Condition

Pressure ulcers are defined by the United States National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) as “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.”¹ Pressure ulcers are a common condition, affecting an estimated 1.3 to 3 million adults in the United States (U.S.).² In 2006, there were more than 500,000 hospital stays in which pressure ulcers were reported. Estimates of pressure ulcer prevalence range from 0.40 to 38 percent in acute care hospitals, 2 to 24 percent in long-term nursing facilities, and 0 to 17 percent in home care settings.^2–4 The variation in estimates is due in part to differences in how ulcers are assessed and defined and in the populations evaluated. The prevalence of facility-acquired pressure ulcers was 6 percent in 2008 and 5 percent in 2009.⁴

Pressure ulcers are often associated with pain and can contribute to decreased function or lead to complications such as infection.⁵ In some cases, pressure ulcers may be difficult to treat despite surgical and other invasive treatments. In the inpatient setting, pressure ulcers are associated with increased length of hospitalization and delayed return to function.⁶ In addition, the presence of pressure ulcers is associated with poorer general prognosis and may contribute to mortality risk.⁶ Between 1990 and 2001, pressure ulcers were reported as a cause of death in nearly 115,000 people, and listed as the underlying cause in more than 21,000 people.⁷ Estimates of the costs of treatment for pressure ulcers vary, but range between $37,800 and $70,000 per case.^6,8

Most current grading systems for pressure ulcers, including the commonly utilized NPUAP/EPUAP system, assign one of four stages, based on the depth of the ulcer and tissue involvement, with higher stages indicating greater severity (Table 1).¹ In this system, stage 1 is defined as superficial erythema without skin breakdown, stage 2 as partial thickness ulceration, stage 3 as full thickness ulceration, and stage 4 as full thickness with involvement of muscle and bone. When a full thickness (at least stage 3) ulcer has overlying purulent material or eschar so that it is not possible to determine the depth or extent of tissue involvement, the ulcer is classified as unstageable. Another category, suspected deep tissue injury, refers to skin changes suggesting an injury to the tissues underneath the skin’s surface, and most commonly occur in the heel area.

Table 1

National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel pressure ulcer classification.

Risk factors for pressure ulcers include older age, cognitive impairment, physical impairments and other comorbidities that affect soft tissue integrity and healing (such as urinary incontinence, edema, impaired microcirculation, hypoalbuminemia, and malnutrition).^5,9 Given the negative impact and burdens associated with pressure ulcers, interventions that can prevent occurrence or reduce severity could have an important impact on quality of life and health status. Such an approach may also be more efficient than interventions for treating ulcers that have already developed. According to one estimate, treatment costs may be as much as 2.5 times the cost of prevention.¹⁰

A number of diverse interventions are available as potential preventive interventions for pressure ulcers. However, research indicates that many patients at high risk of pressure ulcers do not receive preventive interventions.¹¹ Because patients vary in their propensity to develop pressure ulcers and the underlying reasons for being at increased risk, methods for accurately assessing risk could help more efficiently target the use or intensity of preventive interventions. A number of risk assessment instruments and preventive interventions are available.^12–14

The purpose of this report is to review the comparative clinical utility and diagnostic accuracy of risk assessment instruments for evaluating risk of pressure ulcers, and to evaluate the benefits and harms of preventive interventions for pressure ulcers. People at risk for pressure ulcers are cared for in diverse settings, including acute care hospitals, long-term care facilities, and the community at large. This report therefore also reviews how effectiveness varies in specific patient subgroups and in different settings.

Prevention Strategies

Recommended prevention strategies for pressure ulcers generally involve the use of risk assessment tools to identify people at higher risk for developing ulcers in conjunction with interventions for preventing ulcers.^1,15,16 Use of preventive interventions is based in part on assessed risk, with higher-risk patients receiving more intensive interventions. Pressure ulcers are associated with a number of risk factors, including older age, black race, lower body weight, physical or cognitive impairment, poor nutritional status, incontinence, and specific medical comorbidities that affect circulation such as diabetes or peripheral vascular disease.

A number of instruments have been developed to assess risk for pressure ulcers. The three most widely used instruments are the Braden Scale (six items, total scores range from 6 to 23), the Norton Scale (five items, total scores range from 5 to 20), and the Waterlow Scale (11 items, total scores range from 1 to 64) (Table 2).^5,17–19 All three scales include items related to activity, mobility, nutritional status, incontinence, and cognition, though they are weighted differently across studies.¹⁸

Table 2

Commonly used scales for risk assessment of pressure ulcers.

A variety of diverse interventions are available for the prevention of pressure ulcers. Categories of preventive interventions include support surfaces (including mattresses, integrated bed systems, overlays, and cushions), repositioning, skin care (including lotions, dressings, and management of incontinence), and nutritional support.^15,16 Each of these broad categories encompasses a variety of interventions. The term “support surfaces” refers to devices “for pressure redistribution designed for management of tissue loads, micro-climate, and/or other therapeutic functions.”²⁶ Criteria for classifying support surfaces have historically included the material used (e.g., foam, air, gel, beads, water), whether the support surface is static or dynamic (e.g., alternating-air or low-air-loss overlays, mattresses, or bed systems) and whether the support surface requires power.²⁷ More recent proposals are to reclassify support surfaces as “reactive” (a powered or nonpowered support surface with the capacity to change its load distribution properties only in response to applied load) or “active” (a power supported surface that can alter when and where load is applied to a person who sits or lies upon it and does not require a high applied load to redistribute body weight).^26,27 However, most published trials used older and often poorly standardized methods for describing and classifying support surfaces. In this report, we broadly classified support surfaces as static, alternating air, or low-air-loss.

The use of preventive interventions varies according to the level of assessed risk, as well as according to specific patient characteristics or differences in settings. For example, a nutritional supplement may be of limited use in a patient who is not malnourished, and skin care needs may differ for people with incontinence compared with those without. Some interventions that require substantial nursing resources or specialized equipment may not be as feasible for community settings. Preventive interventions may also be used in combination or as part of complex multi-component interventions including repositioning, nutritional support, skin care, and support surfaces.