SPINAL CORD MEDICINE PRESSURE PRESSURE ULCER Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals SECOND EDITION CLINICAL PRACTICE GUIDELINE: Administrative and financial support provided by Paralyzed Veterans of America Consortium for Spinal Cord Medicine Member Organizations Academy of Spinal Cord Injury Professionals Nurses Section Psychologists and Social Workers Section Physicians Section American Academy of Orthopedic Surgeons American Academy of Physical Medicine and Rehabilitation American Association of Neurological Surgeons American Association of Spinal Cord Injury Nurses American College of Emergency Physicians American Congress of Rehabilitation Medicine American Occupational Therapy Association American Physical Therapy Association American Psychological Association, Division 22 American Spinal Injury Association Association of Academic Physiatrists Association of Rehabilitation Nurses Christopher and Dana Reeve Foundation Insurance Rehabilitation Study Group International Spinal Cord Society Paralyzed Veterans of America Rick Hansen Institute Society of Critical Care Medicine U. S. Department of Veterans Affairs United Spinal Association CLINICAL PRACTICE GUIDELINE Spinal Cord Medicine Pressure Ulcer Prevention and Treatment Following Injury: A Clinical Practice Guideline for Health-Care Providers SECOND EDITION Consortium for Spinal Cord Medicine Administrative and financial support provided by Paralyzed Veterans of America © Copyright 2014, Paralyzed Veterans of America This guideline has been prepared based on scientific and professional information available in 2014. Users of this guideline should periodically review this material to ensure that the advice herein is consistent with current reasonable clinical practice. The websites noted in this document were current at the time of publication; however, because web addresses and the information contained therein change frequently, the reader is encouraged to stay apprised of the most current information. ISBN 0-929819-24-1 ii PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY Contents iii Foreword v Preface vi Acknowledgments vii Panel Members – Original Pressure Ulcer CPG ix Reviewers xi Summary of Recommendations 1 The Consortium for Spinal Cord Medicine 1 GUIDELINE DEVELOPMENT PROCESS 1 METHODOLOGY 4 Methods (Second Edition) 5 Introduction 11 Recommendations 11 RISK AND RISK ASSESSMENT 11 DEMOGRAPHIC RISK FACTORS 12 SCI-RELATED RISK FACTORS 13 COMORBID MEDICAL RISK FACTORS 14 NUTRITION 14 PSYCHOLOGICAL, COGNITIVE, CONTEXTUAL, AND SOCIAL FACTORS: SUBSTANCE ABUSE AND ADHERENCE/COMPLIANCE 15 SUPPORT SURFACES FOR BED AND WHEELCHAIR 15 RISK-ASSESSMENT TOOLS 17 PREVENTION STRATEGIES ACROSS THE CONTINUUM OF CARE 17 PRESSURE REDISTRIBUTION 17 VISUAL AND TACTILE SKIN INSPECTIONS 19 TURNING AND REPOSITIONING 20 EFFECTIVE SUPPORT ENVIRONMENT 21 INDIVIDUALIZED PRESSURE REDISTRIBUTION SYSTEM 23 EXERCISE 23 NUTRITION 28 EDUCATION—HEALTH CARE PROFESSIONALS, PERSONS WITH SCI, FAMILY, CAREGIVERS 29 ASSESSMENT AND REASSMENT FOLLOWING PRESSURE ULCER ONSET 29 ASSESSMENT OF THE INDIVIDUAL WITH A PRESSURE ULCER 30 ASSESSMENT AND REASSESSMENT OF THE PRESSURE ULCER 34 TREATMENT – NONSURGICAL 34 CREATING A PHYSIOLOGIC WOUND ENVIRONMENT 34 Cleanse 35 Debridement 37 Selection of Wound Care Dressing 43 Electrical Stimulation 44 Adjunctive Therapies and Biologics 45 MODIFICATION OF TREATMENT PLAN 46 TREATMENT – SURGICAL 46 REFERRAL FOR PRESSURE ULCER SURGERY 48 PREOPERATIVE ASSESSMENT 52 POSTOPERATIVE CARE 54 COMPLICATIONS OF PRESSURE ULCER SURGERY 55 PRESSURE REDISTRIBUTION AND SUPPORT SURFACES 55 BED POSITIONING 57 BED SUPPORT SURFACES 58 WHEELCHAIR SEATING AND POSITIONING 62 WHEELCHAIR SUPPORT SURFACES 65 SUPPORT SURFACES FOR BATHING AND TOILETING 66 OTHER SUPPORT SURFACES 67 Future Research 68 References 82 Glossary 83 Index CLINICAL PRACTICE GUIDELINE iii Foreword ressure ulcers are a frequent, costly, and potentially life-threatening complication of spinal cord injury (SCI). They complicate the rehabilitation Pprocess and are a significant deterrent to participation in activities that contribute to independent, productive, and satisfying lives. Pressure ulcers result in prolonged hospitalizations, delayed community reintegration, reduced quality of life, and loss of self-esteem. The etiology of pressure ulcers is complex and multidimensional. Biochemical, mechanical, and environmental and contextual factors interact at various times to damage tissue. Clinicians and researchers focus on unrelieved pressure, shear, friction, moisture, poor nutrition, immobility, and psychological, social, and economic factors, such as drug abuse, depression, inadequate