Treatment of Pressure Ulcers: Results of a Study Comparing Evidence and Practice
Although pressure ulcers are presumed to be preventable, their prevalence remains high. A 2002 survey of 55 German hospitals and nursing homes found that 25% of the hospital patients and 17% of the nursing home residents identified by the Braden Scale as at-risk had pressure ulcers.1
These wounds are costly in terms of financial expense and human suffering.2,3 Their prevention and treatment must be based on the best available evidence. To examine the regimens used to treat pressure ulcers in German hospitals and nursing homes, the treatment regimens used, and whether treatment was based on best available evidence, the results of a literature review were compared with data from two pressure ulcer prevalence surveys on the use of wound dressings conducted in hospitals and nursing homes in Germany in 20014 and 2002.1 Specifically, the purpose of this study was to evaluate the quantity and level of evidence-based pressure ulcer prevention and treatment literature and its application in practice.
Review of the Literature
A literature search was conducted using MEDLINE®, the Cumulative Index to Nursing & Allied Literature™ (CINAHL®), the Cochrane Library, and the Internet (using Google and the snowball technique of pursuing links and researching references). Keywords included decubitus ulcer and its synonyms in different combinations with therapy, wound management, and specific terms (eg, debridement, alginates, iodine, and zinc oxide) for particular wound treatments, wound dressings, and topical agents. Additional terms used to retrieve literature on grade 1 pressure ulcers were prevention, control, and skin care. The search was restricted to literature published in English or German between 1994 and 2002. Studies on pressure ulcer treatment were included if clinical outcomes specified development of pressure ulcers (grade 1 ulcers) or wound healing (ulcers of grades 2 to 4).
Most of the relevant research already had been reviewed in evidence-based clinical guidelines2,3,5-8 and systematic reviews9-11; the majority of the evidence was found in evidence-based clinical guidelines, which provided recommendations for clinical practice graded according to the strength of the supporting evidence. Despite some evidence classification differences, in general, grade A recommendations (the strongest) are based on the highest level of evidence from results of at least one randomized controlled clinical trial (RCT), grade B recommendations are supported by evidence from non-randomized or descriptive studies, and grade C recommendations (the weakest) are based mainly on expert opinion. All graded recommendations for clinical practice obtained from evidence-based guidelines use the grades allocated by the guidelines.
To facilitate comparison, these classifications also were used to grade evidence from additional studies identified in the literature searches.
Literature Review Results
Pressure ulcers are commonly classified using four grades: grade 1 ulcers present as non-blanchable discoloration of intact skin, grade 2 ulcers are blisters or shallow wounds, and grades 3 and 4 are deep wounds that may contain necrotic tissue.2 For grade 1 identification, warmth, edema, and induration or hardness should be assessed, especially when individuals with darker skin are affected.3
The treatment of grade 1 pressure ulcers is identical to measures taken to prevent and reduce the effects of pressure — ie, protecting the skin from shear forces, friction, and dehydration and maintaining proper moisture balance.6,8 Only grade C level guideline recommendations were available for grade 1 pressure ulcers — ie, treating dry skin with moisturizers and preventing contact with too much moisture or potentially harmful moisture (eg, urine or feces) by using topical barrier agents, with no particular product recommendations.6
Treatment of pressure ulcers grade 2 through 4 includes debriding necrotic tissue, promoting moist wound healing, and controlling bacteria.2,3,5,7 Grade C guideline recommendations support the debridement of necrotic wounds, with the exception of some wounds covered by dry eschar where close observation may be sufficient.2,3,5,7 Although grade B evidence supports larval debridement over other non-surgical techniques,12 no comparable evidence level was found for mechanical, enzymatic, or autolytic debridement.9
Grade A guideline recommendations support moist wound healing.5,7,8 Grade A evidence is also available for using hydrocolloids instead of traditional wet or wet-to-dry gauze dressings,10 for one particular hydrocolloid,13 and for sequential treatment using alginates and hydrocolloids instead of hydrocolloids alone.14 No further evidence was found to support use of any particular moist wound dressings.
