Title

Pressure Ulcers And Other Wounds In The Post-Acute And Long-Term Care Setting

Authoring Organization

Publication Month/Year

November 1, 2017

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Long term care

Intended Users

Podiatrist, physician, nurse, nurse practitioner, physician assistant

Scope

Prevention, Management

Keywords

pressure ulcer, Wound Management

Methodology

Number of Source Documents
96
Literature Search Start Date
January 1, 1962
Literature Search End Date
January 31, 2017
Description of External Review Process
Reviewers from Participating Societies: (1) American Association of Homes and Services for the Aging, (2) American College of Health Care Administrators, (3) American Geriatrics Society, (4) American Health Care Association, (5) American Society of Consultant Pharmacists, (6) National Association of Directors of Nursing Administration in Long-Term Care, (7) National Association of Geriatric Nursing Assistants, and (8) National Conference of Gerontological Nurse Practitioners.
Description of Public Comment Process
All American Medical Director Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to AMDA physician members and independent physicians, specialists, and organizations that are knowledgeable of the guideline topic and the long term care setting. AMDA's guidelines are supported by the following associations/organizations, who are members of its Clinical Practice Guideline Steering Committee.
Specialties Involved
Geriatric Medicine, Post Acute And Long Term Care
Description of Systematic Review
AMDA-PALTC follows the GRADE Method
List of Questions
Refer to full text. The pre-determined questions focus on a systematic review of available evidence relevant to the long-term setting and the topic.
Description of Study Criteria
Study Design refers to the basic study design (broadly, observational studies and randomized trials). Study quality refers to the detailed study methods and execution. Appropriate criteria are used to assess study quality for each important outcome. For randomized trials, for example, these criteria might include the adequacy of allocation concealment, blinding, and follow-up. Reasons for downgrading a quality rating must be explicit (e.g., failure to blind patients and physicians reduced the quality of evidence for an intervention’s impact on pain severity, a serious limitation). Consistency refers to the similarity of effect estimates across studies. If there is important unexplained inconsistency in study results, confidence in the effect estimate for that outcome is reduced. Directness refers to the extent to which the people, interventions, and outcome measures in the studies are similar to those of interest. For example, the directness of the evidence may be uncertain if the people of interest are older, sicker, or have more comorbidity than those in the studies. To determine whether important uncertainty exists, one can ask whether there is a compelling reason to expect important differences in the effect size. Because many interventions have more or less the same relative effects across most pat ly stringent criteria in deciding whether evidence is direct.
Description of Search Strategy
The Guideline lists the electronic databases used to search for articles. The committee assessed and scored the literature per GRADE method.
Description of Study Selection
The committee worked by consensus under the leadership of the Committee Chair.
Description of Evidence Analysis Methods
Judgments about the quality of evidence (see the "Rating Scheme for the Strength of the Evidence" field) require assessing the validity of results for important outcomes in individual studies. Explicit criteria should be used in making these judgments. In the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group approach, a systematic review of available evidence guides these judgments. Sequential judgments are made concerning the following factors: • The quality of evidence across studies for each important outcome • Which outcomes are critical to a decision • The overall quality of evidence across these critical outcomes • The balance between benefits and harms • The strength of recommendations Reviewers consider four key elements: study design, study quality, consistency, and directness. Definitions Study design refers to the basic study design (broadly, observational studies and randomized trials). Study quality refers to the detailed study methods and execution. Appropriate criteria are used to assess study quality for each important outcome. For randomized trials, for example, these criteria might include the adequacy of allocation concealment, blinding, and follow up. Reasons for downgrading a quality rating must be explicit (e.g., failure to blind patients and physicians reduced the quality of evidence for an intervention's impact on pain severity, a serious limitation). Consistency refers to the similarity of effect estimates across studies. If there is important unexplained inconsistency in study results, confidence in the effect estimate for that outcome is reduced. Directness refers to the extent to which the people, interventions, and outcome measures in the studies are similar to those of interest. For example, the directness of the evidence may be uncertain if the people of interest are older, sicker, or have more comorbidity than those in the studies. To determine whether important uncertainty exists, one can ask whether there is a compelling reason to expect important differences in the effect size. Because many interventions have more or less the same relative effects across most patient groups, reviewers should not use overly stringent criteria in deciding whether evidence is direct. Criteria Criteria for decreasing the grade: • Serious (-1) or very serious (-2) limitation to study quality • Important inconsistency (-1) • Some (-1) or major (-2) uncertainty about directness • Imprecise or sparse data (-1) • High probability of reporting bias (-1) Criteria for increasing the grade: • Strong evidence of association: Significant relative