Guideline:
Pressure ulcers in the long-term care setting
Bibliographic Source(s)
- American Medical Directors Association (AMDA). Pressure ulcers in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2008. 44 p. [57 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Medical Directors Association (AMDA). Pressure ulcers. Columbia (MD): American Medical Directors Association; 1996. 16 p.
Guideline Category
Evaluation
Management
Prevention
Risk Assessment
Treatment
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Nurses
Pharmacists
Physician Assistants
Physicians
Social Workers
Guideline Objective(s)
- To improve the quality of care delivered to patients in long-term care facilities
- To offer care providers and practitioners in long-term care facilities a systematic approach to recognizing assessing treating and monitoring patients with pressure ulcers
Target Population
Elderly residents of long-term care facilities with or at risk of pressure ulcers
Interventions and Practices Considered
Recognition/Assessment
- Examination of the patient's skin thoroughly to identify pressure ulcers
- Assessment for risk factors for developing pressure ulcers such as comorbid conditions drugs that may affect ulcer healing history of pressure ulcers impaired or decreased mobility and others using risk assessment instruments (e.g. the Braden Scale for Predicting Pressure Sores the Norton Score)
- Assessment of the patients overall physical and psychosocial health and characterization (staging) of the pressure ulcer
- Identification of physiologic functional and psychosocial factors that can affect ulcer treatment and healing
- Identification of priorities in managing the ulcer and the patient including identification and treatment of causative factors and modifiable comorbid conditions optimal nutritional support prevention and management of infection of the ulcer and others
Treatment/Prevention
- Establishment of a realistic individualized interdisciplinary care plan
- Provision of general support for the patient including hydration nutrition pain management and psychosocial support
- Management of pressure by proper positioning turning and transferring techniques; using appropriate positioning devices support surfaces and offloading devices; maintaining the lowest possible head elevation
- Management of infection using topical antibiotics (e.g. bacitracin-polymyxin) if indicated or silver dressing
- Debridement of necrotic tissue from the ulcer (autolytic enzymatic mechanical surgical)
- Covering and protecting the ulcer and surrounding skin using appropriate ulcer care products and dressings
- Management of comorbid conditions (e.g. anemia chronic obstructive pulmonary disease diabetes heart failure peripheral vascular disease) that may contribute to pressure ulcer risk
Monitoring
- Monitoring and documentation of the patient's progress and ulcer healing
- Recognition and management of ulcer complications such as increasing necrosis infection cellulitis
- Reassessment of treatment and change in approaches if indicated; consideration of surgery and adjunctive therapies (e.g. negative pressure wound therapy)
- Monitoring of the facility's management of pressure ulcers using specific indicators
Major Outcomes Considered
- Prevalence and incidence of pressure ulcers in long-term care settings
- Reliability and validity of risk assessment tools for pressure ulcers
- Efficacy of intervention measures
- Time to healing
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Review of Published Meta-Analyses
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The guideline was developed by an interdisciplinary workgroup using a process that combined evidence- and consensus-based approaches. The workgroups included practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency association or organization such as the Agency for Healthcare Research and Quality (AHRQ) pertinent articles and information and a draft outline the group worked to make a concise usable guideline that is tailored to the long-term care setting. Because scientific research in the long-term care population is limited many recommendations were based on the expert opinion of practitioners in the field.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
Guideline developers reviewed a published cost analysis.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
Guideline revisions were completed under the direction of the Clinical Practice Guideline Steering Committee. The committee incorporated information published in peer-reviewed journals after the original guidelines appeared as well as comments and recommendations not only from experts in the field addressed by the guideline but also from "hands-on" long-term care practitioners and staff.
All American Medical Directors Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include AMDA physician members and independent physicians specialists nurse practitioners pharmacists nurses consultants in the specified area and organizations that are knowledgeable of the guideline topic and the long-term care setting.
