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“Pressure Ulcers:
Reviewing the Evidence on a
Pressing Healthcare Concern”
ASSOCIATION OF REGISTERED NURSES OF NEWFOUNDLAND AND
LABRADOR
APRIL 4, 2017
SHEILA TUCKER
LIAISON OFFICER FOR NEWFOUNDLAND AND LABRADOR
CANADIAN AGENCY FOR DRUGS & TECHNOLOGIES IN HEALTH (CADTH)
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Disclosure - CADTH
• Funded by federal, provincial, and territorial ministries of
health.
• Application fees for three programs:
• CADTH Common Drug Review (CDR)
• CADTH pan-Canadian Oncology Drug Review (pCODR)
• CADTH Scientific Advice
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Disclosure – Sheila Tucker
Relationship with Commercial Interest:
•Grant/Research Support: None
•Speaker Bureau/Honoraria: None
•Consulting fees: None
•Memberships on advisory committees, boards: None
Other Affiliations:
I am a CADTH employee independently based in
Newfoundland.
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Acknowledgements
Brendalynn Ens, Director – Knowledge Mobilization and
Liaison Officer Program, CADTH.
Cindy Mosher, Manager – Client Affairs for Newfoundland
and Labrador and Prince Edward Island. Canadian
Institute for Health Research.
Ann Tucker, R.N.(Ret.)
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Learning Objectives
Through participation in this session, participants will:
• Increase awareness of new and emerging healthcare
interventions for pressure ulcers.
• Review recent evidence on these interventions.
• Consider the implications of this information for policy and
practice in Newfoundland and Labrador.
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Questions for Consideration
What are the implications of the evidence for current practice
in Newfoundland and Labrador?
Are there gaps in current resources used to guide clinical
practice in the prevention and management of pressure
ulcers?
Are there opportunities to strengthen practice?
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Healthcare DevicesDrugsVaccinesMedical interventionsSurgical interventionsLaboratory testsTherapiesDental procedures
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Background
• Prevalence of pressure ulcers in Canada ranges between
25.1% in acute care hospitals and 29.9% in long-term care
facilities.
• Significant implications for health, quality of life for patients
• Treatment is costly and difficult.
• Increases the risk of other adverse events including
infection, sepsis and death.
• Prevention of pressure ulcers is an accepted indicator of
health system quality and patient safety.
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Worsened Pressure Ulcer in Long-Term Care details for
Newfoundland and Labrador
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Results for All Regions Within the Province/Territory: Worsened
Pressure Ulcer in Long-Term Care (Percentage), 2015–2016
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Interactive Map: Worsened Pressure Ulcer in Long-Term Care
(Percentage), 2015–2016
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Hospital Harm Improvement Resource: Pressure Ulcers
CPSI and CIHI (2016)
Steps for preventing pressure ulcers:
1. Conduct a pressure ulcer admission assessment for all
patients.
2. Reassess risk for all patients daily.
3. Inspect skin daily.
4. Manage moisture on skin.
5. Minimize pressure, friction and shear:
a) Turn/reposition patients every two hours.
b) Use pressure-redistribution surfaces.
6. Optimize nutrition and hydration.
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Hospital Harm Improvement Resource: Pressure Ulcers
CPSI and CIHI (2016)
Additional Elements
1. Maximize activity and mobility, reducing or eliminating
friction and shear.
2. Avoid skin massage.
3. Barrier creams (NICE, 2014).
4. Emerging therapies for prevention of pressure ulcers:
• Microclimate control.
• Prophylactic Dressings.
• Fabrics and Textiles.
• Electrical Stimulation of the Muscles for Prevention of
Pressure Ulcers (National Pressure Ulcer Advisory
Panel, et al., 2014)
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New and Emerging Interventions
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Established Interventions for PrU
Prevention
• mattresses and beds
• patient repositioning
• nutrition
• heel supports and other support surfaces
• wheelchair cushions
• silicone foam dressings
• Australian sheepskin
• pads for incontinence
• general skin care and maintenance
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New / Emerging Interventions
Emerging interventions for the PrU prevention (alone or in
combination with established PrU preventive techniques),
including:
• microclimate control techniques
• prophylactic dressings (e.g., polyurethane)
• silk or silk-like fabrics
• electrical muscle stimulation (for spinal cord injuries)
• decision support systems/tools included in EHRs,
monitoring alarms and systems (e.g., Leaf patient
monitoring system)
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Emerging Technologies for the Prevention of Pressure
Ulcers in Acute Care Settings: A Review of Clinical and
Cost-Effectiveness and Guidelines (2016)
Key Findings:
• Prophylactic polyurethane film dressings may be effective in
preventing PrUs in individuals without existing skin or tissue
damage.
• One evidence-based guideline identified – recommended
practices include:
• Microclimate manipulation
• Prophylactic dressings
• Silk-like fabrics, and
• Electrical stimulation (patients w. spinal cord injuries)
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Evidence-based guidelines regarding the use of emerging
technologies when used alone, or in combination with
established interventions, for the prevention of pressure
ulcers in acute care settings
Recommendations:
• Prophylactic practices include management of microclimate
by selecting support services or support surface covers
based on their ability to control moisture and temperature at
the body/support surface interface.
