No one logged in.

National Guideline Clearinghouse (NGC). Guideline summary: Pressure ulcer prevention and treatment following spinal cord injury In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): cited 2000 Aug (reviewed 2005). Available: http://www.guideline.gov.

Bibliographic Source(s)

• Paralyzed Veterans of America. Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health care professionals. Washington (DC): Paralyzed Veterans of America; 2000 Aug. 94 p. [448 references]



• Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med 2001 Spring;24(Suppl 1):S40-101. [448 references] PubMed

Guideline Status

This is the current release of the guideline.

According to the guideline developer this guideline is still considered to be current as of December 2005 based on a review of literature published since the original guideline publication.

Guideline Category

Evaluation
Management
Prevention
Rehabilitation
Risk Assessment
Treatment

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Health Plans
Hospitals
Managed Care Organizations
Nurses
Occupational Therapists
Patients
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers

Guideline Objective(s)

• To provide guidance and assistance in the decisions required to restore health independence control and self-esteem to people with spinal cord injury.
• To provide a conceptual framework within which to develop effective strategies for preventing and treating pressure ulcers.

Target Population

Adolescents and adults with spinal cord injury (SCI)

Interventions and Practices Considered

1. Risk assessment and risk assessment tools
2. Prevention strategies
3. Nutrition assessment of the spinal cord injured patient and support measures for those who are nutritionally compromised
4. Assessment of the individual with a pressure ulcer including history; physical and laboratory tests; psychological status; availability and use of personal care assistance; and positioning/posture and related equipment
5. Assessment of the pressure ulcer
6. Nonsurgical treatment of pressure ulcers including:
   • Cleansing
   • Debridement
   • Dressings
   • Electrical stimulation
   • Continued assessment
7. Surgical treatment of pressure ulcers including excision and resurfacing
8. Preoperative and postoperative care
9. Surgical and nonsurgical management of complications of pressure ulcers
10. Support surfaces and positioning for managing tissue loads including:
    • Bed positioning
    • Bed support surfaces
    • Wheelchair positioning
    • Wheelchair support surfaces

Major Outcomes Considered

• Prevention of pressure ulcers
• Morbidity due to complications of pressure ulcers
• Recurrence of pressure ulcers
• Improvement in overall size and condition of pressure ulcer
• Cost of treating pressure ulcers
• Quality of life

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

A preliminary search of the MEDLINE database from 1966 to 1998 was conducted the main issues associated with pressure ulcers were identified and the volume of literature available on the subject was estimated. The literature search criteria included elderly as well as nonelderly adults. Children under the age of 13 were excluded as were articles involving nontraumatic paralysis. The search was limited to articles published in English. Study designs employing clinical trials (randomized and nonrandomized) cohort studies case controls case series and cross-over studies were included. Case reports and "n-of-one" studies were excluded.

Review articles and overview articles examining pressure ulcers in individuals with spinal cord injury were identified and retrieved if pressure ulcers were the focus of discussion. It is important to note that although review articles were included they were not intended for use as evidence for the guideline. Rather they were used to identify "gray literature" and to cross-reference with the literature search to ensure that all relevant articles on the topic had been identified and retrieved for analysis.

Appropriate key words and Index Medicus subheadings (MeSH subheadings) identified by the panel were used to search the MEDLINE database (1966-98) and the CINAHL nursing database (1982-98). These initial literature searches concentrated on articles focusing on pressure ulcers in individuals with spinal cord injury. A second search was conducted in the MEDLINE database (1993-98) focusing on the general population with pressure ulcers. The purpose of the second search was to identify literature that had emerged since publication of the Agency for Health Care Policy and Research (AHCPR) pressure ulcer guidelines. Whenever possible "exploded" Index Medicus subheadings were used allowing the inclusion of more relevant literature than would be discovered using text word searches. Second-level searches were conducted using the major ands minor Index Medicus subheadings retrieved from relevant articles.

Approximately 1800 abstracts from the literature searches were reviewed using the inclusion and exclusion criteria for relevance to the prevention and treatment of pressure ulcers. Nearly 350 articles were deemed relevant to the guideline and were retrieved. Of these articles more than 200 clearly met the criteria and were slated for data extraction. Another 23 articles did not have abstracts or their relevance was unclear so they were retrieved for further evaluation. Approximately 50 articles were identified that did not have valid study designs but were worthy of retrieval for education and orientation purposes. Finally relevant review articles (approximately 45 in number) were retrieved.

