Assessing the Need for Developing a Comprehensive Content-Validated Pressure Ulcer Guideline
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Index: Ostomy Wound Manage. 2008;54(11):22-30.
Healthcare professionals need evidence-based strategies and guidelines for care to optimize pressure ulcer prevention and management. Differences among pressure ulcer guidelines confuse caregivers, reducing consistency of care. To assess the need for a comprehensive content-validated guideline document, the Association for the Advancement of Wound Care Guideline Subcommittee evaluated current pressure ulcer guideline recommendations by compiling 10 pressure ulcer-specific guidelines existing before June 2008 on the National Guideline Clearinghouse website along with the National Pressure Ulcer Advisory Panel (draft), European Pressure Ulcer Advisory Panel (draft), and Wound Healing Society guidelines. Steps for each aspect of pressure ulcer management were compiled and inconsistent recommendations identified. Currently available pressure ulcer guidelines were found to differ in definitions, aspects of care, validation, evidence criteria, and procedural recommendations, potentially affecting consistency and quality of all aspects of pressure ulcer management, including diagnosis, prevention, treatment, and outcomes measurement. To address these inconsistencies, a comprehensive list of Pressure Ulcer Care Initiative (PUCI) steps was prepared for content validation and posted on www.aawconline.org, enabling healthcare professionals interested in improving the consistency and quality of pressure ulcer prevention and care to participate in this process. All steps with a content validity index >0.75 (rated clinically relevant by survey respondents) and/or with A-level standardized clinical evidence support will be included in the comprehensive PUCI guideline. Content validation of recommendations is an important first step to improving the consistency of pressure ulcer care.
KEYWORDS: pressure ulcer, guideline, evidence, development, content validity
Pressure ulcers (PU) place major social, clinical, and economic burdens on society. They lengthen hospital stays, increase morbidity and mortality, and decrease patient quality of life.1 In the US, PU-related hospital stays increased from 280,000 cases in 1993 to 455,000 cases in 2003. Pressure ulcer treatment costs increased from an estimated $1.3 billion in 1992 to $17.2 billion in 2003, resulting in an average cost of $37,800 per person with a PU. 2 Likelihood of developing a PU increases with length-of-stay in a care setting, immobility, and increasing age. 1 United States PU point prevalence (ie, the percentage of at-risk patients having a PU at any point in time) has been reported as 3% to 10% in home care and approximately 15% in acute care. 2 In the UK General Practice setting from 1988 to 1996, annual period PU prevalence (percentage of patients reported with a PU during 1 year) increased with age from <1% of those 65 or older to 3.3% for persons >95 years of age. 1 Prevalence, incidence, and cost reporting methods vary within different healthcare systems, so the true magnitude of the burden of these wounds is difficult to estimate.
Evidence-based patient, skin, and wound care guidelines have been shown to reduce PU incidence3-6as well as healing time and costs of caring for existing ulcers. 7-10Currently, 10 guidelines on the US Division of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse (NGC) website focus on prevention and treatment. Healthcare professionals depend on these guidelines to help them standardize care, prevent and manage these ulcers, and meet reimbursement requirements or litigation challenges. In many US settings, if a patient develops a preventable PU or has a PU with poor outcomes, providers may face negative reimbursement consequences.