduce this burden, the North American Wound Care Council societies collaborated to identify PU research and education opportunities using the PU “Guideline of Guidelines” developed and tested by Association for the Advancement of Wound Care Guideline Department (AAWC GD). Volunteer AAWC GD members compiled recommendations from PU guidelines available in 2008, searched the lit-erature for additional research as needed, and developed evidence levels for all recommendations using an established level-of-evidence rating scheme. At the same time, AAWC members and Ostomy Wound Management readers were invited via email to participate in a content validation study of the 368 recommendations, rating items on a scale of 1 (not relevant) to 4 (very relevant and succinct). Items with a content validity index (CVI) >0.75 were considered valid. Recom-mendations with support from two or more randomized controlled PU trials or two or more cohort studies for diagnostic or predictive validity (A-level evidence) and a CVI >75 were grouped as ready for implementation. Recommendations with content validity but without A-level evidence were determined to be opportunities for research; recommendations that lacked content validity but that had A-level evidence were viewed as opportunities for education. Thirty-two (32) multidisciplinary healthcare professionals participated in the content validation study. Most (93.2%) recommendations were rated as valid. Of the 97 (26%) recommendations with A-level evidence, 90 (24.5% of total) met both strong content validity and strong evidence criteria and were rated as ready for implementation as standard of care. Most recommendations (253, 68.8%) were rated as valid but had B- or C-level evidence, representing opportunities for research. Only seven (1.9%) recom-mendations had a low CVI but A-level evidence, suggesting a need for education. The results show that most of the guideline recommendations are valid, that the number of PU intervention recommendations with A-level evidence is increasing, but that, in general, the need for research to replace opinion with evidence remains high across the entire spectrum of PU prevention and treatment. Understanding what is known (recommendation: ready to implement), what is not known (research needed), and what clinicians need to know (education needed) is an important step toward reducing the burden of pressure ulcers. Keywords: pressure ulcer, guideline of care, evidence levels, content validity, education, research

Index: Ostomy Wound Management 2011;57(11):22–35

Potential Conflicts of Interest: Joyce Black has received speaker honoraria, served as a consultant or paid advisory board member, and/or received research grants from Cardinal Health (Dublin, OH), Celleration Inc. (Eden Prairie, MN), Coloplast Corp, (Minneapolis, MN), Hill-Rom (Batesville, IN), KCI (San Antonio, TX), Mölnlycke Health Care (Norcross, GA), and Sage Products, Inc. (Cary, IL). Additional author disclosures appear at the end of this article.

Dr. Black is an Associate Professor, College of Nursing, Adult Health and Illness Department, University of Nebraska Medical Center, Omaha, NE. Ms. Girolami is a Clinical Manager, Therapy Support, Inc., Cincinnati, OH; and Co-Chair, Association for the Advancement of Wound Care Guideline Department. Dr. Wood-bury is a Research Consultant to the Canadian Association of Wound Care; and Adjunct Faculty Member, jointly, at the School of Physical Therapy and the De-partment of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada. Ms. Hill is a Consultant Enterostomal Therapist; and Past President Canadian Association of Enterostomal Therapists, Ottowa, Ontario, Canada. Dr. Contreras-Ruiz is Director, Interdisciplinary Wound and Ostomy Care Center. Division of Dermatology, Dr. Manuel Gea Gonzalez General Hospital, Mexico City, Mexico. Dr. Whitney is a Professor, Biobehavioral Nursing and Health Systems; and Acting Associate Dean for Research, Harborview Medical Center Endowed Professor in Critical Care, University of Washington, Seattle, WA. Dr. Bolton is an Adjunct Associate Professor, Department of Surgery (Bioengineering), University of Medicine and Dentistry of New Jersey-Robert Wood Johnson University Medical School (UMDNJ-RWJUMS), New Brunswick, NJ; and Co-Chair, Association for the Advancement of Wound Care Guideline Department. Please address correspondence to: Laura Bolton, PhD, BoltonSCI, LLC, 15 Franklin Place, Metuchen, NJ 08840; email: [email protected].

NOVEMBER 2011 OSTOMY WOUND MANAGEMENT 23www.o-wm.com

PRESSURE ULCER GUIDELINE EVIDENCE

Economic, Social, and Clinical Burden of Pressure Ulcers

Pressure ulcer (PU) prevalence, incidence, and cost re-porting methods vary across different healthcare systems, so the true magnitude of the global burden of PU is difficult to estimate. The costs of treating PUs in the US grew from an estimated $1.3 billion in 1992 to $17.2 billion in 2003, with an average charge of $21,675 per PU treated.1 Actuarial analysis of the 6,319,486 medical errors reported in the US in 2008 described the occurrence of 374,964 PUs as the most frequent and expensive medical error, costing more than $3.8 million.2 In UK general practice, the annual PU prevalence among patients at least 65 years of age was 0.31% to 0.70%, with PU incidence rising with increasing age to 3.3 per 100 person years for those older than 95 years of age.3

Due to the associated pain, related restrictions on social activities, and rehabilitation activities required, PUs also rep-resent a personal burden. PU development can extend hospi-tal length of stay from four4 to 30 days.5 In a prospective co-hort study of 286 patients with a PU identified within 3 days of admission to a tertiary care urban teaching hospital, All-man et al5 reported that when compared to individuals with-out PUs, persons who developed PUs also were more likely to develop nosocomial infections (P = 0.001) and other hospital complications (P <0.001). Septicemia was the underlying or contributing cause of death recorded from death certificates in 40% of the 114,380 PU-associated deaths in 1990–2001 (0.4% of the total) and is the probable causal link between PUs and death.6,7

The burden of living with PUs extends beyond costs to the healthcare system and loss-of-life. Gorecki et al’s8 systematic review of 31 studies found PUs significantly limit many as-pects of an individual’s well-being, including general health and physical, social, financial, and psychological quality of life. The patients in these studies needed knowledge of how the PU developed and how they or others would care for it. They reported improved quality of life when the ulcer healed and that competent care providers were of benefit.

Evidence-based Practice for Consistent Quality CareEvidence-based practice can improve the efficiency and

effectiveness of clinical interventions.9-11 In the last two de-cades, much of the PU prevention and treatment evidence has been propagated through evidence-based guidelines. Professionals around the world have generated evidence-based PU prevention and treatment guidelines.12,13 Many are accessible at the Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse (NGC) website (www.guidelines.gov) or from PU organizations such as the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), and the Wound Healing Society (WHS).

In 2009, the NPUAP and EPUAP released their jointly developed Pressure Ulcer Prevention and Management

Guidelines and published summaries on the websites of both organizations. In a parallel initiative to improve the consistency and quality of PU management,14 the Associa-tion for the Advancement of Wound Care Guideline De-partment (AAWC GD) compiled PU recommendations from guidelines posted by NGC in 2008,15-25 as well as those of the WHS26 and draft27-29 NPUAP-EPUAP International Guidelines (see Table 1) into one document.

Once the AAWC GD compiled best available evidence and established the content validity of clinical relevance for each recommendation, disparities between strength of evidence and strength of opinion (content validity) became clear. These disparities highlighted recommendations that need-ed either more research or more education to improve the consistency and quality of PU care. During the 2009 North American Wound Care Council meeting in Queretaro, Mex-ico, attending societies (see Table 2) pledged to collaborate in publishing these PU management recommendations re-quiring research or education as a way to guide related initia-tives throughout all organizations, thus improving guideline implementation and PU outcomes.