Avoidance of unnecessary dressing change that may damage the wound bed and avoidance of dressings that harden because they may cause pressure damage is supported with Grade B evidence.2 Most other recommendations regarding the selection, application, and surveillance of dressings are grade C.2,3,5,7
Strong grade A guideline recommendations were found for wound cleansing, debridement, and hand washing to control bacteria in pressure ulcers.2,7 Although 1994 recommendations regarding the use of topical antibiotics against high bacterial load and local wound infection2 were grade A, more recent grade A recommendations support systemic antibiotics only.3,5,7 Similarly, grade B recommendations support avoidance of antiseptics,2,5,7 while a 1999 grade C recommendation3 supports judicious use of antiseptics in some infected wounds. All other evidence regarding bacterial control is grade C. As described in a systematic review11 in 2000, no evidence was found to support use of specific antiseptic or antibiotic wound dressings.
Methods: Assessing Evidence in Practice
Two pressure ulcer prevalence surveys were conducted in 20014 and in 2002.1 In 2001, 11 hospitals in and near Berlin took part. In 2002, approximately 2,000 hospitals and 1,500 nursing homes were invited to take part in the study; 40 acute care hospitals and 15 nursing homes (long-term care) throughout Germany participated. All participating patients and residents of each institution were assessed for pressure ulcers by facility nurses with 3 years’ training (the highest degree of qualification in Germany) and work experience. Participating nurses were trained to collect data via an electronic media presentation (Power Point) and a detailed study manual containing definitions and photographic examples of the different pressure ulcer grades. Throughout the data collection process, the researchers were available via a telephone hotline to answer questions and assist nurses who, for example, were unsure how to categorize a wound dressing.
All patients or their legal representatives provided informed consent and approval for the study was obtained from the ethics committee of the Berlin Medical Chamber.
Instrument. The study instrument was a standardized questionnaire that had been tested for comprehensibility and practicability in a pilot study in 2000.15 If a patient was found to have pressure ulcers (including grade 1), nurses were asked to record the wound dressing used by selecting one from a list of 11 categories: dry dressing, wet dressing, antibacterial dressing, alginate, film, hydrocolloid, hydrogel, enzymes, foam, no dressing, or “other” dressing. Detailed explanations of the different dressing categories were provided in the study manual. In 2002, the category “fatty ointment” was added to the questionnaire and was defined as any ointment with a high fat content (usually above 60%) regardless of type of fat or mixture used. The two separate options (hydrocolloids and hydrogels) were replaced by the combined category of hydrocolloids/hydrogels because the number of hydrogels used in 2001 was negligible.
Data analysis. Data were entered into and analyzed by SPSS 11.0 (SPSS, Inc., Chicago, Ill). Dressings were categorized as consistent with or not consistent with current evidence. A third category, evidence base unknown, was assigned if either the results of the literature analysis were inconclusive or information on the properties of the dressings used was insufficient. This category applied to antibacterial and other dressings; they could not be classified as either consistent with or not consistent with evidence because based on the data no conclusion could be drawn as to whether wet, dry, antiseptic, or antibiotic dressings had been used. Because treatment differs for ulcers according to grade, the results for each grade were analyzed separately. For a better comparison of the 2001 and 2002 data, hydrocolloids and hydrogels are shown as the combined category of hydrocolloids/hydrogels for both years.
All variables were analyzed using descriptive statistics.
Evidence in Practice Results
Patients. Of the 11,584 participants assessed, 10,237 were in acute care facilities and 1,347 were nursing home residents. Between 10.6% and 13.2% of study participants had pressure ulcers; some patients had two or more pressure ulcers. More pressure ulcers were observed in the acute care (n = 2,215) than in the nursing home (n = 220) population. More than 50% of all ulcers were grade 1 and less than 5% were grade 4 ulcers (see Table 1).
Grade 1 ulcers.
Consistent with current evidence. As described, for grade 1 ulcers, the category “no dressing” is the only one consistent with current evidence.6 In practice, the highest rate of correctly treated grade 1 ulcers (38.5%) was found in the 2001 data for hospitals; the lowest rate (<6.8%) was found in the 2002 data for nursing homes (see Table 2).
