Wound Care: Pressure Ulcer Best Practices

Pressure ulcers, otherwise known as decubitus ulcers, comprise a significant portion of wounds requiring specialized care and presenting additional costs, so prevention is critically important. A pressure ulcer is any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed. Stage 1 pressure ulcers are defined as nonblanchable erythema of intact skin — the heralding lesion of skin ulceration. Stage 2 is defined as partial thickness skin loss involving epidermis and/or dermis; Stage 3 as full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; and Stage 4 as full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures.

The Wound, Ostomy and Continence Nurses Society (WOCN) says that pressure ulcer prevention is best accomplished by identifying patients who are at risk for the development of pressure ulcers and initiating early preventive measures. According to the WOCN, “This requires an understanding of risk factors, the utilization of research-based risk assessment tools, knowledge of appropriate preventive strategies and access to essential medical equipment such as therapeutic support surfaces.”

Patients who have already developed pressure ulcers require assessment and interventions to identify and correct the causative factor(s) and treatment modalities to assure optimal wound healing. Regular follow-up assessment and modifications of the treatment plan when indicated are also necessary to assure optimal wound repair and efficient use of resources, including supplies.

The difference between colonization and infection of wounds is decided by the concentration of organisms in the wound; an infected wound contains a larger number of microorganisms than a contaminated wound. According to clinical guidelines from the Agency for Healthcare Research and Quality (AHRQ), stage 2, 3 and 4 pressure ulcers should all be considered as colonized with bacteria. Proper wound cleansing and debridement should prevent bacterial colonization from proceeding to the point of clinical infection.

Strategies to manage pressure ulcers and facilitate healing include proper tissue load management (which includes proper positioning and the use of support surfaces) as well as appropriate ulcer care and management of infection.

Initial ulcer care involves debridement, wound cleansing, dressing application and possible adjunctive therapy. Debridement should be performed to remove moist, devitalized tissue. Small wounds can be debrided at bedside, while extensive wounds should be debrided in the operating room or special procedure room. Regarding wound cleansing, experts say that the benefits of cleaning should be weighed against the risk of potential trauma to the tissue bed caused by the cleaning. Solutions such as povidone iodine, iodophor, sodium hypochlorite solution, hydrogen peroxide and acetic acid should not be used because they are potentially cytotoxic. Use normal saline at a pressure between 4 and 15 pounds per square inch (psi). Regarding ulcer dressings, an ideal dressing should protect the wound, be biocompatible, and provide ideal hydration. The cardinal rule is to keep the ulcer tissue moist and the surrounding intact skin dry.

When caring for wounds, sterile instruments and clean dressings must be used. It is advisable to treat the most contaminated ulcer last in patients with multiple wounds. To prevent cross-contamination and the spread of infectious materials it is imperative for clinicians to wear the appropriate personal protective equipment (PPE), as well as change their gloves and perform thorough and proper hand hygiene in between patients.

In June 2009, the International Expert Wound Care Advisory Panel released its white paper, “Legal Issues in the Care of Pressure Ulcer Patients: Key Concepts for Healthcare Providers,” detailing and identifying key concepts to help healthcare professionals with preventive legal care practices taking into consideration the current pressure ulcer regulatory and legal environment. These key concepts are based on a recent roundtable discussion of thought leaders on the various legal implications of these policies and ways in which healthcare workers can reduce their risks. The roundtable and paper were supported by an educational grant from Medline Industries, Inc.

Every year, pressure ulcers affect more than 1 million acute-care and nursing facility patients. Lawsuits over pressure ulcers are becoming increasingly common in both settings, with claims per occupied bed increasing at an annual rate of 14 percent and the average court settlement rising more than $250,000. In addition to the bottom line implications — Medicare data estimates the average cost associated with pressure ulcer treatment is over $40,000 — a pressure ulcer-related lawsuit can do severe damage to a facility’s reputation for providing quality patient care, devastating staff morale and turning clients away.

“The interrelationship between medical decision-making, reimbursement and legal issues relating to pressure ulcers has never been greater and the medical-legal landscape itself has never been more treacherous,” says the paper’s corresponding author Caroline Fife, MD, CWS, associate professor of medicine in the Division of Cardiology at the University of Texas Health Science Center. “This white paper is a valuable resource for clinicians, managers, administrators, risk managers and industry members to establish or reinforce not only the aspects of a good pressure ulcer prevention process, but also how that goal can be achieved without an increase in litigation.”

When the treatment and prevention of pressure ulcers comes under legal scrutiny, it is often alleged as negligence. According to the authors, the readily apparent nature of pressure ulcers means that, unlike many other medical complications, they never go unnoticed by patients and their families.

Co-author Dr. Diane Krasner notes, “It is critical that everyone who is involved with pressure ulcer litigation — patients, families, caregivers, attorneys and healthcare team members — recognize that the vast majority of pressure ulcers are not due to negligence or non-compliance on anyone’s part, but rather they are unavoidable due to a patient’s risk factors, illnesses, co-morbidities and other complicating factors.”