Purpose The purpose of this report is to: 1) describe the develop-

ment and testing of the AAWC “Guideline of Pressure Ulcer Guidelines”, 2) tabulate the strength of evidence and content validity of individual recommendations, and 3) review con-sistencies and inconsistencies between available evidence and relevance ratings (content validity) in order to 4) identify PU prevention and management education and research needs.

Background, Methods, and Procedures A review of existing PU guidelines14 revealed inconsisten-

cies in PU definitions and management. The AAWC autho-rized its multidisciplinary voluntary guideline department

Key Points• In2008,afterdevelopingaguidelinebasedonexist-

ing pressure ulcer guidelines, volunteer members of the AAWC Guideline Department culled and analyzed existing evidence levels of the 368 recommendations within the document.

• Aftercompletionofacontentvalidationstudy(N=32),it was realized that evidence levels did not con-sistently match the opinions of the volunteers who completed the validation study.

• Afewrecommendationswereremovedforlackofevi-dence and content validity.

• Theresultsshowthenumberofrecommendationswith A-level evidence is increasing, but research is still needed to inform a wide variety of current opinions.

Ostomy Wound Management 2011;57(11):22–35


AAWC FEATURE

(AAWC GD) to develop a comprehensive evidence-based, content-validated PU “Guideline of Pressure Ulcer Guide-lines”. This project was called the AAWC Pressure Ulcer Care Initiative (PUCI). The AAWC GD compiled PU management recommendations from available guidelines (see Table 1). Rec-ommendations were grouped into sections addressing PU risk and wound assessment, prevention, and treatment. Standards of PU care from all the guideline reviews were collated into

368 unique recommendations. AAWC members (N = 1,708) and readers of Ostomy Wound Management (N = approxi-mately 23,000) were invited to participate in a content-val-idation survey accessible online at the AAWC website from December 12, 2008 through February 28, 2009. Thirty-two (32) multidisciplinary clinicians responded and completed the survey (see Participating surveyors/respondents).

Participants were asked to rate the relevance of each of the 368 recommendations to best-practice PU care using the following 4-point rating scale: 1 = not clinically relevant; 2 = wording or content confusing and unable to assess relevance without further information; 3 = relevant but needs minor improvement to make relevant and succinct (list recommen-dation in comment box); and 4 = very relevant and succinct.

The content validity index (CVI) was calculated as percent rated relevant (3) or very relevant (4) and considered accept-able if the CVI was at least 0.75.30

Strength of literature-based evidence criteria (see Table 3) were adapted from original AHCPR Pressure Ulcer Guide-lines15,16 to include criteria for diagnostic and screening evi-dence.31 The AAWC GD team searched MEDLINE, CINAHL, and Cochrane literature databases for all 368 recommen-dations to establish standardized strength of best available evidence; A-level evidence for treatment or prevention rec-ommendations was defined as two or more randomized con-trolled trials (RCTs) on individuals with a PU. For PU diag-nosis or risk assessment recommendations, A-level evidence was two or more PU RCTs or PU cohort studies reporting diagnostic or predictive validity for scales designed to diag-nose or screen PU risk (see Table 3).

Using the above criteria for content validity and strength of best available evidence (see Table 4), the authors reviewed the 368 PUCI recommendations to identify PU research and education opportunities. Recommendations with a high CVI (>0.75) and A-level evidence were identified as “ready to im-plement” as best practice PU standards of care. Recommen-dations with content validity but lacking A-Level evidence

Agency for Health Care Policy and Research (AHCPR): Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15

AHCPR: Pressure ulcers in adults: Prediction and pre-vention. Clinical Practice Guideline, No. 3.

American Society of Plastic Surgeons: Evidence based clinical practice guideline: chronic wounds of the lower extremity

Consortium for Spinal Cord Medicine Clinical Practice Guidelines: Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guide-line for health-care professionals

National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP): International guidelines for pressur ulcer prevention and treatment

The John A. Hartford Foundation (JHF) Institute for Ge-riatric Nursing; Pressure Ulcer Prevention, 2003

National Collaborating Centre for Nursing and Support-ive Care and National Institute for Clinical Excellence (NCCNNS/NICE): The use of pressure-relieving de-vices (beds, mattresses, and overlays) for the preven-tion of pressure ulcers in primary and secondary care

Paralyzed Veterans of America (PVA): Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health care professionals

Registered Nurses Association of Ontario (RNAO): Guidelines for risk assessment and prevention of pressure ulcers

Registered Nurses Association of Ontario (RNAO): Assessment and Management of Stage I to IV pressure ulcers

Wound Healing Society: Guidelines for the treatment of pressure ulcers

Wound, Ostomy, and Continence Nurses Society (WOCN): Guideline for prevention and management of pressure ulcers

Table 1. Guideline sources included in the Associa-tion for the Advancement of Wound Care Guideline Department (AAWC GD) Pressure Ulcer Manage-ment Recommendations

Association for the Advancement of Wound Care (AAWC) www.aawconline.org

Canadian Association of Enterostomal Therapy (CAET) www.caet.ca

Canadian Association of Wound Care (CAWC) www.cawc.net

La Asociación Mexicana para el Cuidado Integral y Cicatrización de Heridas AC (AMCICHAC) www.amcichac.com

National Pressure Ulcer Advisory Panel (NPUAP) www.npuap.org

Wound Healing Society (WHS) www.woundheal.org

Table 2. North American Wound Care Council (NAWCC) Collaborating societies



were identified as “opportunities for research” to further validate them as standards of practice. Recommendations lacking content validity but supported by A-level evidence were identified as “opportunities for education” to increase awareness among bedside practitioners. Recommendations lacking both content validity and supporting evidence were identified as “not ready for implementation or inclusion” in an evidence-based content-validated guideline. Recommen-dations were compiled, tabulated, and summarized to inform and guide future practice and research. Results

The average CVI was 0.75 or higher for most (93.2%) of the 368 recommendations (see Figure 1). Of the 6.8% with a CVI <0.75, seven (1.9%) had A-level evidence, indicating an opportunity for education, and 18 (4.9%) had C-level evi-dence, suggesting a need for research and/or education.

Most recommendations (63.0%) were supported by C-Level evidence (see Figure 2). Among the 97 (26.4%) rec-ommendations with A-level evidence, 90 (24.5% of total) met both strong content validity and strong evidence crite-ria. Recommendations meeting “ready for implementation” criteria are summarized in Column 1, Table 5 (available in

PDF format with this article at www.o-wm.com). In addi-tion, recommendations supported by A-level evidence are listed in bold print in the AAWC Guideline of Pressure Ulcer Guidelines, accessible along with evidence tables and profes-sional implementation tools at aawconline.org under the sec-tion on Professional Resources or available in published for-mat through the National Guideline Clearinghouse at www.guidelines.gov; key search words aawc pressure ulcer.

Of the 232 (63.0%) recommendations supported by C-level evidence, 214 (58.2%) had a CVI >0.75, represent-ing significant opportunities for research (see Column 2, Table 5). The 18 (4.9%) with C-level evidence and a CVI <0.75 were considered not relevant, not evidence-based, and therefore not appropriate for inclusion in an evidence-based, content-validated PU guideline (see Table 6, avail-able in PDF format with the article online at www.ow-m.com). Among the 97 (26.4%) recommendations supported by A-level evidence, 90 (24.5%) had a CVI >0.75. The re-maining seven recommendations with a CVI <0.75 (1.9%) represent opportunities for education (see Column 3, Table 5). The 39 (10.6%) recommendations supported by B-level evidence all had a CVI >0.75 and represent areas believed to be effective with at least one RCT (or cohort study report-ing screening or diagnostic validity for PU risk or PU as-sessment measures) supporting efficacy. These recommen-dations are nearly ready for implementation, requiring only one more qualifying study before meeting the standardized criterion for evidence-based practice. Overall, most re-search is needed in the areas of PU treatment and preven-tion (see Figure 3), key areas affecting both PU outcomes and costs of care.