risk greater than 2 (less than 0.5), based on consistent evidence from two or more observational studies, with no plausible confounders (+1) • Very strong evidence of association: Significant relative risk greater than 5 (less than 0.2), based on direct evidence with no major threats to validity (+2) • Evidence of a dose-response gradient (+1) • All plausible confounders would have reduced the effect (+1) These criteria are cumulative – e.g., if randomized controlled trials (RCTs) have serious limitations and there is uncertainty about the directness of the evidence, the grade of evidence would drop from high to low. Methods Used to Formulate the Recommendations Expert Consensus Description of Methods Used to Formulate the Recommendations Original guidelines are developed by interdisciplinary workgroups, using a process that combines evidence- and consensus-based approaches. Workgroups include practitioners and others involved in patient care in long term care (LTC) facilities. Beginning with pertinent literature searches for articles and information related to the guideline subject and a draft outline/framework, each group works to develop a concise, usable guideline that is tailored to the LTC setting. Because scientific research in the LTC population is limited, many recommendations are based on findings from research involving community-living older adults. Some recommendations are based on the expert consensus opinion of practitioners and experts in the field of geriatric medicine. The American Medical Directors Association (AMDA) Clinical Practice Guideline Steering Committee directs the guideline development and revision process. Each year the Steering Committee reviews all AMDA clinical practice guidelines that are 3 years old and commissions a thorough literature review to determine whether the content of each guideline remains current. The AMDA Clinical Practice Committee Chair selects the existing guidelines to be revised and new guidelines to be created based on 1) the Steering Committee's recommendations, 2) data collected, and 3) an assessment of the difficulty of development and relevance to the AMDA membership. AMDA's Board of Directors has final approval over this process.
Description of Evidence Grading
The methodology is described on page 46. The quality of evidence indicates the extent to which one can be confident that an estimate of effect is correct. High: At least 1 randomized controlled trial OR 3 pre/post interventions or other prospective interventions or 3 well-structured, relevant observational studies Moderate: Studies that use well-tested methods to make comparisons in a fair way, but where the results leave room for uncertainty (e.g., because of the size of the study, losses to follow-up, or the method used for selecting groups for comparison) Low: Studies in which the results are doubtful because the study design does not guarantee that fair comparisons can be made.
Description of Recommendation Grading
The strength of a recommendation indicates the extent to which one can be confident that adherence to the recommendation will do more good than harm. • Strong: Benefits clearly outweigh risks. • Weak: Benefits are balanced with risks. • Insufficient: Evidence is inadequate to make a recommendation. Criteria for decreasing the grade of a recommendation:  Serious (- 1) or very serious (- 2) limitation to study quality,  Important inconsistency (- 1),  Some (- 1) or major (- 2) uncertainty about directness,  Imprecise or sparse data (- 1),  High probability of reporting bias (- 1). Criteria for increasing the grade of a recommendation:  Strong evidence of association: Significant relative risk greater than 2 (less than 0.5), based on consistent evidence from two or more observational studies, with no plausible confounders (+1);  Very strong evidence of association: Significant relative risk greater than 5 (less than 0.2), based on direct evidence with no major threats to validity (+2);  Evidence of a dose-response gradient (+1);  All plausible confounders would have reduced the effect (+1). These criteria are cumulative – e.g., if RCTs have serious limitations and there is uncertainty about the directness of the evidence, the grade of evidence would drop from high to low.
Description of Funding Source
AMDA — The Society for Post-Acute and Long-Term Care Medicine (AMDA) provided the funding for the development of this guideline. The annual dues of the member physicians and other practitioners fund AMDA’s work. AMDA does not permit direct company support of the development of clinical practice guidelines or guideline revisions. Work group individuals who developed this guideline are volunteers and not paid by AMDA. Members of the work group are not employees, consultants, or speakers for a company with a commercial product within the subject matter of this guideline. AMDA facilitates and coordinates the guideline development and revision process. AMDA, its members, and peer organizations review, provide feedback, and do not have editorial control over the work group. All recommendations are based on the work group’s independent evaluation of the evidence.
Company/Author Disclosures
AMDA — The Society for Post-Acute and Long-Term Care Medicine (AMDA) provided the funding for the development of this guideline. The annual dues of the member physicians and other practitioners fund AMDA’s work. AMDA does not permit direct company support of the development of clinical practice guidelines or guideline revisions. Work group individuals who developed this guideline are volunteers and not paid by AMDA. Members of the work group are not employees, consultants, or speakers for a company with a commercial product within the subject matter of this guideline. AMDA facilitates and coordinates the guideline development and revision process. AMDA, its members, and peer organizations review, provide feedback, and do not have editorial control over the work group. All recommendations are based on the work group’s independent evaluation of the evidence.
Percentage of Authors Reporting COI
100