Quality indicators for prevention and management of pressure ulcers

Quality Indicators for Prevention and Management of Pressure Ulcers
in Vulnerable Elders
Barbara M. Bates-Jensen, PhD, RN, CWOCN
Pressure ulcers can lead to pain, disfigurement, and
slow recovery from comorbid conditions. They in-terfere
with activities of daily living, predispose to osteo-myelitis
and septicemia (1), and are strongly associated
with longer hospital stays and mortality. Frailty and
chronic illness, both common among older adults, pre-dispose
to pressure ulcers (1–3).
The prevalence of pressure ulcers is 10% to 14%
among hospitalized patients of all ages (4, 5) and up to
24% among patients in nursing homes (2). One goal of
Healthy People 2010 is to reduce the prevalence of pres-sure
ulcers in nursing home patients by 50% (6). Pre-vention
and treatment of pressure ulcers are an impor-tant
aspect of care for vulnerable elders. This paper
presents quality indicators for the prevention and care of
pressure ulcers among vulnerable elders and the evidence
supporting these indicators.
METHODS
The methods for developing these quality indica-tors,
including literature review and expert panel consid-eration,
are described in detail in another paper in this
issue (7). For pressure ulcers, the structured literature
review identified 177 titles, from which abstracts and
articles that were relevant to this report were identified.
Fifteen potential quality indicators were proposed on
the basis of the literature and the author’s expertise and
files from previous reviews of the subject (8, 9). The
search terms and results of the literature review can be
accessed at www.acponline.org/sci-policy/.
RESULTS
Of the 15 potential quality indicators, 10 were
judged to be valid by the expert panel and 1 additional
indicator was created by the panel (see the quality indi-cators
on pp 653-667). One indicator was merged with
an accepted indicator, and 4 were not accepted (www
.acponline.org/sci-policy/). The literature supporting
each of the indicators judged to be valid by the expert
panel process is reviewed below.
Quality Indicators 1 and 2: Pressure Ulcer Prevention
Risk Assessment
IF a vulnerable elder is admitted to an intensive care
unit or a medical or surgical unit of a hospital and can-not
reposition himself or herself or has limited ability to
do so, THEN risk assessment for pressure ulcers should
be done on admission BECAUSE risk assessment can
predict pressure ulcer formation in such high-risk
groups and forms the basis for intervention.
Positioning Needs and Pressure Reduction
IF a vulnerable elder is identified as at risk for pres-sure
ulcer development or a pressure ulcer risk assess-ment
score indicates that the person is at risk, THEN a
preventive intervention addressing repositioning needs
and pressure reduction (or management of tissue loads)
must be instituted within 12 hours BECAUSE reduc-tion
or elimination of risk factors can prevent pressure
ulcer formation.
Supporting Evidence. Several cohort and prospective
studies and various expert groups provide evidence sup-porting
timely risk assessment. Braden and Bergstrom
(10) studied the predictive validity of risk assessment for
pressure ulcers in 102 newly admitted nursing home
residents. Using the Braden Scale (Figure) with a cutoff
score of 18, they demonstrated that the sensitivity, spec-ificity,
positive predictive value, and negative predictive
value of the admission assessment for subsequent devel-opment
of pressure ulcers were 75%, 59%, 41%, and
86%, respectively. Of the 28 residents who developed
pressure ulcers, the ulcer developed within about 2
weeks after admission in 71%, and all ulcers developed
less than 4 weeks after admission (10).
A multisite cohort study of 843 patients who were
followed for 4 weeks found that the Braden Scale was
predictive of pressure ulcer development in tertiary care
Ann Intern Med. 2001;135:744-751.
For the author affiliation and current address, see end of text.
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centers, Veterans Affairs medical centers, and skilled
nursing facilities (11). As part of the study, prescription
of preventive interventions for turning and pressure re-duction
were evaluated in all three health care settings.