• Apply a polyurethane foam dressing to an individual’s bony
prominances, or by using silk-like fabrics instead of cotton
or cotton-blends.
• Electrical stimulation recommended for patients with spinal
cord injuries.
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Horizon Scanning
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Patient Lifts and Transfer Equipment (Turning Devices) for
Preventing Pressure Ulcers: A Review (2013)
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Treatment
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Treatment
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CADTH Project in Process
Polyurethane Foam Dressings For the Prevention of Pressure
Ulcers: Clinical and Cost-Effectiveness and Guidelines
• Summary of the evidence with critical appraisal
To learn more about this and other CADTH products and
services, sign up at www.cadth.ca/subscribe to get updates
sent directly to your inbox.
• New at CADTH – monthly newsletter
• CADTH E-Alerts - Calls for stakeholder feedback and patient group
input, plus other time-sensitive announcements.
• CADTH Events
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Other Wound Care Topics
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Implementation Support
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CADTH Support Policy / Practice Change?
Knowledge Mobilization and Liaison Officer Program (KMLO)
• Work with healthcare decision makers at all levels to identify
evidence needs.
• Facilitate evidence requests to CADTH.
• Provide support in using evidence to change and/or
introduce new policy and practice.
• Evaluation and impact assessment.
• For further information visit the CADTH website at
www.cadth.ca or contact Sheila Tucker at [email protected]
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ReferencesDressing Materials for the Treatment of Pressure Ulcers in Patients in Long-Term Care
Facilities: A Review of the Comparative Clinical Effectiveness and Guidelines. 2013,
November. [Internet] Ottawa: CADTH (Rapid Response) Available from:
https://www.cadth.ca/dressing-materials-treatment-pressure-ulcers-patients-long-term-
care-facilities-review-comparative
Dumville JC, Webster J, Evans D, Land L . “Negative pressure wound therapy for treating
pressure ulcers : Review “. Cochrane Database of Systematic Reviews 2015, Issue 5. Art.
No.: CD011334.
Electrically Stimulated Underwear for Pressure Ulcers . Top 10 New and Emerging Health
Technology Watch List: 2015 [Internet] Canadian Network for Environmental Scanning in
Health. Available from: https://www.cadth.ca/electrically-stimulated-underwear-pressure-
ulcers
Emerging Technologies for the Prevention of Pressure Ulcers in Acute Care Settings: A
Review of Clinical and Cost-Effectiveness and Guidelines. 2016, September [Internet]
Ottawa: CADTH (Rapid Response) Available from: https://www.cadth.ca/emerging-
technologies-prevention-pressure-ulcers-acute-care-settings-review-clinical-and-cost-0
Hospital Harm Improvement Resource: Pressure Ulcer. 2016. Canadian Patient Safety
Institute; Canadian Institute for Health Information. [Internet] Available from:
http://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-
Measure/Documents/Resource-Library/HHIR%20Pressure%20Ulcer.pdf
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References Continued
Negative Pressure Wound Therapy for Patients with Diabetic Foot Ulcers and Pressure
Ulcers: Clinical Effectiveness . 2012, March. [Internet] Ottawa: CADTH (Rapid Response)
Available from: https://www.cadth.ca/negative-pressure-wound-therapy-patients-diabetic-
foot-ulcers-and-pressure-ulcers-clinical
Patient Lifts and Transfer Equipment for Preventing Pressure Ulcers: A Review of Clinical and
Cost-Effectiveness and Guidelines. 2013, March. [Internet] Ottawa: CADTH (Rapid
Response) Available from: https://www.cadth.ca/patient-lifts-and-transfer-equipment-
preventing-pressure-ulcers-review-clinical-and-cost
Percentage of Residents Whose Stage 2 to 4 Pressure Ulcer Worsened: Details for
Newfoundland and Labrador. Canadian Institute for Health Information (CIHI).
Smart-e-Pants: Using Intermittent Electrical Stimulation to Prevent Pressure Ulcers . 2015,
April. [Internet] Ottawa: CADTH (Issues in Emerging Health Technologies) Available from:
https://www.cadth.ca/smart-e-pants
Your Health System: Worsened Pressure Ulcer in Long Term Care Details for Newfoundland
and Labrador. 2016. Canadian Institute for Health Information. Available from:
http://yourhealthsystem.cihi.ca/hsp/indepth?lang=en#/indicator/052/2/C10151/
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Additional Evidence Resources
Agency for Healthcare Research and Quality
Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness: Executive
Summary https://www.effectivehealthcare.ahrq.gov/ehc/products/309/1490/pressure-
ulcer-prevention-executive-130508.pdf
Pressure Ulcer Treatment Strategies: Comparative Effectiveness (2013)
http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-
reports/?pageaction=displayproduct&productid=1492
National Institute for Clinical Excellence (NICE)
Pressure Ulcers. Guidance. https://www.nice.org.uk/guidance/conditions-and-
diseases/skin-conditions/pressure-ulcers
The NICE way to Stop the Pressure (Blog) https://www.nice.org.uk/news/blog/the-
nice-way-to-stop-the-pressure
Algorithm for risk assessment, prevention and management in adults: Implementing
the NICE guideline on Pressure ulcers (CG179) (2014)
https://www.nice.org.uk/guidance/cg179/resources/algorithm-for-risk-
assessment-prevention-and-management-in-children-485835373
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