Opportunities for education. Seven pressure ulcer man-agement recommendations were supported by A-level evi-dence but were not rated as relevant, suggesting needs for education (see Table 4 and Table 5).

Level A. Results of a meta-analysis or two or more pressure ulcer (PU)-related randomized controlled trials (RCT) on humans provide support (or for diag-nostics or risk assessment: prospective cohort [CO] studies and/or controlled studies reporting recog-nized diagnostic or predictive validity measures)

Level B. Results of one PU-related RCT in humans plus two or more similar historically controlled trials (HCT) or convenience controlled trials (CCT), or one HCT and one CCT provide support or when appropri-ate, results of two or more RCTs in an animal model validated as clinically relevant to PU provide indirect support. For diagnostics or risk assessment, one PU-related prospective CO study and/or a controlled study reporting recognized diagnostic or predictive validity measures

Level C. This rating requires one or more of the following: − C1: Results of one controlled trial on PU prevention or

treatment — eg, RCT, CCT, or HCT (or for diagnostics or risk prediction one prospective CO study may be substituted for a controlled trial)

− C2: Results of at least two case series (CS) or de-scriptive studies or a cohort study in humans

− C3: Expert opinion (EO)

Table 3. Definitions and levels of strength of evi-dence ratings (adapted15,16,33)

Table 4. Criteria for opportunities for research or education

Level of evidence and content validity

Research or education opportunity status

A-level evidence and CVI value >0.75

Strong evidence and valid-ity: ready for implementation

<A-level evidence and CVI value >0.75

Strong content valid-ity only: opportunity for research

A-level evidence and CVI value <0.75

Strong evidence only: op-portunity for education

<A-level evidence and CVI value <0.75

Weak evidence and con-tent validity: opportunity for research and education


AAWC FEATURE

1. Using a valid, reliable anthropometric measurement or body mass index (BMI) assessed by properly trained staff while conducting the nutritional assessment was identified as a PU risk factor in one RCT32 and four cohort studies,33-36 but the recommendation had a CVI of 0.71.

2. Culture or ethnicity can affect family and self-care at-titudes and practices related to risk of developing a PU. Bergstrom and Braden37 noted a higher incidence of new PU for whites (15%) than blacks (5%) in 843 Midwest nursing homes, tertiary care, or Veteran’s Administration medical fa-cilities. Saladin et al38 reported that in a sample of 475 reha-bilitation hospital residents with spinal cord injury, African Americans and Native Americans had the highest odds of de-veloping a PU during the last recorded 12 months. Low social support and high injury severity also were associated with PU risk. Among 114,380 PU-caused US deaths from 1990–2001, Redelings et al6 reported higher mortality rates for Af-rican Americans than for other racial/ethnic groups. The low content validity score for this recommendation may reflect variations among the studies in setting, social support, and outcome measures reported, important factors to address in this opportunity for education.

3/4. Measuring technique for PU length and width as part of PU assessment. Using either technique, geometric longest length and longest perpendicular width,39-42 or anatomi-cal head-toe length and side-side width,43-44 is supported by A-level evidence as long as one method is used consistently within institutions and across the care continuum to track individual PU healing progress. Both methods had strong evidence and a CVI <0.75, making both techniques oppor-tunities for education.

5. Safety and efficacy of some enzymatic debridement in-terventions had A-level evidence with low content validity.

Prospective RCTs have reported collagenase efficacy similar in debriding efficacy to that of some enzymes45 or autolytic debridement46 and less effective than papain-urea, which is no longer available in some countries, although healing re-sults were similar.47

6. Use of a hydrocolloid dressing either alone as a PU dressing48,49 or sequentially with calcium alginate dressings50 had A-level RCT evidence with a CVI = 0.71. Systematic re-views44,51 concluded that hydrocolloid dressings are more ef-fective at healing PU than gauze, and one48 further concluded that they have more absorption capacity, require less time for dressing change, and induce less pain during dressing change with fewer side effects than any form of gauze studied. Other reviews and meta-analyses confirm the conclusions that PU heal more cost effectively when dressed with a hydrocolloid dressing compared to gauze52 and with less pain and fewer infections compared to PUs dressed with gauze.53,54

7. Application of infrared or monochromatic light stimula-tion as an adjunctive intervention to manage PUs unrespon-sive to conventional therapy after 30 days was supported by three RCTs55-57 conducted on more than 200 Stage I to Stage III PUs, and one controlled study on a PU model in mice.58

One area where low content validity (CVI = 0.52) de-scribed clinical reality more accurately than best available evidence was in use of topical growth factors, which are not indicated for PU management. Gauze dressings were used to deliver growth factors and placebo (considered substan-dard practice41) in two PU RCTs,59,60 so growth factor per-formance may not have been optimized in these studies. No RCTs compared growth factors to moisture-retentive dressings such as hydrocolloid, hydrogel, or foam dressings, a practice that represents best evidence for healing and cost effective PU outcomes.44

Research opportunities. The 253 recommendations supported by strong opinion (CVI >0.75) and less than A-level evidence are opportunities for research summarized below for each aspect of PU management. The number of content-validated recommendations needing more research to qualify for an A-level evidence base is listed in paren-theses after each major category of PU management. Most recommendations needing research were in the areas of PU treatment and prevention.

Patient assessment (54 recommendations or 14.6% of 368). Research is needed to validate the need for all patient and PU assessments to be performed consistently on approved institutional forms or tools accessible to all members of the interdisciplinary PU or wound management team. Required frequency of PU risk assessment needs research in all settings, as does screening or diagnostic efficacy of having a previous or current PU as a risk factor for PU development.

Nutritional PU risk factor assessments needing validation research include factors affecting swallowing or nutrient in-take, absorption or retention status, and laboratory reports of total protein, hematocrit, or transferrin.

Figure 1. Distribution of average content validity index and evidence levels of the 368 pressure ulcer patient and ulcer assessment, prevention, and treatment rec-ommendations *Belief exceeds evidence: one more qualifying study needed for content-validated, evi-dence-based status.


AAWC FEATURE

Medical/surgical history factors requiring validating re-search to confirm value in PU management include docu-menting a comprehensive systems assessment. This entails recording sensory deficits; bowel and bladder habits; lower extremity perfusion deficits; edema; spastic or flaccid ex-tremities; range of motion; malignancy; renal, pulmonary, or other severe chronic or terminal disease or condition; a history of extended pressure from hard surfaces related to Emergency Department wait, or ambulance ride; and proce-dures related to dialysis, catheters, or radiology.

Psychological and quality of life assessment parameters needing research to validate their value in PU management include sufficient cognition and motivation by patient, fam-ily, and care provider to use and follow-through on protocols of care, plus access to skilled, knowledgeable healthcare pro-fessionals and social, financial, and reimbursement resources to empower proper action.

Environmental assessment factors requiring research to verify value in PU care include documentation of posture irregularities, access to and proper fitting or use of devices, and prescribed offloading or pressure-redistribution mo-dalities avoiding pressure, friction, and shear during all cli-ent/patient activities or interactions with staff, such as re-positioning or transfers.

Physical exam including PU assessment (21 recommenda-tions or 5.7% of 368). Research is needed to validate perform-ing head-to-toe assessment of bony prominences and devia-tions, as well as areas of skin in contact with removable tubes or other devices. Ulcer staging requires stronger validation research, as does documenting PU evolution, duration, com-plications, and related treatment. Required frequency of PU assessment also needs research.

