Pressure ulcers in the long-term care setting

Guideline Developer(s)

American Medical Directors Association

Date Released

1996 (revised 2008; reaffirmed 2013)

Evidence Supporting the Recommendations

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.

Implementation of the Guideline

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.

  1. 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
  1. 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
  1. 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
  1. 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

Benefits/Harms of Implementing the Guideline Recommendations

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

Rating Scheme for the Strength of the Recommendations

Not applicable

Qualifying Statements

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.


Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

2008 Original Guideline Document

Not stated

2013 Reaffirmation

MEDLINE and PubMed were searched for updated literature related to the subject published between June 2011 and January 2013. This search is performed annually and completed by the clinical practice committee vice-chair. If new literature does not change the content or scope of the original guideline, it is deemed to be current.

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 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.

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.

Identifying Information and Availability

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]


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.

The American Medical Directors Association (AMDA) reaffirmed the currency of this guideline in 2013.

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:

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. This summary was updated by ECRI Institute on March 16, 2011 following the U.S. Food and Drug Administration advisory on negative pressure wound therapy (NPWT) systems. The currency of the guideline was reaffirmed by the developer in 2013 and this summary was updated by ECRI Institute on December 2, 2013.

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.



Pressure ulcers

Note: Although other types of ulcers (diabetic, ischemic, venous) may be treated similarly, this guidance should not be construed as applying to their care.

Guideline Category

Risk Assessment

Clinical Specialty

Infectious Diseases
Internal Medicine
Preventive Medicine

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Physician Assistants
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


  1. Examination of the patient's skin thoroughly to identify pressure ulcers
  2. 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)
  3. Assessment of the patients overall physical and psychosocial health and characterization (staging) of the pressure ulcer
  4. Identification of physiologic, functional, and psychosocial factors that can affect ulcer treatment and healing
  5. 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


  1. Establishment of a realistic, individualized interdisciplinary care plan
  2. Provision of general support for the patient including hydration, nutrition, pain management, and psychosocial support
  3. 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
  4. Management of infection using topical antibiotics (e.g., bacitracin-polymyxin) if indicated or silver dressing
  5. Debridement of necrotic tissue from the ulcer (autolytic, enzymatic, mechanical, surgical)
  6. Covering and protecting the ulcer and surrounding skin using appropriate ulcer care products and dressings
  7. Management of comorbid conditions (e.g., anemia, chronic obstructive pulmonary disease, diabetes, heart failure, peripheral vascular disease) that may contribute to pressure ulcer risk


  1. Monitoring and documentation of the patient's progress and ulcer healing
  2. Recognition and management of ulcer complications such as increasing necrosis, infection, cellulitis
  3. Reassessment of treatment and change in approaches if indicated; consideration of surgery and adjunctive therapies (e.g., negative pressure wound therapy)
  4. 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


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.


  • 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.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness
Staying Healthy

IOM Domain



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