What’s New in the Patient Safety World
April 2015
New ACP Guideline on Decubitus Prevention and Treatment
In our February 2015
What’s New in the Patient Safety World column “17%
Fewer HAC’s: Progress or Propaganda?” we concluded that the reduction in
hospital-acquired conditions (HACs) documented in an AHRQ study (AHRQ
2014) was likely legitimate. In that
AHRQ study preliminary estimates for 2013 show a further 9 percent decline in
the rate of hospital-acquired conditions (HACs) from 2012 to 2013, and a 17
percent decline from 2010 to 2013. About 40 percent of this reduction is from
ADEs (adverse drug events), about 20 percent is from pressure ulcers,
and about 14 percent from catheter-associated urinary tract infections
(CAUTI’s).
So some progress has taken place in reducing hospital-acquired pressure ulcers. Pressure ulcers were targets that were included in some of the improvement projects in the Partnership for Patients initiatives that worked with the HEN’s (Hospital Engagement Networks) funded through the Affordable Care Act (ACA).
Meanwhile, the Pennsylvania Patient Safety Authority notes that hospital-acquired pressure ulcers remain a top concern for hospitals. The PPSA recently reported on hospital-acquired pressure ulcers (HAPU’s) reported through Pennsylvania’s PA-PSRS database over the period 2007 to 2013 (Feil 2015). The total number of reports increased from 2007 through 2009, due in part to addition of some new reporting hospitals and changes in reporting of pressure ulcers not only for the PA-PSRS but also for new CMS requirements. Then total pressure ulcer event reports decreased 10.0% from 2009 to 2013. Between 2012 and 2013 alone, there was a 5.9% decrease.
The PPSA notes that hospitals which have implemented evidence-based best practices in pressure ulcer risk assessment and prevention, such as those participating in the Pennsylvania Hospital Engagement Network Pressure Ulcer Prevention project, have reported successful reductions in the incidence of HAPUs stage II or greater. The PPSA study includes links to evidence-based pressure ulcer prevention guidelines.
But just how strong is the evidence for pressure ulcer prevention and treatment? The American College of Physicians (ACP) recently released 2 guidelines, one on the comparative effectiveness of risk assessment scales and preventive interventions for pressure ulcers (Qaseem 2015a) and a second on the comparative effectiveness of treatments of pressure ulcers (Qaseem 2015b). Both grade the quality of evidence and strength of recommendations by using ACP's clinical practice guidelines grading system.
On the prevention
side the following were recommended by ACP:
Recommendation 1: ACP recommends that clinicians should perform a risk assessment to
identify patients who are at risk of developing pressure ulcers. (Grade: weak
recommendation, low-quality evidence)
Recommendation 2: ACP recommends that clinicians should choose advanced static mattresses
or advanced static overlays in patients who are at an increased risk of
developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence)
Recommendation 3: ACP recommends against using alternating-air mattresses or
alternating-air overlays in patients who are at an increased risk of developing
pressure ulcers. (Grade: weak recommendation, moderate-quality evidence)
One the treatment
side the following were recommended by ACP:
Recommendation 1: ACP recommends that clinicians use protein or amino acid
supplementation in patients with pressure ulcers to reduce wound size. (Grade:
weak recommendation, low-quality evidence)
Recommendation 2: ACP recommends that clinicians use hydrocolloid or foam dressings in
patients with pressure ulcers to reduce wound size. (Grade: weak
recommendation, low-quality evidence)
Recommendation 3: ACP recommends that clinicians use electrical stimulation as adjunctive
therapy in patients with pressure ulcers to accelerate wound healing. (Grade:
weak recommendation, moderate-quality evidence)
Probably the most important take-home message from the two ACP articles and the accompanying editorial (Black 2015) is that the evidence base for pressure ulcer prevention is, in fact, quite weak. In that editorial, Black notes that the 2014 International Clinical Practice Guideline on Prevention and Treatment Pressure Ulcers includes only 77 statements with evidence to support them, whereas the remaining 498 statements are based on expert opinion. She cites the need for more objective scientific research into the issues. Nevertheless, the bedside clinician and other caregivers are left with tools and treatments that may not have the highest levels of evidence and must try to implement them in the best manner while we await those more scientific outcomes studies.
Something must be working to see the sort of improvements seen in the AHRQ study and the PPSA study. To see the multiple tools and interventions and their corresponding levels of evidence, we refer you to the two ACP guidelines (Qaseem 2015a, Qaseem 2015b), the 2014 International Clinical Practice Guideline on Prevention and Treatment Pressure Ulcers and the PPSA article (Feil 2015).
References:
AHRQ. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013. AHRQ Partnership for Patients 2014
http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2013.pdf
CMS. Partnership
for Patients.
http://partnershipforpatients.cms.gov/
Feil M, Bisbee J. Hospital-Acquired Pressure Ulcers Remain a Top Concern for Hospitals. Pa Patient Saf Advis 2015; 12(1): 28-36
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/mar;12%281%29/Pages/28.aspx
Qaseem A, Mir TP, Starkey M, Denberg TD for the Clinical Guidelines Committee of the American College of Physicians. Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med 2015; 162(5): 359-369
http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD for the Clinical Guidelines Committee of the American College of Physicians. Treatment of Pressure Ulcers: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med 2015; 162(5): 370-379
http://annals.org/article.aspx?articleid=2173506
Black J. Pressure Ulcer Prevention and Management: A Dire Need for Good Science (Editorial). Ann Intern Med 2015; 162(5): 387-388
http://annals.org/article.aspx?articleid=2173511
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2014
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