The Wound Healing Society (WHS) has released its updated 2023 Guidelines for the Treatment of Pressure Ulcers, providing comprehensive evidence-based recommendations for healthcare professionals. This update builds upon previous guidelines and addresses new developments in pressure ulcer management.
Background on Pressure Ulcers
Pressure ulcers affect approximately 2.5 million Americans annually, with particularly high risk among older adults, critically ill patients, and those with spinal cord injuries. Despite preventive measures, the incidence has not decreased in decades. Hospital-acquired pressure ulcers cost the healthcare system an estimated $26.8 billion annually, with over 50% of costs attributed to treating Stage 3 and 4 injuries.
Key Areas of Focus in the 2023 Guidelines
Positioning and Support Surfaces
The guidelines recommend establishing repositioning schedules to avoid placing patients on pressure ulcers and bony prominences. For non-ambulatory patients, maintaining the head of the bed at the lowest elevation consistent with medical needs is important to prevent shearing forces.
Support surfaces should be matched to individual needs for pressure redistribution, with recommendations for reactive support surfaces (foam, air, or gel-filled devices) for patients who can assume various positions, and active support surfaces (such as alternating-pressure mattresses) for those with multiple pressure ulcers or limited mobility.
For wheelchair users, proper assessment for appropriate seating systems is crucial, with emphasis on postural support and pressure redistribution. Doughnut-type devices should be avoided.
Nutrition
Nutritional assessment is essential upon entry to healthcare settings or with changes in health status. The guidelines recommend positive nitrogen balance (approximately 30-35 calories/kg/day and 1.25-1.50g of protein/kg/day) for optimal healing. Vitamin and mineral supplements should be provided when deficiencies are confirmed or suspected, with emerging evidence supporting the role of arginine in pressure ulcer healing.
Infection Management
The guidelines emphasize removing necrotic tissue through various debridement methods and determining infection levels through tissue biopsy or validated quantitative swab techniques. Biofilms, which contribute to chronic non-healing wounds, should be managed through sharp debridement and appropriate antimicrobial treatments.
For suspected osteomyelitis, bone biopsy for culture and histology is recommended, followed by adequate debridement and culture-guided antibiotics. Dry, stable heel ulcers without signs of inflammation may not require debridement.
Wound Bed Preparation
Proper wound bed preparation involves examining the patient’s overall condition, including systemic diseases, medications, and nutritional status. Initial and maintenance debridement is recommended to remove necrotic tissue and reduce bacterial burden.
The guidelines emphasize maintaining moisture balance in non-ischemic wounds and managing exudate to facilitate healing. Regular documentation of wound characteristics and healing progress is essential to determine if treatment is optimal.
Dressings
The guidelines recommend using dressings that maintain a moist wound environment, manage exudate, protect periulcer skin, and minimize friction and shearing. Cost-effectiveness should be considered when selecting dressings, taking into account factors like healthcare provider time, patient care goals, and healing rates.
Surgical Treatment
Surgical interventions are recommended for wounds that don’t respond to conservative care, with consideration for patient factors and prognosis. Composite tissue closure (using flaps) provides the best chance of sustained wound closure, though recurrence remains a concern.
A new recommendation highlights the potential benefits of incisional negative pressure wound therapy to reduce postoperative complications after flap reconstruction. Standardized protocols for perioperative and postoperative management can lead to reduced complications and recurrence.
Adjuvant Therapies
The guidelines discuss various adjuvant therapies, including growth factor therapy, negative pressure wound therapy (NPWT), electrical stimulation, ultrasound, and laser therapy, which may be considered when conventional treatments fail.
Palliative Wound Care
A new section addresses palliative wound care for seriously ill patients. Key recommendations include using the Jackson-Cubbin Scale to identify ICU patients at high risk for pressure ulcers and the Palliative Performance Scale for home palliative care patients.
For patients receiving palliative care, repositioning schedules should align with individual comfort and tolerance. The guidelines acknowledge that patients and families may prioritize comfort over pressure reduction. Proper pain assessment and management during dressing changes are emphasized, along with odor control using topical metronidazole, antiseptics, or charcoal dressings.
Conclusion
The 2023 WHS Guidelines for Pressure Ulcer Treatment provide a comprehensive, evidence-based framework for managing this complex and costly condition. By implementing these recommendations, healthcare professionals can improve outcomes, reduce complications, and enhance the quality of life for patients with pressure ulcers.