Diagnostic tests requiring more research to support their value in managing PU include vascular laboratory tests of tissue perfusion, blood analysis to assist in diagnosing infec-tion or comorbid conditions affecting healing, testing PU biopsies after 12 weeks of nonhealing for suspected malig-nancy, and patient-appropriate bone imaging for suspected osteomyelitis.

PU prevention of occurrence or recurrence (75 recommenda-tions or 20.4% of 368). Recommendations for all aspects of skin inspection and maintenance required further research to support efficacy in improving PU outcomes. These include inspecting skin beneath clothing or devices; managing excess moisture by use of absorbent products or incontinence inter-ventions; use of effective no-rinse, pH-balanced skin cleans-ers with tepid bathing standards; hydrating dry skin with moisturizing agents; avoiding vigorous massage; using skin protectants, film, or hydrocolloid dressings over bony promi-nences to reduce friction and shear; and using support sur-faces that wick away moisture and prevent skin overheating.

Hydration and nutrition recommendations for PU pre-vention needing a stronger evidence base include frequency and methods of providing hydrating fluids or nourishment and orienting that frequency to patient and family needs and wishes.

Rehabilitative and restorative programs to address im-mobility and/or inactivity in bed- or chair-bound patients as soon as their condition allows and to manage muscle spasms appropriately require research to support implementing pro-gressive mobility or exercise.

Many recommendations for positioning standards of care to manage pressure/shear/friction remain untested in rig-orous RCTs, although quasi-experimental before-and-after

Figure 2. Evidence level distribution of 368 pressure ulcer patient and ulcer assessment, prevention, and treatment recommendations.

Figure 3. Numbers of recommendations in each cat-egory requiring pressure ulcer research (68.8%) and education (1.9%). Numbers do not sum to 368 because they exclude the 90 recommendations ready for imple-mentation and the 18 recommendations lacking both content validity and A-level evidence.

www.o-wm.com


studies suggest at least transient value in PU prevention. Recommendations need-ing research include keeping the head of the bed at or below 30˚ or at the low-est degree of elevation consistent with its occupant’s medical condition; avoiding trochanter pressure when sidelying by using a 30˚ laterally inclined position; us-ing small positioning changes to redistribute pressure every 2 to 3 hours; using lift sheets or devices (and removing them when done) to reduce dragging, folding, stretching of skin, and friction during turns and transfers; using trapeze or side rails to facilitate patient independence in offloading; preventing contact between bony prominences with cushions or devices; and placing heating or cooling blan-kets above the individual, rather than beneath weight-bearing zones. Research also is needed to prove efficacy of self-conducted, pressure-relief exercises every 15 min-utes by capable chair-bound individuals and avoiding sitting for more than 4 hours.

Offloading equipment recommendations in need of RCT research for prevent-ing PU included those that advise avoiding doughnut-shaped devices and using medical grade sheepskins except with added heel and elbow protection61; assessing function and effectiveness of support surfaces as patient status changes; ensuring access to and use of appropriate positioning and continence devices for all patients in at-risk environments and that regular positioning guidelines are followed, in-cluding an effective seating system, 3- to 4-inch thick high-density foam, or thera-peutic cushioning systems, regular positioning, measured pressure redistribution, and evaluation of supportive aids by trained assessors for chair-bound patients.

Research is needed to assess the value of all aspects of caregiver and family health-care provider education as well as use of an interdisciplinary team to develop and implement an individualized plan of care based on an evidence-based position state-ment, such as the AAWC Statement on Benefits of Team Care available at aawconline.com. With the exception of healthcare professionals trained in offloading or nutri-tion, qualifications for participation on interdisciplinary teams needs research.

Pressure ulcer treatment strategies (103 recommendations or 28.0% of 368). Rec-ommendations in need of research for implementing and continuing measures to prevent PU and optimize healing include setting treatment goals consistent with the patient’s goals, values, and lifestyle and continuing and/or evaluating response to previous and current prevention or treatment interventions.

Research is needed supporting several aspects of removing or alleviating the PU cause: effective pressure-redistribution products for all but individual Stage I or Stage II PUs; avoiding direct placement on the PU; use of cushions, repositioning, positioning schedules, protocols, and aids and their frequency of use; and use of static support surfaces that prevent “bottoming out” — ie, allow the bony promi-nence to be felt beneath the support surface.

Soft tissue and bone debridement interventions needing research to strength-en efficacy and/or safety evidence include all bone debridement methods; surgi-cal, high-flow irrigation; laser and maggot debridement; and recommendations that debridement is contraindicated for stable heel ulcers in critically unstable or gravely ill persons. Wet-to-dry gauze debridement is substandard practice based on pain and healing outcomes,44,48 but still requires RCTs supporting its inad-equacy for PU debridement.

All cleansing interventions need PU research, including cleansing the ulcer and surrounding skin with nonantiseptic, nontoxic clean or sterile water, normal saline, or Ringers solution applied at 4 to 15 lb per square inch of PU or skin surface with enough cleanser to remove debris while avoiding manual scrubbing.

Recommendations to manage bacterial colonization and infection needing re-search include use of universal precautions or standards for clean or sterile wound care technique, hand washing, and use of protective equipment in all settings; eval-uating the PU at each dressing change for signs and symptoms of clinical infection, including unexplained lack of healing progress during 2 to 4 weeks of optimal care;


AAWC FEATURE

using a validated quantitative swab culture of 1 cm2 viable wound surface to determine type and level of wound micro-organisms if signs of infection are noted; and treating at-risk patients’ distant infections, such as urinary tract infections. Topical antimicrobial agent use/protocols as PU cleansers or dressings needs more re-search to determine safety, efficacy, and duration of use.

PU dressing interventions requiring more research in-clude managing excess ulcer drainage with a Hydrofiber® dressing, filling ulcer cavities, providing thermal insulation, and managing exuberant granulation tissue. Research also is needed to confirm schedules for monitoring or changing PU dressings, observing the wound status, and revising wound dressings according to PU outcomes and patient goals.

Managing ulcer-related pain also needs research on re-ferral strategies, psychosocial interventions, or massage to manage muscle cramping or lymphatic conditions; avoid-ing massage over reddened bony prominences; systemic pain medication use; and using postural changes and support sur-faces that minimize pain.

Nutritional interventions with insufficient evidence of ef-ficacy include regular body weight evaluations, use of vita-min A or E supplements, and a hydration program including daily 30 to 35 cc of fluid per kg of body weight or as medi-cally indicated depending on individual needs. Use of ana-bolic agents or appetite stimulants also requires research to address weight loss in underweight individuals or persons losing weight at unhealthy rates.

Advanced adjunctive interventions in need of RCTs on PUs unresponsive to 30 days of best available evidence-based therapy include hyperbaric oxygen therapy, negative pressure wound therapy (vacuum), allografts, contact or noncontact therapeutic ultrasound, and ultraviolet (UV) light/multi-wavelength phototherapy.

More research is needed to support all aspects of surgi-cal interventions for PU, including direct closure, flaps, and skin grafts. Preoperative measures with insufficient evidence include smoking cessation, bowel regulation, medical stabil-ity with adequate nutrition and hydration, and reducing the tissue bacterial burden to <105 colony forming units/g of wound tissue before surgical closure. Postoperative measures in need of research include pressure redistribution interven-tions; adequate nutrition and hydration; gradually increased mobility and sitting; patient and caregiver education about re-injury and recurrence; and daily skin and wound exami-nations to check for surgical complications such as wound dehiscence, infection, abscess, hematoma, seroma, or proce-dure-related pain.