Regardless of setting, turning schedules and pressure re-duction
were prescribed less frequently (7.7% and 34%)
for patients at no risk or low risk (Braden Scale scores $
16) than for patients at moderate or high risk (Braden
Scale scores # 15; 51% and 69%) (12). In another pro-spective
cohort study of 200 newly admitted nursing
home residents, the best predictor of all stages of pres-sure
ulcer formation was Braden Scale score (13). Other
investigators also found an association between preven-tive
interventions and Braden Scale scores, in particular
the subscale scores for mobility, friction, and shear (14).
Prevention interventions are ordered and seem to be
used more frequently for people with high-risk Braden
Scale scores. However, data showing the effectiveness of
the interventions themselves are lacking. Various expert
groups, including the National Pressure Ulcer Advisory
Panel (NPUAP) (15), the Agency for Health Care Pol-icy
and Research (AHCPR) Panel for Prevention and
Figure. The Braden Scale for predicting risk for pressure ulcers.
Quality Indicators for Pressure Ulcers ACOVE
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Prediction of Pressure Ulcers (2), and the American
Medical Directors Association (AMDA) (3) recommend
performing risk assessment in persons who cannot repo-sition
themselves or have limited ability to do so.
Quality Indicator 3: Pressure Ulcer Prevention
Nutrition
IF a vulnerable elder is identified as at risk for pres-sure
ulcer development and has malnutrition (involun-tary
weight loss of $10% over 1 year or low albumin or
prealbumin levels), THEN nutritional intervention or
dietary consultation should be instituted BECAUSE
poor diet, particularly low dietary protein intake, is an
independent predictor of pressure ulcer development.
Supporting Evidence. Studies have shown a relation-ship
between risk factors for malnutrition, such as invol-untary
weight loss, anorexia, gastrointestinal illnesses,
cancer, low caloric intake, and low albumin level and
pressure ulcer formation; some studies have found a re-lationship
between ulcer severity and severity of malnu-trition
(16 –18). Furthermore, several studies have
shown associations between low serum albumin level
and the presence (19, 20), severity (17, 18), and healing
(21, 22) of pressure ulcers. Other measures of nutri-tional
status, such as body weight, have been shown to
correlate with presence (19, 20) and severity (17) of
pressure ulcers. Although no direct evidence shows that
adequate nutrition will prevent ulcers, these studies pro-vide
indirect evidence that prevention of malnutrition
will reduce risk for pressure ulcer formation.
Quality Indicator 4
Pressure Ulcer Evaluation
IF a vulnerable elder presents with a pressure ulcer,
THEN the pressure ulcer should be assessed for loca-tion,
depth and stage, size, and presence of necrotic tis-sue
BECAUSE baseline assessment guides interventions,
provides data for later comparison to evaluate healing,
and can help predict time to healing.
Supporting Evidence. No controlled trials of assess-ment
of pressure ulcers have been done, and some ex-perts
believe that such studies may be impractical or
irrelevant (23). Several sets of guidelines support formal
assessment of pressure ulcers, with documentation of
findings, and focus on wound characteristics as a useful
method for evaluating and documenting healing. The
NPUAP suggested that 1) assessment should include
multiple characteristics; 2) pressure ulcer staging is use-ful
for diagnostic purposes only; and 3) size and stage
are insufficient measures of healing and, although im-portant,
should be used in conjunction with assessment
of other wound characteristics (24). Others have also
acknowledged the role of assessment in planning and
evaluating therapy (3, 25, 26).
Observational data support these consensus state-ments
and suggest that many wound characteristics are
important predictors of healing or determinants of in-terventions.
Wound Depth and Stage
Pressure ulcers are commonly classified according to
staging systems based on the depth of tissue destruction.
