Guidelines for Managing: Pressure Ulcers with Negative Pressure Wound Therapy

Advances in Skin & Wound Care, Nov/Dec 2004 by Gupta, Subhas

ABSTRACT

Pressure ulcers are a serious health issue, leading to clinical, financial, and emotional challenges. Numerous treatment modalities are available to promote wound healing, yet clinicians may be unsure how to incorporate these treatment options into an overall plan of care for the patient with a pressure ulcer. A consensus panel of experienced wound care clinicians convened in July 2004 to review the mechanisms of action and research basis for one such treatment modality: negative pressure wound therapy. After answering key questions about this modality, they developed an algorithm to assist the clinician in making decisions about using negative pressure wound therapy appropriately in patients with Stage III and Stage IV pressure ulcers.

ADV SKIN WOUND CARE 2004;17(SUPPL 2):1-16.

ISSN: 1527-7941; online ISSN: 1538-8654

PRESSURE ULCERS-defined as any lesion caused by unrelieved pressure, resulting in damage of underlying tissue1-are acknowledged to be a clinical challenge for both the clinician and the patient. Healing is unpredictable; it often stalls due to such local and systemic factors as bacterial load and infection; edema; pressure; moisture; chronic medical conditions or comorbidities, such as anemia, diabetes mellitus, and renal or hepatic dysfunction; tissue oxygénation; and nutritional status.2 Because of this, pressure ulcers arc considered chronic wounds, defined by Lazarus et al3 as wounds that have "failed to proceed through an orderly and timely process to produce anatomic and functional integrity, or proceeded through the repair process without establishing a sustained anatomic and functional result."

Technologic advances have given clinicians a myriad of options for managing pressure ulcers, which can lead to improved outcomes of care. The downside, however, is that this product explosion has the potential to cause confusion about which products to use with which wounds and when to discontinue a treatment in favor of another.

In the case of negative pressure wound therapy (NPWT), some clinicians remain unclear as to the best way to use this modality in an overall pressure ulcer treatment strategy. For that reason, a panel of clinicians with expertise in wound management (Table 1) gathered in Chicago in July 2004 to discuss this issue. The panel was charged with (1) evaluating the existing literature base on NPWT and pressure ulcers, (2) evaluating current best practices for pressure ulcer management, (3) developing consensus on guidelines for the use of NPWT in patients with pressure ulcers, and (4) identifying priorities for future research.

For the purposes of this discussion, the term "guideline" was used in the same manner as it was by the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality [AHRQ]) when its series of Clinical Practice Guidelines was developed.4 According to the AHCPR, "Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical conditions...The guideline reflects the state of knowledge, current at the time of publication, on effective and appropriate care...The recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the practitioner in light of available resources and circumstances provided by individual patients."4

The definitions of pressure ulcer stages adopted by the AHCPR guideline panel4 were also followed by the NPWT consensus guideline panel.

INCIDENCE AND PREVALENCE

Although it is accepted that pressure ulcers are a problem to be addressed across care settings, the exact incidence and prevalence are unclear. Reports of pressure ulcer incidence vary widely, from 0.4% to 38% in acute care, from 2.2% to 23.9% in long-term care, and from 0% to 17% in home care, according to a report from the National Pressure Ulcer Advisory Panel (NPUAP).5 Prevalence rates show the same variability: 10% to 18% in acute care, 2.3% to 28% in long-term care, and 0% to 29% in home care.5 The numbers should be interpreted cautiously, however, because of discrepancies in methodology. The most accurate current prevalence rates in the acute care setting come from 3 multisite studies reported in 2000 and 2001: 14.8%, 15%, and 15%.6-8

FINANCIAL COST OF CARE

Cost is another relative unknown, although again, it is generally accepted to be high. Analyzing data from previously published studies, Beckrich and Aronovitch9 concluded that 1.6 million pressure ulcers develop in hospitals in the United States each year, with a cost of $2.2 to $3.6 billion. They estimated an incremental cost of $125 to $200 for managing each Stage I or Stage II pressure ulcer that develops in the hospital; for each Stage III or Stage IV pressure ulcer, they estimated a cost of $14,000 to $23,000.9 However, higher-stage pressure ulcers rarely heal in the hospital setting, which means these numbers most likely underestimate the true cost to heal Stage III and Stage IV pressure ulcers.10