All recommendations addressing documentation of re-sponse to treatment required more research, including use of photographs, validated tools such as the Bates-Jensen Wound Assessment Test,62 DESIGN Tool,37 and PUSH Tool,43 which may improve in value by adding validated size and depth scales.63 Recommendations to revise treatment plans if no sig-nificant reduction in wound area occurs after 2 to 4 weeks or

to address patient issues in response to complications or non-adherence to care plans also require a stronger research base.

Palliative care for qualifying individuals is a key area in need of research on skin, pain, and PU assessment and man-agement. An operational definition with good predictive validity is needed for terminal ulcers. Research is needed to refine methods for establishing and achieving individualized care goals consistent with medical condition and patient and family wishes, needs, and capabilities; and for protecting the skin, maintaining patient hydration and nutrition, prevent-ing skin breakdown, and stabilizing and managing the PU and surrounding skin as much as possible while optimizing patient comfort. Research is needed to support effective pain management strategies, including analgesics and dressings that keep wounds moist with infrequent dressing changes, while implementing all PU and infection prevention and management principles acceptable to the patient and family.

Guideline recommendations not ready to implement without further research or content validation. Recom-mendations not accepted as evidence-based practice or rel-evant to PU management or prevention are summarized be-low and in Table 6. These were evenly distributed among PU debridement or cleansing interventions, adjunctive therapy, aspects of individual risk, or skin color assessment. One rec-ommendation, obtaining fall history, would have been in this category, but was moved from the section on environmental assessment to the section on medical history at Content Va-lidity Survey respondent’s suggestions.

Eighteen recommendations no longer are included in the final guideline because they require more evidence and con-tent validation (see Table 6).

Discussion As with many areas of medical practice, most PU recom-

mendations supported by strong opinion (CVI >0.75) have become usual and customary practice, even though 68.8% require more evidence to qualify as A-level, evidence-based care. If genuine knowledge is science based,64 these results mean clinicians think they know much more than they do. The good news is that the percent of PU management recom-mendations based on A-level evidence rose to 26.4% from about 20% with A-level supporting evidence when the AH-CPR (now AHRQ) Pressure Ulcer Prevention and Treatment Guidelines15,16 were first created.

All evidence-based PU efforts continue to be limited by in-complete understanding of PU etiology and the multiple in-teracting factors that cause a PU or delay its healing. As long as the words used to describe PU, treatment or prevention in-terventions, or responses to treatment mean different things to different people, understanding the safety and efficacy of interventions to prevent or treat a PU will have limited clarity. Operationally defined quality measures and indicators65 can help standardize PU management. RCTs that test hypotheses need to use clear operational definitions of interventions such



as offloading, pressure redistribution, and moist wound healing or outcomes such as healing, pain, or infection to avoid confus-ing the field.66 This work is but a tentative step toward encour-aging those much-needed definitions and RCTs.

Research considerations. Diagnosis. Some aspects of individual care seem too obvi-

ous to test. Others are difficult to test for diagnostic or screen-ing validity in cohort studies or for comparative efficacy and safety in RCTs. Many diagnostic or screening recommen-dations would benefit from well-designed clinical research, mining electronic medical record databases to establish their respective clinical diagnostic or predictive validity. Such ac-tions could be refined if they were subject to systematic study.

Systematically studying clinical judgment certainly would be complex, but could enlighten wound care practices. For example, guideline statements address the need for clinical-decision making based on clinical, nutritional, psychosocial, and environmental assessments were seen as clinically impor-tant, but lack evidence to support their utility. The thorough examination of an individual’s health condition and ability to comply with therapies is fundamental. Research in this area could address data collection, retrieval, and validation.

Research on the natural history of PU healing — eg, the PU healing rate in individuals with various comorbidities or receiving various treatments — would be informative for policy makers. Although research in PU healing may seem too complex due to confounding comorbidity factors, most chronic illnesses have similar patterns of comorbid condi-tions. Valuable warning patterns can be found by mining ap-propriate databases, which could prepare PU professionals to heed and address risk for slow healing before it becomes a serious problem.

Assessment. Accurate depth assessment of partial- or full-thickness PU predicts healing time.67 Accurate PU area as-sessment provides advance warning that the ulcer is not on a healing trajectory.68 Yet concerns related to accuracy of PU size, depth, and stage assessment remain.64 Staging systems are used to support reimbursement in some countries, in-cluding the US, yet only one cohort study69 (reporting diag-nostic validity of but a single stage: blanchable erythema) was found. Much work remains to establish the true value of using staging systems in documenting the extent of a PU or to develop plans for care. Research should focus on how to improve accuracy and reliability of PU assessment, as well as diagnostic and predictive validity of assessment parameters used in diagnosing and screening nonhealing wounds. For example, Kurd et al70 reported improved healing outcomes in RCTs for venous leg ulcers and diabetic foot ulcers if wound care providers received feedback of 4-week healing rates, a procedure supported by A-level evidence. However, no simi-lar RCTs have been conducted for PUs, although technology could easily facilitate accurate staging and surface area and volume measurement. Likewise, educational research meth-ods could facilitate recognition of PU complications.

Documentation. Accurately recording PU etiology, dura-tion, and prior treatments has great utility in clinical set-tings. Data are cumbersome to find and often are lost when individuals change healthcare systems or providers. Inter-actions between skin moisture and resulting fragility and pressure, friction, or shear damage may blur distinctions between etiologies.71

Skin health. Maintaining skin health is a vital yet barely researched area. Clinical trials on skin care regimens would be informative and reduce costs if one regimen were shown to be more efficacious. The relationship of moist skin to PU development, particularly regarding the microclimate (tem-perature and humidity) at the interface between the bed and the body, is not well studied and remains poorly understood. Animal studies to clarify how moisture injures skin, as well as how to keep skin properly moisturized and clean while protecting it from excess moisture, would provide supportive data for clinical care because it would be unethical to subject individuals to injurious situations. Related studies on the use of incontinence containment devices and associated inci-dence of PU formation also are needed.

Research could help identify the best educational meth-ods to teach skin inspection. Clinical issues with skin inspec-tion often coincide with the inability to see all the skin due to immobility, obesity, or the presence of splints, dressings, and the like. Developing systems that could sense changes in skin condition beneath opaque devices would be a good use of technology.

Nutrition and hydration. The hydration/protein-calorie connection to PU development is fairly well understood, but the need to determine the doses needed to maintain skin health and promote healing, especially in individuals with significant bowel and/or liver disease, remains unaddressed. An ethical analysis and qualitative research of enteral and parenteral nutrition would help guide discussions with fami-lies on this sensitive topic.

Restorative care. Although frequently used in long-term care when individuals no longer show improvement toward goals, restorative care with regard to PU formation needs to be better explored, perhaps by examining time to ulceration in individuals of similar risk. The effect of splinting and range-of-motion exercises on the time to ulcerate could also be examined.

Shear. Knowledge is increasing regarding the effect of shear on PU formation and the development of undermin-ing in existing PUs. Research is needed on how to protect skin from shear when the head of the bed must be elevated, as for individuals on ventilators and persons who are tube fed. For too long, the skin has been sacrificed for the lungs. Clinicians need to find methods to meet the needs of both body systems.