Stage 1 lesions are least severe, and stage 4 are most
severe. Staging systems are best used to diagnose wound
severity and show a relationship to healing outcomes,
but they do not facilitate monitoring of healing over
time (2, 24, 26, 27). Full-thickness wounds (stage 3 and
stage 4) generally take longer to heal than partial-thick-ness
wounds (stage 2) (28). A prospective study showed
that stage 2 pressure ulcers were 5.2 times more likely to
heal than stage 4 pressure ulcers (29). Several other pro-spective
studies also found that wound depth was a pre-dictor
of healing and time to healing (21, 30). Two
retrospective studies demonstrated that wound depth
was related to healing characteristics (31) and that
change in depth was related to healing time (8), yet both
studies found that initial wound depth did not correlate
with healing.
Size
Several studies have demonstrated a relationship be-tween
wound surface area and time to complete healing.
In a prospective study to determine progress of healing
within specific time frames, van Rijswijk (32) examined
the characteristics of full-thickness pressure ulcers in 119
patients (48 of whom had full-thickness ulcers) who
were seen in diverse settings. Healing was measured by
using surface area tracings, with follow-up of 15
months. Mean reduction in wound surface area for ul-cers
that healed versus those that did not was significant
at 2 weeks (45% vs. 23%) and at 4 weeks (77% vs.
18%). In a secondary analysis of full-thickness pressure
ACOVE Quality Indicators for Pressure Ulcers

ulcers, only 25% healed completely within 50 days, but
three quarters had 50% reduction in surface area within
39 days (33). Ulcers with a surface area decrease of at
least 39% after 2 weeks healed more quickly than those
with a lesser decrease in surface area (median time to
healing, 53 vs. 70 days). Retrospective studies also sup-port
the relationship between early reduction in surface
area and shorter time to healing (8, 31).
Presence of Necrotic Tissue
Wound bed characteristics determine treatment op-tions
(8, 34). Several studies have shown that replace-ment
of necrotic tissue with granulation and epithelial
tissue is indicative of healing (32), and the presence of
necrotic tissue at baseline is associated with slower heal-ing
(35).
Other Characteristics and Assessment Tools
Results of studies of other wound characteristics,
such as exudate and undermining, in relation to healing
time have been inconclusive (8, 21, 33–36). Nonethe-less,
assessment is recommended because it can guide
treatment (8).
Use of a standardized instrument or tool for assess-ment
and documentation of pressure ulcers, such as the
Pressure Sore Status Tool (37) or the Pressure Ulcer
Scale for Healing (36), is suggested, but no study has
examined the effect of standardized evaluation and doc-umentation
on pressure ulcer outcomes.
Quality Indicators 5 and 6
Management of Full-Thickness Pressure Ulcers
IF a vulnerable elder presents with a clean full-thickness
pressure ulcer and has no improvement after 4
weeks of treatment, THEN the appropriateness of the
treatment plan and the presence of cellulitis or osteomy-elitis
should be assessed BECAUSE clean full-thickness
pressure ulcers should show evidence of healing or im-provement
within 4 weeks and lack of improvement
should stimulate a change in approach.
Management of Partial-Thickness Pressure Ulcers
IF a vulnerable elder presents with a partial-thick-ness
pressure ulcer and has no improvement after 2
weeks of treatment, THEN the appropriateness of the
treatment plan should be assessed BECAUSE partial-thickness
pressure ulcers should show evidence of heal-ing
or improvement within 2 weeks and lack of im-provement
should stimulate a change in approach.
Supporting Evidence. No direct evidence indicates
that reassessment of nonhealing ulcers will improve out-comes.
However, it is logical that reassessment is a nec-essary
first step to identify causes of and, hence, treat
nonhealing ulcers.
