Under Pressure to Heal an Ulcer?

Abstract & Commentary

By Allan J. Wilke, MD, Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of Medicine—Huntsville Regional Medical Campus. Dr. Wilke reports no financial relationship to this field of study.

This article originally appeared in the March 2006 issue of Internal Medicine Alert. It was reviewed by the physician editor, Stephen Brunton, MD, and peer reviewed by Gerald Roberts, MD. Dr. Brunton is Clinical Professor at the University of California, Irvine. He is a consultant for Sanofi-Aventis, Ortho-McNeil, McNeil, Abbott, Novo Nordisk, Eli Lilly, Endo, EXACT Sciences, and AstraZeneca, and serves on the speaker's bureau for McNeil, Sanofi-Aventis, and Ortho-McNeil. Dr. Roberts is Clinical Professor of Medicine at Albert Einstein College of Medicine. He reports no financial relationship relevant to this field of study.

Synopsis: Healing of Stage II-IV pressure ulcers is associated with use of moist dressings and adequate nutrition. An additional factor for Stage III and Stage IV ulcers is cleansing with soap and water or saline.

Source: Bergstrom N, et al. The National Pressure Ulcer Long-Term Care Study: Outcomes of Pressure Ulcer Treatments in Long-Term Care. J Am Geriatr Soc. 2005;53:1721-1729.

The National Pressure Ulcer Long-Term Care Study (NPULTC) was a retrospective cohort study with convenience sampling conducted between February 1, 1996, and October 31, 1997. Using data from medical records, Minimum Data Sets, physician orders, and medication logs, the researchers examined the resident, the ulcer, and the care to identify factors that are associated with prevention and healing. The patients were studied over 12 weeks. Each pressure ulcer (PrU) was measured and described (ie, presence of eschar, necrosis, granulation tissue, drainage, undermining, tunneling, or infection, and wound bed color, location, and stage). Stage I PrUs, PrUs smaller than 0.25 cm2 and PrUs in unusual locations (navel, chin, penis, etc) were excluded. The primary outcome was change in PrU area. Treatment modalities were grouped into broad categories: cleansing, dressing, support surfaces, and nutritional supplements. No attempt was made to evaluate specific products.

After exclusion there were 882 subjects with 1,589 PrUs. Most common locations were coccyx, back, or buttocks (44%), foot or malleolus (36%), trochanter (2%), and ischial tuberosities (5%). Stage III and Stage IV ulcers had the greatest reduction in size when patients were receiving sufficient enteral feedings (≥ 30 kcal/kg/day), when cleansing consisted of soap and water or saline, and when moist, rather than dry, dressings were used. Two patient characteristics were also associated with better healing: having no or uncomplicated dementia or having dementia with agitation or depression. Stage II PrUs followed the same pattern, except that cleansing with soap and water or saline healed more slowly. Not surprisingly, debridement was associated with an increase in ulcer size. Factors not associated with healing were diabetes, incontinence, age, cardiovascular disease, requiring assistance with activities of daily living, and type of bed (support surface).

Commentary

Pressure ulcers are a common and costly problem in acute care, nursing home, and home care populations. In 1994 the cost of treatment in the United States was estimated to exceed $1.335 billion.1 Liability related to PrUs is increasing.2,3 Judgments were highest for PrUs caused by multiple factors. The highest awards for PrUs caused by a single factor were seen when that factor was inadequate nutrition.

This group has previously written about prevention of PrUs.4,5 The factors that help prevent PrUs include adequate nutritional support, fluid orders, medications, and nursing staffing patterns. Most studies of PrUs have looked at single interventions. The NPULTC is unique in that it examined multiple factors that influenced each other. For instance, a treatment that failed to heal a PrU might be followed by debridement, which in turn, increased the size of the ulcer. The 12-week study period was too short to allow healing of all ulcers. The fact that a PrU is getting smaller does not necessarily mean it will eventually heal completely. Ross Products Division of Abbott Laboratories provided funding for this study.

The Agency for Health Care Policy and Research, now the Agency for Healthcare Research and Quality (AHRQ) published guidelines for the prevention and treatment of pressure ulcers in 1992 and 1994, respectively. These guidelines were reviewed in 2001 and were found to be valid still. Physicians caring for bed- or chair-bound patients would do well to review them now.

References

1. Miller H, Delozier J. Cost Implications of the Pressure Ulcer Treatment Guideline. Center for Health Policy Studies. Columbia, MD: Contract No. 282-91-0070. 1994:17.

2. Bennett RG, et al. The Increasing Medical Malpractice Risk Related to Pressure Ulcers in the United States. J Am Geriatr Soc. 2000;48:73-81.

3. Voss AC, et al. Long-Term Care Liability for Pressure Ulcers. J Am Geriatr Soc. 2005;53:1587-1592.

4. Horn SD, et al. The National Pressure Ulcer Long-Term Care Study: Pressure Ulcer Development in Long-Term Care Residents. J Am Geriatr Soc. 2004;52:359-367.

5. Horn SD, et al. RN Staffing Time and Outcomes of Long-Stay Nursing Home Residents: Pressure Ulcers and Other Adverse Outcomes are Less Likely as RNs Spend More Time on Direct Patient Care. Am J Nurs. 2005;105:58-70.