Major Recommendations
The algorithm Pressure Ulcers in the Long-Term Care Setting is to be used in conjunction with the clinical practice guideline. The numbers next to the different components of the algorithm correspond with the steps in the text. Refer to the "Guideline Availability" field for information on obtaining the full text guideline.
Clinical Algorithm(s)
A clinical algorithm is provided for Pressure Ulcers in the Long-Term Care Setting.
Type of Evidence supporting the Recommendations
The type of evidence supporting the recommendations is not specifically stated.
The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based thinking.
Potential Benefits
By following essential steps and providing appropriate care of both the patient and the wound pressure ulcers are most likely to be effectively prevented and treated. Consistent and correct performance of the basic measures discussed in this guideline can help facilities demonstrate that they did everything reasonable to try to prevent pressure ulcers and heal existing ones.
Potential Harms
Not stated
Contraindications
- Autolytic debridement is contraindicated in ulcers with local infection of surrounding tissues.
- Negative-pressure wound therapy (NPWT) should not be used in the presence of osteomyelitis in necrotic ulcers with eschar if there is a fistula within the ulcer cavity or if the ulcer is bleeding more than minimally.
Qualifying Statements
- This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association and the American Health Care Association their heirs executors administrators successors and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use negligent or otherwise of this clinical practice guideline.
- The utilization of the American Medical Directors Association's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and caregivers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinicians' ability to practice.
- AMDA guidelines emphasize key care processes and are organized for ready incorporation into facility-specific policies and procedures to guide staff and practitioner practices and performance. They are meant to be used in a manner appropriate to the population and practice of a particular facility.
Description of Implementation Strategy
The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.
- Recognition
- Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG
- Assessment
- Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes
- Implementation
- Identify and document how each step of the CPG will be carried out and develop an implementation timetable
- Identify individual responsible for each step of the CPG
- Identify support systems that impact the direct care
- Educate and train appropriate individuals in specific CPG implementation and then implement the CPG
- Monitoring
- Evaluate performance based on relevant indicators and identify areas for improvement
- Evaluate the predefined performance measures and obtain and provide feedback
Guideline implementation will be affected by resources available in the facility including staffing and will require the involvement of all those in the facility who have a role in patient care.
Table 12 in the original guideline document provides ample performance measurement indicators and Appendix 1 provides suggested components of a staff training program in pressure ulcer prevention and management.
Implementation Tools
Clinical Algorithm
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety
Bibliographic Source(s)
- American Medical Directors Association (AMDA). Pressure ulcers in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2008. 44 p. [57 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Guideline Developer Comment
Organizational participants included:
- American Association of Homes and Services for the Aging
- American College of Health Care Administrators
- American Geriatrics Society
- American Health Care Association
- American Society of Consultant Pharmacists
- National Association of Directors of Nursing Administration in Long-Term Care
- National Association of Geriatric Nursing Assistants
- National Conference of Gerontological Nurse Practitioners
Source(s) of Funding
Funding was supported by the following: Ross Products Division of Abbott Laboratories
Guideline Committee
Steering Committee
Composition of Group that Authored the Guideline
Committee Members: Lisa Cantrell RN C; Charles Cefalu MD MS; Sherrie Dornberger RNC CDONA FDONA; Sandra Fitzler RN; Joseph Gruber RPh FASCP CGP; Marianna Grachek MSN CNHA CALA; Susan M. Levy MD CMD; Evvie F. Munley; Jonathan Musher MD CMD; Barbara Resnick PhD CRNP; William Simonson Pharm.D. FASCP CGP
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Medical Directors Association (AMDA). Pressure ulcers. Columbia (MD): American Medical Directors Association; 1996. 16 p.
Guideline Availability
Electronic copies: None available
Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on July 12 1999. The information was verified by the American Medical Directors Association as of August 8 1999. This summary was updated by ECRI Institute on May 20 2008.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is copyrighted by the American Medical Directors Association (AMDA) and the American Health Care Association. Written permission from AMDA must be obtained to duplicate or disseminate information from the original guideline. For more information contact AMDA at (410) 740-9743.
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