These two quality indicators are supported by evi-dence
on rate of healing and healing outcomes from
several studies. A randomized, controlled trial involving
85 patients found that up to 42% of stage 2 ulcers
healed within 30 days and 75% healed within 60 days,
whereas only 17% of stage 3 and 4 ulcers healed within
60 days (30). Similar outcomes were noted in a prospec-tive
cohort study of 89 nursing home residents with
stage 2 or greater pressure ulcers. After 6 weeks of
follow-up, 65% of stage 2 ulcers, 14% of stage 3 ulcers,
and no stage 4 ulcers healed (29). In Brandeis and col-leagues’
(28) cohort study of 1626 patients with a stage
2 or greater pressure ulcer who were admitted to 1 of 51
nursing, up to 54% of stage 2 ulcers healed in 3 months
and 74% healed in 6 months (28). Healing rates for
stage 3 and 4 ulcers were slower; 31% and 23% healed
in 3 months and 59% and 33% healed in 6 months,
respectively. Data from a randomized, controlled trial
(35) indicated much faster healing times for stage 2 ul-cers
and provide primary support for the 2-week time
frame for the partial-thickness quality indicator: The
median healing time was 9 to 11 days, and three quar-ters
of the ulcers healed within 14 to 26 days, depending
on topical treatment.
In a retrospective study of 143 pressure ulcers,
change in surface area at 1 week was a strong predictor
of time to 50% healing. The median time to 50% heal-ing
among ulcers at all stages that had decreased surface
area within 1 week was 21 to 26 days; in contrast,
wounds with no change in surface area reached 50%
healing in a median of 34 days (8), and an increase in
surface area at 1 week was predictive of nonhealing.
Reported mean or median times to healing are 8.7
to 38 days (22, 30, 35) for partial-thickness stage 2
ulcers; full-thickness stage 3 or 4 ulcers will heal after 8
to 10 weeks of therapy in 10% to 40% of patients (28,
32). Some investigators have shown that the percentage
reduction in surface area after 1, 2, or 4 weeks of treat-ment
is predictive of time to healing (8, 33). The basis

for the 4-week timeframe in the full-thickness quality
indicator is primarily supported by van Rijswijk and
Polansky’s study of full-thickness pressure ulcers and
percentage reduction in surface area as predictors of
time to healing (33).
Quality Indicator 7
Pressure Ulcer Debridement
IF a vulnerable elder presents with a full-thickness
sacral or trochanteric pressure ulcer covered with ne-crotic
debris or eschar, THEN debridement by using
sharp, mechanical, enzymatic, or autolytic procedures
should be done within 3 days of diagnosis BECAUSE
dead tissue is a physical obstacle to healing tissue and
provides a medium for bacterial invasion and prolifera-tion,
which places the patient at high risk for wound
infection.
Supporting Evidence. Wound debridement can be
performed by using sharp, mechanical, enzymatic, or
autolytic methods. Sharp debridement involves use of a
scalpel, scissors, or other sharp instrument to remove
nonviable tissue. One multicenter trial of the effects of a
topical growth factor versus placebo on wound healing
in 118 patients noted incidentally that sharp debride-ment
was positively associated with healing of diabetic
ulcers (38). In this study, all patients received sharp de-bridement
initially and then as needed throughout 20
weeks of follow up. In post hoc analysis, centers that
used sharp debridement more frequently (debridement
at up to 87% of visits) produced better healing rates (up
to 83%) than did centers that used sharp debridement
less often (debridement at 15% to 43% of visits; up to
64% healed). Sharp debridement can be safely per-formed
in a fairly aggressive manner at the bedside in a
sequential fashion (daily or every other day) by various
health care providers. Attention to patient comfort is
recommended (systemic or topical analgesia), and some
have suggested benefits to combining bedside sequential
sharp debridement with other forms of debridement to
maximize response (39).
Mechanical debridement involves the use of wet-to-dry
dressings, whirlpool, or lavage or wound irrigation.
The AHCPR panel recommended cautious use of
mechanical wet-to-dry dressings for debridement be-cause
removal of dressing may cause trauma to new
granulation and epithelial tissue. Because debridement
with wet-to-dry dressings is painful, the AHCPR panel
recommends pain management, such as administration
of a systemic analgesic before dressing removal (25).
Coarsely woven gauze or cotton sponges appear to be
more effective than finer materials in mechanical de-bridement
(40).
Enzymatic debridement involves applying a concen-trated,
commercially prepared enzyme to the surface of
the necrotic tissue, with the expectation that it will ag-gressively
degrade necrosis by digesting devitalized tis-sue.