Pressure redistribution. Although interventions to change the position of a bed-ridden individual are supposed to be based on individual needs, there is little information to guide


AAWC FEATURE

this decision process. Should everyone be turned every 2 hours? How does the surface the individual is lying on affect turning schedules? Should turning/repositioning frequency increase when Stage I PUs develop or is that too late? At the very least, studies to examine individual conditions that pre-dict an ideal turning frequency could be helpful in determin-ing staffing ratios in many institutions.

The design of wheelchairs and bedside chairs has not changed in decades. Technology may be able to assist with the development and testing of “smart surfaces” that either in-form the staff or move the individual when tissue is becom-ing hypoxic. In the interim, studies of staff training methods on how to reposition individuals in wheelchairs and bedside chairs would assist in meeting the need for prevent PUs in the chairbound individual.

Education considerations. Assessment of non-Caucasians. Assessing the skin in darkly

pigmented individuals remains a clinical concern. Erythema and blanching in darkly pigmented skin is difficult to see, so techniques are needed to advance the ability to note early signs of pressure damage72 or predict healing delay.73

Wound measurement. Whether a wound is healing often is determined by wound measurements. The PUSH Tool43 mea-sures ulcer length. Langemo et al74 reported that this form of wound measurement was not the most accurate, but serves as a repeatable measure of changes over time. Simple longest length x longest perpendicular width is most strongly cor-related with planimetric chronic wound area and has been validated as a predictor of delayed healing.75

Growth factors. Growth factor use currently is indicated only for the treatment of lower extremity diabetic neuro-pathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply. In addition, the Food and Drug Administration (FDA) has added a warning for becaplermin gel (Regranex®, Systagenix Wound manage-ment, Quincy, MA) that describes an increased risk of death from cancer in individuals treated with three or more tubes of the product compared with those individuals who did not use the product. Although ulcers severe enough to require three or more tubes of growth factor may impact health suf-ficiently to correlate with cancer deaths, causal relationships remain to be explored. The FDA recommends that growth factors be used only when the benefits can be expected to outweigh the risks.

ConclusionUsing currently available evidence-based guidelines of

care, supplemented with the best available additional re-search as needed, the AAWC GD developed a “Guideline of Pressure Ulcer Guidelines”. Content validity of the 368 individual recommendations was tested (N = 32 volun-teers) and the strength of evidence supporting each recom-mendation was tabulated, reviewed, and compared to the CVI. Eighteen recommendations did not meet the criteria

for inclusion (C-level evidence and low CVI), leaving a total of 350 recommendations meriting inclusion in the evidence-based, content-validated PU guideline. Of those, 90 were found to be ready for implementation (A-level evidence and good content validity). However, most recommendations (63%) continue to have C-level evidence, and discrepancies between levels of evidence and CVI ratings were observed. Specifically, for 68.8% of recommendations, survey partici-pant ratings were higher than existing levels of evidence, sug-gesting a need for research. At the same time, the CVI for a few recommendations (1.9%) was low, while their level of evidence was high, indicating a need for education.

The consistency and quality of current PU protocols of care will improve only if existing science-based knowledge is used and research required to replace opinion with evidence is conducted. Education, learning, and organized implemen-tation programs are vital to foster attitude and behavioral changes required to implement the evidence-based prin-ciples identified. Hopefully, present healthcare profession-als will use this content-validated, evidence-based AAWC “Guideline of Pressure Ulcer Guidelines” to inform their PU practice and educate colleagues, staff, care givers, and all who affect persons with or at risk for PU about ulcer assessment, prevention, and treatment principles and strategies.

Organizations are working together to highlight this uni-fied approach; generating one consistent “guideline of PU guidelines” is a pioneering step. Now clinicians can be united in understanding what is known (ready to implement), what is not known (research needed), and what should be known (education needed). Placing this work in clinical perspective, the content validation process is a slice in time of recommen-dations that healthcare professionals believe are relevant to PU management. The evidence is but a summary of best evidence available while this AAWC “Guideline of Pres-sure Ulcer Guidelines” was being developed. Ideally, clini-cal opinions and evidence already have improved as these results are being reported. The guidelines are but a sign-post along the path to improving consistency and quality of PU care and related outcomes. Education is the key to implementing good evidence-based practice. Research is needed to forge new knowledge in areas where ignorance still prevails. The authors hope that future PU professionals will not stop at this signpost, but will build on this work to conduct the research needed to create future complete, comprehensive A-level PU protocols. n

AcknowledgmentsThe authors gratefully acknowledge Dr. William Ennis,

whose leadership as President of the AAWC Board of Di-rectors made initiation of this project possible; AAWC staff Lynn Donze and Cathy DiJohn, who managed the online content validation survey; and AAWC GD multidisciplinary members who developed the AAWC Guideline of Pressure Ulcer Guidelines, making it fair, balanced, evidence-based,



and clinically relevant: Mona M. Baharestani, PhD, ANP, CWON, CWS (NPUAP Liaison); Teri M. Berger, RN, CWCN; Laura L. Bolton, PhD (co-chair); Linda Foster, RN, CWCN; DeSales (Dee) Foster, MSN, CWOCN, CRNP; Susan Gi-rolami, RN, BSN, CWOCN (co-chair); Roslyn Jordon, RN, BSN, CWOCN; Soofia Khan, MD, MBBS, MS GenSurgery; Patrick McNees, PhD, FAAN (ad hoc); Diane Merkle, APRN, CWOCN; Laurie Rappl, DPT, CWS; Stephanie A. Slayton, PT, DPT, CWS; Jeremy Tamir, MD, FAPWCA; and Katherine Whittington, RN, MS, WOCN.

Additional DisclosuresDrs. Contreras-Ruis and Whitney have nothing to dis-

close. Ms. Girolami is the Clinical Manager, Therapy Sup-port, Inc, Cincinnati, OH. Dr. Woodbury is a consultant and/or paid advisory board member of the Canadian Association of Wound Care. Dr. Bolton is a former employee of Johnson & Johnson Wound Management (Somerville, NJ) and Con-vaTec (Skillman, NJ); Chief Scientific Advisor, Derma Scienc-es, Inc (Princeton, NJ); and a member of the Medical Advi-sory Board, Systagenix Wound Management (Quincy, MA).

References1. Reger SI, Ranganathan VK, Sahgal V. Support surface interface pressure,

microenvironment and the prevalence of pressure ulcers: an analysis of the literature. Ostomy Wound Manage. 2007;53(10):50–58.

2. Shreve J, Van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. The Society of Actuaries, 2010. The Economic Measurement of Medical Errors. Available at: www.soa.org/files/pdf/research-econ-measurement.pdf. Ac-cessed April 3, 2011.

3. Margolis DJ, Bilker W, Knauss J, Baumgarten M, Strom BL. The incidence and prevalence of pressure ulcers among elderly patients in general medi-cal practice. Ann Epidemiol. 2002;12(5):321–325.

4. Graves N, Birrell F, Whitby M. Effect of pressure ulcers on length of hospi-tal stay. Infect Control Hosp Epidemiol. 2005;26:293–297

5. Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure ulcers, hospital complications and disease severity: impact on hospital costs and length of stay. Adv Skin Wound Care. 1999;12(1):22–30.

6. Redelings MD, Lee NE, Sorvillo F. Pressure ulcers: more lethal than we thought? Adv Skin Wound Care. 2005;18:367–372.

7. Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospital acquired pres-sure ulcers and risk of death. JAGS. 1996;44(12):1435–1440.

8. Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, et al. Impact of pressure ulcers on quality of life in older patients: a system-atic review. JAGS. 2009;57:1157–1183.

9. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Available at: www.nap.edu/catalog/10027.html. Accessed August 1, 2008.