Number of Source Documents

More than 200 source documents were selected from the primary and secondary literature searches.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Hierarchy of the Levels of Scientific Evidence:

1. Large randomized trials with clear-cut results (and low risk of error)
2. Small randomized trials with uncertain results (and moderate to high risk of error
3. Nonrandomized trials with concurrent or contemporaneous controls
4. Nonrandomized trials with historical controls
5. Case series with no controls

Methods Used to Analyze the Evidence

Meta-Analysis
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Standardized data extraction forms were used to extract relevant information from the articles found to meet the inclusion and exclusion criteria. Extracted information was compiled into evidence tables according to subject area. The methodologists categorized the articles into topic areas and disseminated relevant articles and evidence tables to panel members for study and consideration. Articles identified as relevant by panel members were extracted and supplemental evidence tables were created and disseminated.

The methodologists employed the hierarchy of the levels of scientific evidence first discussed by Sackett (1989) and later enhanced by Cook et al. (1992) and the U.S. Preventive Health Services Task Force (1996). Each of the guideline recommendations was classified according to the level of scientific evidence used in the development of the recommendation. Additionally each study was evaluated for internal and external validity.

Statistical meta-analyses or other specialized studies were conducted as needed.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The guideline development process adopted by the Spinal Cord Medicine Consortium consists of 12 steps leading to panel consensus and organizational endorsement. After the steering committee chooses a topic a panel of experts is selected. Panel members must have demonstrated leadership in the topic area through independent scientific investigation and publication. Following a detailed explication and specification of the topic by select steering committee and panel members consultant methodologists review the international literature prepare evidence tables that grade and rank the quality of research and conduct statistical meta-analyses and other specialized studies as needed. The panel chair then assigns specific sections of the topic to the panel members based on area of expertise. Writing begins on each component using the references and other materials furnished by the methodology support group.

After the panel members complete their sections a draft document is generated during the first full meeting of the panel. The panel employs an iterative process in document preparation to incorporate new literature citations or other evidence-based information not previously available.

Rating Scheme for the Strength of the Recommendations

Categories of the Strength of Evidence Associated with the Recommendation:

1. The recommendation is supported by scientific evidence from properly designed and implemented controlled trials providing statistical results that consistently support the guidelines statement
2. The recommendation is supported by scientific evidence from properly designed and implemented clinical series that support the guidelines statement
3. The recommendation is supported by expert opinion

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

After legal review to consider antitrust restraint-of-trade and health policy matters the draft document was reviewed by clinical experts from each of the consortium organizations plus other select clinical experts and consumers. The review comments were assembled analyzed and entered into a database and the documents revised to reflect the reviewers' comments. Following a second legal review the draft document was distributed to all consortium organization governing boards. Final technical details were negotiated among the panel chair members of the organizations' boards and expert panelists. If substantive changes were required the draft received a final legal review.

Major Recommendations

The following provides a summary of the recommendations presented in the guideline document. The reader is directed to the original guideline for a detailed discussion of each of the following topics.

The levels of evidence (I-V) grades of recommendations (A-C) and strength of panel opinion (low moderate and strong) are repeated at the end of the Major Recommendations.

Prevention

Risk Factors Risk Assessment and Risk Assessment Tools

1. Conduct comprehensive systematic and consistent assessment of pressure ulcer risk factors in individuals with spinal cord injury.
   • Assess and document risk on admission and reassess on a routine basis as determined by the health-care setting institutional guidelines and changes in the individual's health status.
   • Use clinical judgment as well as a risk assessment tool to assess risk.Assess demographic physical/medical and psychosocial risk factors associated with
   • pressure ulcer prevention.

   Scientific evidence: I II III V; Grade of recommendation: A B C; Strength of panel opinion: Strong

Prevention Strategies

2. Implement pressure ulcer prevention strategies as part of the comprehensive management of acute spinal cord injury and review all aspects of risk when determining prevention strategies.
   • Avoid prolonged positional immobilization whenever possible.
   • Institute pressure relief as soon as emergency medical condition and spinal stabilization allow.
   • Initiate intraoperative pressure reduction strategies.

   Scientific evidence: III V; Grade of recommendation: C; Strength of panel opinion: Strong

3. Conduct daily comprehensive visual and tactile skin inspections with particular attention to the areas most vulnerable to pressure ulcer development including but not limited to:
   • Ischii
   • Sacrum/coccyx

http://www.pva.org/site/PageServer?pagename=pubs_generalpubs#cpg