A randomized, controlled trial of enzymatic de-bridement
for necrotic wounds reported a mean time of
8 days to debride stage 4 pressure ulcers with an amor-phous
hydrogel dressing and a mean time of 12 days for
debridement with an enzymatic preparation containing
streptokinase and streptodornase (41). These times did
not differ significantly, suggesting that an agent with
enzyme activity was unnecessary.
Autolytic debridement is use of the body’s own
mechanisms to remove nonviable tissue. Maintaining a
moist wound environment allows collection of fluid at
the wound site, which allows enzymes within the wound
to digest necrotic tissue. Autolytic debridement, which
typically involves adequate wound cleansing to wash out
partially degraded nonviable tissue, is more effective
than wet-to-dry gauze dressings because it removes only
necrotic tissue and therefore protects healthy tissues
(42– 44). Mulder and colleagues (42) evaluated 16 pa-tients
in a randomized, controlled trial of a hypertonic
hydrogel versus wet-to-dry gauze for wound debride-ment
(the hypertonicity of the gel assists with autolytic
debridement by pulling fluid into the area through os-motic
forces) (42). The results suggested that the hydro-gel
could safely facilitate removal of dry adherent eschar
from wounds. Other investigators also have found
amorphous hydrogels to be effective in removing ne-crotic
debris from wounds (43– 45).
Quality Indicator 8
Pressure Ulcer Management: Cleansing
IF a vulnerable elder has a stage 2 or greater pressure
ulcer, THEN a topical antiseptic should not be used on
the wound BECAUSE topical antiseptics may harm the
healthy wound bed.
Supporting Evidence. No controlled trials have exam-ined
the effectiveness or safety of wound cleansing. Con-traindications
to the use of antiseptic and antimicrobial

solutions for cleansing clean pressure ulcers are based on
several laboratory studies (46–49). Two studies tested
antimicrobial wound cleansers and solutions for toxicity
to polymorphonuclear leukocytes. Results showed that
even serial dilutions of the products diminished the vi-ability
and function of polymorphonuclear leukocytes;
in contrast, nonantimicrobial solutions did not cause
substantial toxicity to polymorphonuclear leukocytes
(46, 47). On the basis of early animal model studies (48,
49), the AHCPR guidelines recommend normal saline
as the preferred cleanser because it is noncytotoxic (25).
Quality Indicators 9 and 10
Pressure Ulcer Debridement for Systemic Infection
IF a vulnerable elder with a full-thickness pressure
ulcer presents with systemic signs and symptoms of in-fection,
such as elevated temperature, leukocytosis, con-fusion,
and agitation, and these signs and symptoms do
not have another identified cause, THEN the ulcer
should be debrided of necrotic tissue within 12 hours
BECAUSE debridement will reduce dead tissue that
provides a medium for bacterial invasion and may lead
to systemic infection.
Pressure Ulcer Culture for Systemic Infection
IF a vulnerable elder with a full-thickness pressure
ulcer presents with systemic signs and symptoms of in-fection,
such as elevated temperature, leukocytosis, con-fusion,
and agitation, and these signs and symptoms do
not have another identified cause, THEN a tissue biopsy
or needle aspiration sample should be obtained and
sent for culture and sensitivity testing within 12 hours
BECAUSE high bacterial burdens inhibit wound heal-ing
and may lead to systemic infection, and needle as-piration
or tissue biopsy is the best indicator of bacterial
invasion into tissue.
Supporting Evidence. Wound infection extends the
inflammatory phase of healing, delays collagen synthesis,
retards epithelialization, and causes more injury to the
tissues because the bacteria produce toxic by-products
and compete with fibroblasts and other cells for limited
amounts of oxygen and nutrients (50, 51).