10. McInerney JA. Reducing hospital-acquired pressure ulcer preva-lence through a focused prevention program. Adv Skin Wound Care. 2008;(2):75–78.

11. Lyder CH, Shannon R, Empleo-Frazier O, McGeHee D, White C. A com-prehensive program to prevent pressure ulcers in long-term care: explor-ing costs and outcomes. Ostomy Wound Manage. 2002;48(4):52–62.

12. Japanese Society of Pressure Ulcers. Guideline for Prevention and Man-agement of Pressure Ulcers. Tokyo: Shorin sha;2009.

13. Australian Wound Management Society Clinical Practice Guideline for Pre-diction and Prevention of Pressure Ulcers, 2001. Available at: www.awma.com.au/publications/2007/cpgpppu. Accessed December 22, 2010.

14. Bolton L, Girolami S, Slayton S, Berger TM, Foster L, Whittington KT, Merkle D, and the Association for the Advancement of Wound Care Guideline Department. Assessing the need for developing a comprehen-sive content-validated pressure ulcer guideline. Ostomy Wound Manage. 2008;54(11):22–30.

15. Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15. Rockville, MD: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. December 1994. AHCPR Publication No. 95-0652.

16. AHCPR Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Pressure ulcers in adults: Prediction and prevention. Clinical Prac-tice Guideline, No. 3. Rockville, MD: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Re-search. May, 1992. AHCPR Publication No. 92-0047.

17. American Society of Plastic Surgeons (ASPS). Evidence based clinical practice guideline: chronic wounds of the lower extremity. May 2007. Available at: www.plasticsurgery.org. Accessed March 15, 2008.

18. Solutions® Algorithms (ConvaTec). National Guideline Clearinghouse. Available at: www.guideline.gov. Accessed October 30, 2007.

19. Registered Nurses Association of Ontario (RNAO). Risk assessment and prevention of pressure ulcers. Toronto, Ontario: March 2005. Available at: www.guideline.gov. Accessed July 1, 2008.

20. Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Available at: www.guide-line.gov. Accessed July 1, 2008.

21. Registered Nurses Association of Ontario (RNAO) Assessment and Man-agement of Stage I to IV pressure ulcers. March 2007. Available at: www.guideline.gov. Accessed July 1, 2008.

22. The John A. Hartford Foundation (JHF) Institute for Geriatric Nursing; Pres-sure Ulcer Prevention, 2003. Available at: www.guideline.gov. Accessed July 1, 2008.

23. National Collaborating Centre for Nursing and Supportive Care and Na-tional Institute for Clinical Excellence (NCCNNS/NICE). The use of pres-sure-relieving devices (beds, mattresses, and overlays) for the prevention of pressure ulcers in primary and secondary care. October 2003. Available at: www.guideline.gov. Accessed July 1, 2008.

24. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Pres-sure ulcer prevention and treatment following spinal cord injury: a clini-cal practice guideline for health-care professionals. J Spinal Cord Med. 2001;24 (suppl 1):S40–S101.

25. Paralyzed Veterans of America (PVA). Pressure ulcer prevention and treat-ment following spinal cord injury: a clinical practice guideline for health care professionals, August 2000. Available at: www.guideline.gov. Ac-cessed July 1,2008.

26. Whitney J, Phillips L, Aslam R, Barbul A, Gottrup F, Gould Ll, Robson M, Rodeheaver G, Thomas D, Stotts N. Guidelines for the treatment of pres-sure ulcers. Wound Repair Regen. 2006;14(6):663–679.

27. Vanderwee K (written on behalf of the EPUAP Guideline Development Group). Development of clinical practice guideline on pressure ulcers. EPUAP Review. 2008;9(1):6–8.

28. European Pressure Ulcer Advisory Panel (EPUAP). Abstracts from the tenth anniversary EPUAP open meeting. EPUAP Review. 2008;9(1):9–20.

29. National Pressure Ulcer Advisory Panel (NPUAP). Ushering in new interna-tional guidelines for pressure ulcer prevention and treatment: public policy and clinical practice. Presentation at the 11th National NPUAP Biennial Conference. Arlington, VA. February 27-28, 2009.

30. Yaghmaie F. Content validity and its estimation. J Med Education. Spring 2003. Available at: www.sbmu.ac.ir/Journal/MedEdu/jm. Accessed Sep-tember 2, 2003.

31. Sackett D, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. WhatisEBM?Availableat:www.cebm.net/index.aspx?o=1014.AccessedDecember 23, 2008

32. Scott EM, Baker EA, Kelly PJ, Stoddard EJ, Leaper DJ. Measurement of interface pressures in the evaluation of operating theatre mattresses. J Wound Care. 1999;8(9):437–441.

33. Hengstermann S, Fischer A, Steinhagen-Thiessen E, Schulz RJ. Nutrition status and pressure ulcer: what we need for nutrition screening. JPEN J Parenter Enteral Nutr. 2007;31(4):288–294.

34. Lindgren M, Unosson M, Krantz AM, Ek AC. Pressure ulcer risk factors in patients undergoing surgery. J Adv Nurs. 2005;50(6):605–612.

35. Pinchcofsky-Devin G, Kaminski MV. Correlation of pressure sores and nu-tritional status. JAGS. 1986;34(6):435–440.

36. Uzun O, Tan M. A prospective, descriptive pressure ulcer risk factor and prevalence study at a university hospital in Turkey. Ostomy Wound Man-age. 2007;53(2):44–56.

37. Bergstrom N, Braden BJ. Predictive validity of the Braden Scale among black and white subjects. Nurs Res. 2002;51(6):398–403.

38. Saladin LK, Krause JS. Pressure ulcer prevalence and barriers to treat-ment after spinal cord injury: comparisons of four groups based on race-ethnicity. NeuroRehabilitation. 2009;24(1):57–66.

39. Bates-Jensen BM, The Pressure Sore Status Tool a few thousand assess-ments later. Adv Skin Wound Care. 1997;10(5):65–73.

40. Buntinx F, Beckers H, Keyser AGD, Flour M, Nissen G, et al. Inter-ob-server variation in the assessment of skin ulceration. J Wound Care. 1996;5(4):166–170.

41. National Institute for Clinical Excellence (NICE), Royal College of Nursing. The management of pressure ulcers in primary and secondary care: a clinical prac-


AAWC FEATURE

tice guideline. September 22, 2005. 42. Sanada H, Moriguchi T, Miyachi Y, Ohura T, Nakajo T, Tokunaga K, et al. Reli-

ability and validity of DESIGN, a tool that classifies pressure ulcer severity and monitors healing. J Wound Care. 2004;13(1):13–18.

43. Stotts NA, Rodeheaver GT, Thomas DR, Frantz RA, Bartolucci AA, Sussman C, et al. An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH). J Gerontol A Biol Sci Med Sci. 2001;56(12):M795–M799.

44. Gunes U, Eser I. Effectiveness of a honey dressing for healing pressure ulcers. J WOCN. 2007;34(2):184–190.

45. Pullen R, Popp R, Volkers P, Fusgen I. Prospective randomized double blind study of the wound-debriding effects of collagenase and fibrinolysis/deoxyribo-nuclease in pressure ulcers. Age and Aging. 2002;31(2):126–130.

46. Burgos A, Gimenez J, Moreno E, Lamberto E, Utrera M, Urraca EM, et al. Cost efficacy, efficiency and tolerability of collagenase ointment versus hydrocol-loid occlusive dressing in the treatment of pressure ulcers: a comparative ran-domised multicentre study. Clinical Drug Invest. 2000;19(5):357–365.

