While pressure ulcers are common among people with impaired mobility, a new study has found surprisingly inadequate scientific evidence on the best strategies to prevent them.
The study, led by researchers at Women's College Hospital and Baycrest Geriatric Health Care System in Toronto, is reported in the August 23, 2006 issue of the Journal of the American Medical Association (JAMA).
The late actor Christopher Reeve, best known as "Superman", spoke openly about his struggle with pressure ulcers after being paralyzed in a horseback riding accident. He died at the age of 52 from complications reportedly associated with an infected pressure ulcer.
It is not just spinal cord injury patients who are vulnerable to pressure ulcers. Sixty percent of pressure ulcers develop in patients admitted to hospital. Many of these patients are elderly and/or have diabetes or vascular disease. Immobile patients can develop pressure ulcers within three to six hours of lying on an emergency room stretcher. Elderly persons in long-term care, particularly those who are immobile, incontinent or have dementia, are also at risk.
"Pressure ulcers are common in a variety of settings and are associated with adverse health outcomes and high treatment costs," says lead author Dr. Madhuri Reddy, a geriatrician and chronic wound specialist who conducted the study at Women's College Hospital in collaboration with Baycrest.
"We found that the majority of published studies which have examined interventions to prevent pressure ulcers have been inadequate in their design and have not generated robust scientific evidence from which to develop comprehensive and unequivocal best practice guidelines."
Pressure ulcers can range from a slight discoloration of the skin to open sores that go all the way to the bone. They frequently develop in the tail bone area, hip and heel, may prolong hospital stay and be complicated by pain and infection which may even result in death.
In the U.S., 2.5 million pressure ulcers are treated each year in acute care facilities alone, estimated at a staggering cost of $11 billion. The cost of treating an individual pressure ulcer ranges from $500 to $40,000 depending on the severity of the wound. The prevalence of pressure ulcers in Canada has been found to be at least as high as in the U.S., with an average of one in four patients across healthcare settings suffering from a pressure ulcer (ref: Prevalence of pressure ulcers in Canadian healthcare settings, Ostomy Wound Management; 2004; 50 (10): 22 -- 38).
"There seems to be a huge mismatch between the billions of dollars we're spending on treating this condition, including an incredible amount of nursing time, and the relatively little effort in determining best practices for prevention," says Dr. Paula Rochon, a geriatrician and senior scientist at Baycrest, and senior author on the study.
Using MEDLINE and other databases, the research team identified only 59 randomized control trials of pressure ulcer prevention conducted over the last 30 years, involving a total of 13,845 patients. Fifty-nine studies in 30 years, say researchers, is a surprisingly meager research effort given the magnitude of the problem. Most of the patients in the studies were in acute care hospitals (67%), 17% were in long-term care, and the rest in rehabilitation or mixed care settings. Prevention methods included use of specialized mattresses, repositioning, mixed nutritional supplements and skin lotions.
To assess the scientific rigor of the studies, investigators applied a checklist (CLEAR NPT quality-rating guidelines) for non-pharmacological interventions. The checklist included indicators such as adequate randomized selection of participants for the study, assessor and patient blinding to the intervention, and consistent follow-up schedule.
Results Only three of the 59 studies fulfilled all six criteria on the quality checklist. While repositioning is certainly thought to be a crucial intervention, it is still not known how often patients should be turned, or the best method to use. The use of support surfaces, optimizing nutritional status, and moisturizing skin around vulnerable areas requires more rigorous evaluation, say investigators.
"The bottom line is we still don't know what the most cost-effective strategies are for preventing pressure ulcers in different high risk populations," says Dr. Reddy who recently moved to Hebrew Rehabilitation Centre in Boston.
"We need to do more head-to-head comparisons of the most promising interventions, ensure the studies are single or even double blinded where possible, and use a high quality randomized selection protocol."
The JAMA study researchers included Dr. Reddy (Women's College Hospital), Dr. Rochon (Baycrest) and Dr. Sudeep Gill (Queen's University). Funding was provided in part by the Canadian Institutes of Health Research.
Women's College Hospital is an academic ambulatory care hospital with a focus on women's health. Baycrest is an internationally-renowned academic health sciences centre that focuses on the care of older adults. Both organizations are located in Toronto and affiliated with the University of Toronto.
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