Signs and symptoms of systemic infection may be
due to spread from a full-thickness pressure ulcer. To
treat the infection, the source of the infection must be
identified; impediments to healing must be removed;
and, if possible, the organism causing the infection must
be identified. Standard swab cultures do not aid in di-agnosis
of infection in pressure ulcers because they de-tect
only surface contaminants and not the organism
that caused the tissue infection (52). The AHCPR pres-sure
ulcer treatment guidelines recommend wound cul-ture
of a tissue biopsy or needle aspiration sample when
infection is suspected (25). This procedure may be im-practical
at some centers, and the NPUAP supports use
of a specialized swab technique to culture pressure ulcer
wound beds (24, 53). The recommended method of
quantitative swab culture involves cleansing the wound
with solution that contains no antiseptic. The end of a
sterile cotton-tipped applicator is rotated in a 1-cm2 area
of the wound for 5 seconds (53, 54) with enough pres-sure
to cause tissue fluid to be absorbed in the cotton tip
of the swab. The swab tip is inserted in the tube con-taining
transport media and is sent to the laboratory.
Swab culture was not included in the indicator because
of the difficulty in distinguishing technique from the
medical record.
Tissue biopsy is removal of a piece of tissue by using
a scalpel or a punch biopsy instrument. The area may be
treated with topical anesthetic or injected with local an-esthetic.
The biopsy is performed, pressure is applied to
the area to control bleeding, and the tissue is sent to the
laboratory. Needle aspiration involves insertion of a 22-
gauge needle (attached to a 10-mL disposable syringe
with 0.5 mL of air in the syringe) through intact skin
next to the wound. Suction is achieved by briskly with-drawing
the plunger to the 10-mL mark. The needle is
moved backward and forward at different angles for two
to four explorations. The plunger is gently returned to
the 0.5-mL mark, the needle is withdrawn and capped,
and the specimen is sent to the laboratory.
In the setting of possible systemic infection, the full-thickness
ulcer should be treated to decrease the likeli-hood
that it is a source of hematogenous bacterial seeding.
This is particularly true for wounds with foul-smelling
drainage that are generally infected or filled with ne-crotic
debris. For such ulcers, healing time is prolonged
because tissue destruction may be progressive (55). De-bridement
of the wound, with special attention to areas
of undermining or tunneling, removes dead tissue that
provides a medium for bacterial growth and invasion.
Because systemic infection is life-threatening, debride-ment
of the wound bed should be done within 12
hours.

Quality Indicator 11
Topical Dressings
IF a vulnerable elder presents with a clean full-thickness
or a partial-thickness pressure ulcer, THEN a
moist wound-healing environment should be provided
with topical dressings BECAUSE wounds heal better in
a moist environment.
Supporting Evidence. Several investigators have com-pared
a moist environment with dry dressings for
wound healing. All have noted faster healing with moist
wound dressings than with wet-to-dry saline gauze
dressings (22, 56, 57). The AHCPR guidelines on pres-sure
ulcer treatment (25), which are supported by the
American Medical Directors Association (3) and
NPUAP (24), also advocate the use of moist dressings
over dry dressings.
DISCUSSION
Despite an increase in pressure ulcer research since
the publication of the AHCPR guidelines on pressure
ulcers, few quality indicators are supported by substan-tial
evidence. Through a literature search and synthesis
coupled with a two-stage expert panel process, 11 valid
quality indicators for pressure ulcers were identified.
These indicators span pressure ulcer care from preven-tion
and assessment to topical treatments. Although
they are not comprehensive, they provide a baseline for
measures that may discriminate between quality and
substandard care.
From University of California, Los Angeles, Los Angeles, California; and
the Borun Center for Gerontological Research, Los Angeles, California.
Grant Support: By a contract from Pfizer Inc. to RAND.
Acknowledgments: The author thanks Dan Osterweil, MD, for review
of an earlier version of the paper containing the full set of proposed
quality indicators, and Patricia Smith for technical assistance.
Requests for Single Reprints: Barbara Bates-Jensen PhD, RN,
CWOCN, UCLA Borun Center for Gerontological Research, 7150
Tampa Avenue, Reseda, CA 91335.
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