Not consistent with current evidence. Dry dressings have no protective function and dressings such as alginates, enzymes, and wet dressings also are not suitable or recommended for grade 1 ulcers.6-8,16 The 2002 study data show that unsuitable dressings were used on 5.0% of the ulcers in nursing homes and 2.5% in hospitals; in 2001, they were applied to 18.4% of the pressure ulcers in the hospitals. This was due to the much higher percentage of ulcers treated with wet dressings in 2001 (14.6%) compared to 2002 (hospitals 0.4%, nursing homes 0.8%).
Evidence base unknown. No evidence was found for or against the application of films, hydrocolloids, foams, and antibacterial dressings. The categories “antibacterial” dressings, “other” dressings, and fatty ointments could not be classified by evidence base because those categories include a variety of different dressings and substances. In 2002, 51.9% of the ulcers in the hospitals and 68.6% of those in the nursing homes were given treatment that could not be categorized. This was mainly due to the high proportion of ulcers treated with fatty ointment: 41.6% of the ulcers in the hospital patients and 61.0% of ulcers in the nursing home residents were treated with fatty ointment. In 2001, without the fatty ointment option, only 24.6% of the ulcers were provided a treatment that could not be categorized.
Grade 2 ulcers.
Consistent with current evidence. Films, hydrocolloids/hydrogels, foams, and wet dressings, described as suitable for promoting moist wound healing,7,17-20 are appropriate treatment for grade 2 ulcers. Films, hydrocolloids/hydrogels, and foams can be left on the wound for several days,7,17-19 which avoids injuries sustained by frequent dressing changes. Wet (saline gauze) dressings also are suitable for promoting a moist wound environment but need to be changed frequently.7,20
According to the 2001 data for hospitals, approximately half (51.5%) of the grade 2 ulcers were correctly treated, compared to less than one third of the ulcers (27.8%) in the nursing homes of 2002 (see Table 3). Similar to grade 1, more ulcers (20.0%) received wet dressings in 2001 than in 2002 (hospitals, 1.2%; nursing homes, 7.4%).
Not consistent with current evidence. The use of dry dressings, fatty ointments, and no dressing is not consistent with current evidence for the treatment of Grade 2 ulcers because these options do not facilitate a moist environment and can cause trauma from exposure and dressing changes.7
In 2002, more than one third of the ulcers — 33.7% of grade 2 pressure ulcers in acute care patients and 37% of ulcers in nursing home residents — received treatment not consistent with current evidence. In 2001, 15.1% of these ulcers received these treatments. Inappropriate treatments provided in the nursing homes in 2002 consisted mostly of dry dressings (16.7% of ulcers) and fatty ointments (16.7%). The 2002 hospital data indicated that the most commonly used inappropriate treatments were no dressing (12.3% of ulcers) and fatty ointment (15.8%). In 2001, most of the incorrectly treated ulcers (12.7%) also were not dressed.
Evidence base unknown. Antibacterial and other dressings could not be classified because it was not known whether they were moist, dry, antiseptic, or antibiotic. Alginates are generally considered inappropriate because grade 2 ulcers tend to produce only small amounts of exudate.7,21,22 Enzymes are designed to chemically debride necrotic tissues, which also are rarely present in grade 2 ulcers. It is not clear whether they may23 or may not24 damage non-necrotic wound areas.
In practice in 2001, 13.9% of ulcers in the hospitals received treatment for which no evidence base is available. In 2002, this applied to 8.8% of ulcers in the hospitals and 14.8% in the nursing homes.
Grade 3 and grade 4 ulcers. Owing to the small number of these wounds and their similar treatment requirements, the data for grade 3 and grade 4 ulcers are presented together (see Table 4).
