Pressure Ulcers in Long-Term Care

  • E. Foy White-Chu
    Department of Medicine, Hebrew Senior Life, 1200 Centre Street, Roslindale, MA 02131, USA

    Division of Gerontology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Harvard Medical School, Boston, MA 02215, USA
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  • Petra Flock
    Division of Geriatrics, University of Massachusetts Medical School, 119 Belmont Street, Worcester, MA 01605, USA

    Summit ElderCare, 88 Masonic Home Road, Charlton, MA 01507, USA
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  • Bryan Struck
    Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, 1100 N Lindsay, Oklahoma City, OK 73104, USA

    Geriatrics and Extended Care, Oklahoma City VA Medical Center, 921 NE 13th VAMC 11g, Oklahoma City, OK, 73104, USA
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  • Louise Aronson
    Corresponding author.
    Division of Geriatrics, University of California at San Francisco, 3333 California Street, Suite 380, San Francisco, CA 94118, USA
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        • Reddy M.
        • Gill S.S.
        • Rochon P.A.
        Preventing pressure ulcers: a systematic review.
        JAMA. 2006; 296: 974-984
        • Horn S.D.
        • Bender S.A.
        • Ferguson M.L.
        • et al.
        The national pressure ulcer long-term care study: pressure ulcer development in long-term care residents.
        J Am Geriatr Soc. 2004; 52: 359-367
        • Berlowitz D.R.
        • Brandeis G.H.
        • Anderson J.
        • et al.
        Effect of pressure ulcers on the survival of long-term care residents.
        J Gerontol A Biol Sci Med Sci. 1997; 52A: 106-110
        • Wysocki A.B.
        Decubitus ulcers.
        in: Freedberg I.M. Eisen A.Z. Fitzpatrick’s dermatology in general medicine. 5th edition. McGraw-Hill, New York (NY)1999: 1538-1554
        • Lyder C.H.
        Pressure ulcer prevention and management.
        JAMA. 2003; 289: 223-226
        • Park-Lee E.
        • Caffrey C.
        Pressure ulcers among nursing home residents: United States—2004.
        NCHS Data Brief. 2009; 14: 1-6
        • Thomas D.R.
        Issues and dilemmas in the prevention and treatment of pressure ulcers.
        J Gerontol. 2001; 56A: M328-M340
        • Centers for Medicare and Medicaid Services
        Federal Register Part II 42 CFR Parts 411, 412, 413, and 489: changes to the hospital inpatient prospective payment systems and fiscal year 2008 rates; Final Rule.
        Federal Register. 2007; 72: 47201-47205
        • Brem H.
        • Maggi J.
        • Nierman D.
        • et al.
        High cost of stage IV pressure ulcers.
        Am J Surg. 2010; 200: 473-477
        • Health Council of the Netherlands
        Pressure ulcers.
        Health Council of the Netherlands, The Hague (The Netherlands)1999 (Publication 1999/23)
        • Bennet G.
        • Dealey C.
        • Posnett J.
        The cost of pressure ulcers in the UK.
        Age Ageing. 2004; 33: 230-235
        • Allman R.M.
        Pressure ulcer prevalence, incidence, risk factors, and impact.
        Clin Geriatr Med. 1997; 13: 421-436
        • Cullum N.
        • Clark M.
        Intrinsic factors associated with pressure sores in elderly people.
        J Adv Nurs. 1992; 17: 427-431
        • Agency for Health Care Policy and Prevention
        Pressure ulcers in adults: prediction and prevention. Clinical Practice Guideline Number 3.
        US Department of Health and Human Sciences, Rockville (MD)1992
        • Horn S.D.
        • Bender S.A.
        • Bergstrom N.
        Description of the National Pressure Ulcer Long-Term Care Study.
        J Am Geriatr Soc. 2002; 50: 1816-1825
        • Garcia A.D.
        • Thomas D.R.
        Assessment and management of chronic pressure ulcers in the elderly.
        Med Clin North Am. 2006; 90: 925-944
        • Bergstrom N.
        • Braden B.J.
        • Kemp M.
        • et al.
        Reliability and validity of the Braden Scale: a multi-site study.