personal and financial resources, and non- compliance to acknowledged preventive behaviors as the most significant aspects of pressure ulcer development. Every person with SCI is at risk for the development of pressure ulcers and almost all will develop at least one serious pressure ulcer during their lifetime. The prevention and management of pressure ulcers are processes that are inextricably linked across the continuum of care of individuals with SCI. Current prevention programs, specifically hospital-based education interventions, have had limited success in reducing the occurrence of pressure ulcers especially after these individuals return to their families and community. This may be due, in part, to very short hospital stays, currently 3 to 4 weeks, in many rehabilitation facilities, resulting in extremely limited pressure ulcer prevention education. Furthermore, despite the plethora of education and treatment programs and protocols described in the literature, few have been validated for their ability to promote the preventive behaviors that reduce the occurrence or recurrence of pressure ulcers, especially after the person has returned to his or her home and community where out-patient educational resources are very limited. Since the publication of the original clinical practice guideline Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals (2000), a number of present scientific studies have advanced our knowledge of the factors that contribute to the formation of pressure ulcers and have provided new directions for improving preventive techniques and treatment. The purpose of this new/ updated clinical practice guideline is to present the current state of the science in pressure ulcer research and clinical practice and scientifically sound strategies that are effective in identifying risk and reducing the incidence, prevalence, and recurrence of this lifelong complication of SCI. More than 225 new articles specific to pressure ulcers among persons with spinal cord injury have been reviewed and graded. The recommendations in this guideline cover a broad spectrum of issues that have been addressed by the new multidisciplinary pressure ulcer clinical practice guideline development panel and several consultants. The significant constructs of this problem are risk and risk assessment; prevention strategies across the continuum of care; assessment and reassessment, following the onset of a pressure ulcer, of the individual with a pressure ulcer and of the ulcer itself; nonsurgical and surgical treatments interventions and their complications; and pressure redistribution and support surfaces and positioning for managing tissue loads for the bed and wheelchair. The recommendations are based on an extensive review and analysis of the available scientific literature and represent the most current understanding of the interventions applied in clinical practice. Where the scientific literature failed to provide guidance in the development of this document, the panel iv PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY members based their recommendations on expert consensus. The panel was conscientious in identifying areas where knowledge gaps exist so that future research can be directed toward enhancing prevention and efforts. The guideline is designed to be used by physicians in a number of specialties (including internal medicine, plastic surgery, and physical medicine and rehabilitation), nurses, physical and occupational therapists, social workers, and psychologists. It also may be useful to individuals with SCI, their families, and significant others, although the original consumer guide will be updated as well. Additionally, this guideline has implications for administrators, personal care attendants, third-party payers, and those who direct public policy. The Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury Clinical Practice Guideline, 2nd Edition is the result of a collaborative effort among a group of professionals with extensive experience in studying and treating pressure ulcers. Their dedication is reflected in the pages of this document. Susan L. Garber, MA, OTR, FAOTA, FACRM Panel Chair CLINICAL PRACTICE GUIDELINE v Preface s chairman of the Steering Committee of the Consortium for Spinal Cord Medicine, it is a great pleasure for me to introduce the revision of the clinical Apractice guideline Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury. The initial clinical practice guideline for Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury was published in 2000. We were very fortunate to have the chairman of the initial guideline, Susan L. Garber, MA, OTR, FAOTA, return