47. Alvarez OM, Fernandez-Obregon A, Rogers RS, Bergmano L, Black Masso J. A prospective, randomized comparative study of collagenase and papain-urea for pressure ulcer debridement. WOUNDS. 2002;14(8):293–301.

48. Bouza C, Saz Z, Muñoz A, Amate JM. Efficacy of advanced dressings in the treatment of pressure ulcers: a systematic review. J Wound Care. 2005;14(5):193–199.

49. Heyneman A, Beele H, Vanderwee K, Defloor T. A systematic review of the use of hydrocolloids in the treatment of pressure ulcers. J Clin Nurs. 2008;17(9):1164–1173.

50. Belmin J, Meaume S, Rabus MT, Bohbot S. Investigators of the sequential treat-ment of the elderly with pressure sores (STEPS) trial. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ul-cer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc. 2002;50(2):269–274.

51. Cullum N, Petherick E. Pressure ulcers. BMJ Clinical Evidence. Available at: http://clinicalevidence.bmj.com/ceweb/conditions/. Accessed February 1, 2008.

52. Kerstein MD, Gemmen E, van Rijswijk L, Lyder CH, Phillips T, Xakellis G, Golden

K, Harrington C. Cost and cost effectiveness of venous and pressure ulcer pro-tocols of care. Dis Manage Health Outcomes. 2001;9(11):651–663.

53. de Laat EH, Scholte op Reimer WJ, van Achterberg T. Pressure ulcers: diag-nostics and interventions aimed at wound-related complaints: a review of the literature. J Clin Nurs. 2005;14(4):464–472.

54. Hutchinson JJ, McGuckin M. Occlusive dressings: a microbiologic and clinical review. Amer J Infect Control. 1990;18(4):257–268.

55. Dehlin O, Elmstahl S, Gottrup F. Monochromatic phototherapy: effective treat-ment for grade II chronic pressure ulcers in elderly patients. Aging Clin Exp Res. 2007;19(6):478–83.

56. Halford M, Rustagi K, Ziemkiewicz E. The effects of polarized light therapy in pressure ulcer healing. Vojnosanit Pregl. 2008;65(1):906–912.

57. Schubert V. Effects of phototherapy on pressure ulcer healing in elderly patients after a falling trauma. A prospective, randomized, controlled study. Photoder-matol Photoimmunol Photomed. 2001;17(1):32–38.

58. Lanzafame RJ, Stadler I, Coleman J, Haerum B, Oskoui P, Whittaker M, Zhang RY. Temperature-controlled 830-nm low-level laser therapy of experimental pressure ulcers. Photomed Laser Surg. 2004;22(6):483–488.

59. Rees RS, Robson MC, Smeill JM, Perry BH. Becaplermin gel in the treatment of pressure ulcers: a phase II randomized, double-blind, placebo-controlled study. Wound Repair Regen. 1999;7(3):144–147.

60. Robson MC, Phillips LG, Thomason A, Altrock BW, Pence PC, Heggers JP, Johnston AF, McHugh TP, Anthony MS, Robson LE, et al. Recombinant hu-man PDGF-BB for the treatment of chronic pressure ulcers. Ann Plast Surg. 1992;29(3):193–201.

61. Reddy M, Gill S, Rochon P. Preventing pressure ulcers: a systematic review. JAMA. 2006;296( 8):974–984.

62. Bolton L, McNees P, van Rijswijk L, de Leon J, Lyder C, Kobza L, Edman K, Scheurich A, Shannon R, Toth M, and the Wound Outcomes Study Group. Wound healing outcomes using standardized assessment and care in clinical practice. J WOCN. 2004;31(3):65–71.

63. Günes UY. A prospective study evaluating the Pressure Ulcer Scale for Healing (PUSH Tool) to assess Stage II, Stage III, and Stage IV pressure ulcers. Ostomy Wound Manage. 2009;55(5):48–52.

64. Hippocrates Law: Book I Section Ib. IV. As quoted in Emily Beck (ed). Bartlett’s Familiar Quotations, 15th ed. Boston, MA: Little, Brown & Company Ltd;1980.



Laura Bolton, PhDGrace Blaney, CWOCN, APN

Stephanie Slayton, PTJill Guidry, CWOCN

Kathy Whittington, CWOCNLynne Bevins, PT

Joe Ciccio, PTNina Howard, RN

Wanda Warren, PTMelisa Tiffany, RN, CWOCN, APN

Mary Long, RN, CWOCN, APNJanice Reilly, RN

Kathy Scocina, RN, CWOCN, APN, CNS Janice Locke, APN, WCC

Mr. Pulaskipt, PTEvelyn Rivera, CWOCN

Scott Faulkner, MDVera Lucey, CWOCNTherese Henn, NP

Linda Schnupp, CWOCNMichele Wyllie, RNJeremy Tamir, MD

Peggy Riedesel, PTMelissa Epler, CWOCNTeri Berger, CWOCN

Theresinia Menassa, RNSue Girolami, RN, CWOCN

Mona Baharestani, PhD, RN, CWOCN, APNStephanie Cox, RN, CWOCN

Soofia Kahn, MD, MBBS, MS GenSurg, FAABMRLia van Rijswijk, RN, MSN, CWCN

Participating surveyor/respondents

65. Bates-Jensen BM. Quality indicators for prevention and management of pres-sure ulcers in vulnerable elders. Ann Intern Med. 2001;135(8 Pt 2):744–751.

66. van Rijswijk L, Gray M. Evidence, research, and clinical practice: a patient-centered framework for progress in wound care. Ostomy Wound Manage. 2011;57(9):26–38.

67. Smitten A, Bolton L. Burden of pressure ulcer care. Ayello E. Research Forum. Adv Skin Wound Care. 2005;18(4):192–193.

68. van Rijswijk L, Polansky M. Predictors of time to heal deep pressure ulcers. WOUNDS. 1994;6(5):159–165.

69. Konishi C, Sugama J, Sanada H, Okuwa M, Konya C, Nishizawa T, Shimamura K. A prospective study of blanchable erythema among university hospital pa-tients. Int Wound J. 2008;5(3):470–475.

70. Kurd SK, Hoffstad OJ, Bilker WB, Margolis DJ. Evaluation of the use of prog-nostic information for the care of individuals with venous leg ulcers or diabetic neuropathic foot ulcers. Wound Repair Regen. 2009;17(3):318–325.

71. Houwing RH, Arends JW, Dijk MRC, Koopman E, Haalboom JRE. Is the distinc-tion between superficial pressure ulcers and moisture lesions justifiable? A clini-cal-pathologic study. SkinMed Dermatology for the Clin. 2007;6(3):113–117.

72. Judy D, Brooks B, Fennie K, Lyder C, Burton C. Improving the detection of pressure ulcers using the TMI ImageMed system. Adv Skin Wound Care. 2011;24(1):18–24.

73. Nakagami G, Sanada H, Iizaka S, Kadono T, Higashino T, Koyanagi H, Haga N. Predicting delayed pressure ulcer healing using thermography: a prospective cohort study. J Wound Care. 2010;19(11):465–470.

74. Langemo D, Anderson J, Hanson D, Hunter S, Thompson P. Measuring wound length, width, and area: which technique? Adv Skin Wound Care. 2008;21(1):42–45.

75. Kantor J, Margolis DJ. Efficacy and prognostic value of simple wound measurements. Arch Dermatol. 1998;134:1571–1574.

Documents

Understanding Pressure Ulcer Research and …...22 OSTOMY WOUND MANAGEMENT NOVEMBER 2011 AA ERE Understanding Pressure Ulcer Research and Education Needs: A Comparison of the Association