ACP Updates Guidelines on Bedsore Prevention, Treatment

Marcia Frellick

March 03, 2015

The American College of Physicians (ACP) has released updated recommendations for preventing and treating pressure ulcers, or bedsores, in two evidence-based clinical guidelines published in the March 3 in the Annals of Internal Medicine.

Amir Qaseem, MD, PhD, MHA, from the ACP in Philadelphia, Pennsylvania, and colleagues on the Clinical Guidelines Committee, write that regarding prevention, physicians should first assess risk for bedsores. For those at higher risk, ACP recommends an advanced static mattress (made of foam or gel that stays put when a person lies down) or an advanced static overlay (a material attached to the top of a mattress such as sheepskin or a pad filled with air, water, gel, or foam.) These are also less expensive and associated with a lower risk for bedsores compared with the alternating air (also called dynamic) or low-air-loss mattresses that are more frequently used.

Those at higher risk for pressure ulcers include blacks or Hispanics and those with lower body weight, cognitive or physical impairments, and other comorbid conditions that affect soft tissue, such as incontinence, edema, malnutrition, and diabetes.

Clinicians should make individual decisions on whether to use a single or multicomponent intervention, based on risk assessment.

Hydrocolloid Dressings Better Than Gauze

Recommendations to physicians for the treatment of pressure ulcers include using protein or amino acid supplements and hydrocolloid or foam dressings to reduce wound size. The evidence also showed that hydrocolloid dressings are better than gauze for reducing wound size and resulted in similar complete wound healing as foam dressings.

The researchers found that although radiant heat dressings accelerated wound healing, there was no evidence they were better than other dressings for improving complete wound healing.

The ACP also recommends that physicians use electrical stimulation in addition to other therapies to speed wound healing. The most common adverse effect for this stimulation was skin irritation. Frail elderly patients were more susceptible to harms from electrical stimulation.

In an accompanying editorial, Joyce Black, PhD, RN, CWCN, from the University of Nebraska Medical Center, College of Nursing, Omaha, said the recommendations point out the need for more studies and strong evidence of effects on outcomes.

She said some information and consideration was missing from the new guidelines.

She notes, for instance, that although the ACP recommends protein or amino acid supplementation to reduce the size of existing ulcers, it provides no dosing recommendations.

She also notes that the ACP recommends electrical stimulation, but access to practitioners licensed to perform it can be limited.

David Fleming, MD, MA, FACP, the ACP's president, told Medscape Medical News he agrees that access can be an issue when new guidelines are issued, and each hospital system will have to look at cost-effectiveness.

As to the dosing recommendations, he says, those need to be patient-specific. "It really requires experts in nutritional science who know how to apply it to a patient," he said.

Cost Per Case Ranges From $38,000 to $70,000

Guidelines for bedsores, Dr. Fleming said, had long been a target area for the committee, and although there was not a single driving reason the recommendations came this year, the timing could not be better, considering the costs and opportunities for better care associated with the preventable wounds.

"The cost of treating each case of pressure ulcer ranges from $38,000 to $70,000," he said. The sores also extend hospitalization and require ongoing intensive wound care and can result in financial penalties for hospitals under healthcare system reform.

He acknowledges that changing mattresses to the advanced static variety could result in a large financial outlay for hospitals. Each hospital system will have to consider the ACP guidelines with other evidence, look at its own demographics, and see what makes sense, Dr Fleming said.

"What many systems have found is that substantive financial investment up front in the right kind of technologies can save millions in the long run downstream by decreasing complications and decreasing hospitalizations," he said.

Several coauthors of the studies report personal fees from Allergan, Bayer, Blue Cross Blue Shield Association, General Electric, UBC, and Genentech and grants from Pfizer. Dr Black and Dr Fleming have disclosed no relevant financial relationships.

Ann Intern Med. 2015;162:359-379, 387-388. Prevention article abstract, Treatment article abstract, Editorial full text

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