Consistent with current evidence. Alginates, hydrocolloids/hydrogels, enzymes, foams, and wet dressings promote a moist wound environment and enable autolytic debridement. Enzymes also support chemical debridement, although evidence for their superiority over autolytic debridement is lacking.7,9 Alginates, hydrocolloids/ hydrogels,7,16-18 and foams can be left in situ for several days7; thus, avoiding injuries to the wound. However, enzymes and wet dressings7,20 have to be changed at least once a day.
In all institutions, less than half of the grade 3 and 4 ulcers received appropriate treatment. Enzymes were applied to less than 7% of the ulcers.
Not consistent with current evidence. Dry dressings and fatty ointments do not keep the wounds moist and do not promote autolytic debridement. These treatments also increase the risk of mechanical injuries to the wound and no evidence exists to support their use.
In 2002 data, the proportion of incorrectly treated ulcers occurring in nursing homes was slightly higher than in hospitals in 2002 and 2001 (15% versus +11%). This was due to a higher proportion of deep wounds being treated with fatty ointment (9% compared to 4% in the hospitals in 2002).
Evidence base unknown. No conclusions can be drawn regarding the categories “antibacterial” and “other” dressings because the exact type of dressing used was not known. Film dressings support a moist wound environment but require a wound filler for these deep wounds.7,19 Using no dressing is believed to be appropriate for some grade 3 and grade 4 ulcers — eg, when dry eschar2,3 forms a natural protective dressing beneath which moist wound healing can occur.2 In practice, between 10% (nursing homes 2002) and 27% (hospitals 2001) of the ulcers received treatments that could not be categorized as evidence-based or not evidence-based.
Discussion
For grade 1 pressure ulcers, comparing existing evidence and practice regarding skin care was limited due to the lack of available evidence and the fact that the most frequently applied treatment in practice — ie, fatty ointment — could not be evaluated because the active agents were not known.
The data regarding the care of Grades 2, 3, and 4 pressure ulcers provided better information. It was found that although the literature contains strong evidence to support the use of products that facilitate moist wound healing, less than half of the wounds received these treatments. This suggests a lack of knowledge among health professionals providing care and confirms data from other studies.25 Economic considerations also may have affected treatment decisions. This may have been a problem particularly in the participating nursing homes, where the proportion of traditional dry dressings and fatty ointment (at comparatively lower material costs than modern wound dressings) was higher than in the hospitals.
Treatment data also may have been affected by the different survey instruments used in 2001 and 2002. The increased frequency of the categories of “wet,” “other,” and “no dressings” in 2001 suggests that, in the absence of the fatty ointment option, the “fatty ointment” treatment was assigned to one of those categories. With regard to the category “wet dressing” (which increased for all pressure ulcer grades), some questions may arise whether this category actually contained wet (saline gauze) or “other” dressings in 2001. This restricts the comparison of the data from 2001 and 2002 and the comparison of evidence and practice.
Limitations
The small sample is not representative of local pressure ulcer treatment in Germany. Also, because participation in the surveys was voluntary, a selection bias may have occurred — that is, institutions taking part may have an above-average commitment to quality improvement and evidence-based care.
This study also is limited due to the small number of grade 3 and 4 pressure ulcers, particularly the very low number of wounds occurring in nursing homes. In addition, the study is limited due to the fact that the specific dressings used in the categories of “fatty ointment,” “antibacterial,” and “other” dressing are not known. Further, additional information from the nurses regarding dressing specifics for these three categories would have been useful but was beyond the scope of the two surveys.
Conclusion
Because the percentage of patients with pressure ulcers who did not receive evidence-based treatments was high, it can be assumed that many of these wounds are put at risk for delayed healing and complications.
This leads to increased suffering of the individuals and health services costs. Therefore, efforts to disseminate research findings into practice and to educate health professionals in evidence-based wound treatment have to be intensified.
Although many different moist wound dressings are available today, most of which have been tested in RCTs, evidence supporting the use of particular dressings is lacking. More clinical research is needed, preferably RCTs, to examine the effectiveness of different categories of dressings in comparable wound situations. This could enable classifications of wound dressings according to their function rather than by their chemical composition, which might help practitioners choose the appropriate wound treatments with greater confidence, consistency, and effectiveness.
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