The American College of Physicians has released two evidence-based clinical practice guidelines for the prevention and treatment of bedsores, according to a news release.

PT_news-01The guidelines were published March 3 in the Annals of Internal Medicine.

“Up to $11 billion is spent annually in the U.S. to treat bedsores and a growing industry has developed to market various products for pressure ulcer prevention,” ACP President David Fleming, MD, said in the release. He added the evidence-based recommendations can help healthcare professionals provide quality care to patients but also avoid unnecessary or wasteful practices.

In a related editorial, Joyce Black, PhD, RN, CWCN, of the University of Nebraska Medical Center in Omaha, writes the recommendations “also highlight the scarcity of definitive data on other interventions to promote wound healing.”

To develop the guidelines, the authors conducted a systematic review of published evidence. Pressure ulcer incidence and severity, resource use, diagnostic accuracy, measures of risk and harms were the outcome measures included when crafting the risk assessment and prevention guideline. For the treatment guideline, the outcomes included complete wound healing, wound size reduction, pain, prevention of sepsis, prevention of osteomyelitis, recurrence rate and harms of treatment.

Preventing bedsores

ACP recommends physicians perform an assessment to identify patients who are at risk of developing bedsores. According to the guidelines, the evidence is not conclusive to show any difference between clinical judgment or risk assessment scales on reducing bedsore incidence.

Risk factors include older age, being black or Hispanic, lower body weight, cognitive impairment, physical impairments and other comorbidities that affect soft tissue integrity and healing, such as urinary or fecal incontinence, diabetes, malnutrition, edema, impaired circulation of the blood in the smallest blood vessels and low blood level of albumin.

For patients who are at increased risk of developing bedsores, the guidelines recommend using an advanced static mattress (a mattress made of foam or gel that does not move when a person lies on it) or an advanced static overlay (a material such as sheepskin or a pad filled with air, water, gel or foam that is secured to the top of a bed mattress), which are associated with a lower risk of bedsores compared with standard hospital mattresses. Advanced static mattresses and overlays also are less expensive than alternating air or low-air-loss mattresses and can be used as part of multicomponent approach to bedsore prevention, according to the ACP.

Because the evidence does not show a clear benefit for prevention, ACP recommends against using alternating air mattresses and alternating air overlays for patients who are at increased risk of developing bedsores. Also known as dynamic mattresses and overlays, these devices can alter the level of support by adjusting the level of air or fluid.

In the High Value Care section of the guideline, the authors wrote that advanced static mattresses and overlays were associated with a lower risk of bedsores compared to standard mattresses in higher risk patients. Many hospitals in the U.S. use alternating air and low-air-loss mattresses and overlays despite the lack of evidence showing any potential benefit in the reduction of bedsores in high-risk populations. Using these support systems is expensive and adds unnecessary burden on the healthcare system, according to the ACP.

Guidelines for risk assessment and prevention:

Treating bedsores

To reduce wound size in patients with pressure ulcers, the ACP recommends using protein or amino acid supplementation and hydrocolloid or foam dressings. The review found protein or amino acid supplementation reduced pressure ulcer wound size, but there was insufficient evidence for optimal dose or form of protein. Also, protein supplementation was assessed in conjunction with standard therapies such as dressings or support surfaces.

The evidence showed hydrocolloid dressings are better than gauze dressings for reducing wound size and resulted in similar complete wound healing as foam dressings. ACP also recommends using electrical stimulation as adjunctive therapy in patients with pressure ulcers to accelerate wound healing.

According to the guideline, low-quality evidence or mixed results were found for other complementary treatments such as therapeutic ultrasound, negative-pressure wound therapy, light therapy and laser therapy.

In the High Value Care section of the guideline, ACP states that it does not recommend the use of various advanced support surfaces, including alternating pressure and low-air-loss beds, since the quality of evidence evaluating these surfaces was limited and the harms from these type beds were poorly reported and could be significant given the immobility of the patient.

Additionally, although low-quality evidence showed that dressings containing Platelet Derived Growth Factor promoted healing, ACP supports the use of other dressings, such as hydrocolloid and foam dressings, which are effective at promoting healing and cost less than PDGF dressings.

Treatment guidelines:

Need for more evidence

In the editorial, Black wrote that not considering the levels of risk in the recommendations for support surfaces is disappointing. Older studies the ACP cited in the guidelines compared foam mattresses with a “standard hospital bed,” which Black notes is not described and could even include spring mattresses.

“Evidence supports the use of reactive surfaces, such as foam mattresses, for prevention in low-risk patients who can be moved from side to side,” she wrote.

Black wrote the ACP’s recommendation to avoid high cost interventions such as alternating air or low air loss surfaces is reasonable, but suggests using the interventions in only selected very high-risk patients, which could improve the cost-benefit ratio.

According to the editorial, the guidelines make clear the lack of evidence for other treatments to improve wound healing. The international guideline includes consensus-based advice on topical treatments for chronic wounds such as antiseptic dressings containing silver, honey or cadexomer iodine, Black wrote.

“Evidence is scarce in the science of pressure ulcers, and definitive analysis of benefits and harms of various interventions is difficult because of the limited available studies,” she wrote in the editorial. “Although clinical guidelines can be augmented with expert opinion, a dire need remains in the field of pressure ulcer prevention and treatment for scientists, clinical research and implementation science.”