        Nurs Res. 1998; 47: 261-269
        • Norton D.
        • McLaren R.
        • Exton-Smith A.N.
        An investigation of geriatric nursing problems in hospital.
        National Corporation for the Care of Old People (now Centre for Policy on Ageing), London1962
        • Waterlow J.
        Pressure sores: a risk assessment card.
        Nurs Times. 1985; 81: 49-55
        • Goldberg S.R.
        • Dieglemann R.F.
        Wound healing primer.
        Surg Clin North Am. 2010; 90: 1133-1146
        • Eming S.A.
        • Krieg T.
        • Davidson J.M.
        Inflammation in wound repair: molecular and cellular mechanisms.
        J Invest Dermatol. 2007; 127: 514-525
        • Bucalo B.
        • Eaglstein W.H.
        • Falanga V.
        Inhibition of cell proliferation by chronic wound fluid.
        Wound Repair Regen. 1993; 1: 181-186
        • Clark M.
        Repositioning to prevent pressure sores—what is the evidence?.
        Nurs Stand. 1998; 13: 58-64
        • Thompson P.
        • Langemo D.
        • Anderson J.
        • et al.
        Skin care protocols for pressure ulcers and incontinence in long-term care: a quasi-experimental study.
        Adv Skin Wound Care. 2005; 18: 422-429
        • Hampton S.
        • Collins F.
        Reducing pressure ulcer incidence in a long-term setting.
        Br J Nurs. 2005; 14: S6-S12
        • Cullum N.
        • Deeks J.
        • Sheldon T.A.
        • et al.
        Beds, mattresses and cushions for preventing and treating pressure sores.
        Cochrane Database Syst Rev. 2000; 1 ([Cochrane Review]) (Oxford: Update Software): CD001159
        • Berlowitz D.R.
        • Ash A.S.
        • Brandeis G.H.
        • et al.
        Rating long-term care facilities on pressure ulcer development: importance of case-mix adjustment.
        Ann Intern Med. 1996; 124: 557-563
        • Theodosat A.
        Skin diseases of the lower extremities in the elderly.
        Dermatol Clin. 2004; 22: 13-21
        • Wipke-Tevis D.D.
        Caring for vascular leg ulcers: essential knowledge for the home health nurse.
        Home Healthc Nurse. 1999; 17: 87-94
        • Holloway G.A.
        Arterial ulcers: assessment, classification, and management.
        in: Krasner D.L. Rodeheaver G.T. Sibbald R.G. Chronic wound care: a clinical source book for healthcare professionals. 4th edition. HMP Communications, Wayne (PA)2007: 443-449
        • Steed D.L.
        Wounds in people with diabetes: assessment, classification, and management.
        in: Krasner D.L. Rodeheaver G.T. Sibbald R.G. Chronic wound care: a clinical source book for healthcare professionals. 4th edition. HMP Communications, Wayne (PA)2007: 537-542
        • Collier M.
        The assessment of patients with malignant fungating wounds—a holistic approach: Part 1.
        Nurs Times. 1997; 93: S1-S4
      1. (Available at:) (Accessed December 30, 2010)
        • National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel
        Prevention and treatment of pressure ulcers: clinical practice guideline.
        National Pressure Ulcer Advisory Panel, Washington, DC2009
        • Levine J.A.
        • Roberson S.
        • Ayello E.A.
        Essentials of MDS 3.0 section M: skin conditions.
        Adv Skin Wound Care. 2010; 23: 273-284
        • Keast D.H.
        • Bowering C.K.
        • Evans A.W.
        MEASURE: a proposed assessment framework for developing best practice recommendations for wound assessment.
        Wound Repair Regen. 2004; 12: S1-S17
        • Landis S.
        • Ryan S.
        • Woo K.
        • et al.
        Infections in chronic wounds.
        in: Krasner D.L. Rodeheaver G.T. Sibbald R.G. Chronic wound care: a clinical source book for healthcare professionals. 4th edition. HMP Communications, Wayne (PA)2007: 299-321
      2. (Available at:) (Accessed December 30, 2010)
        • Reddy M.
        • Gill S.S.
        • Kalkar S.R.
        Treatment of pressure ulcers: a systematic review.
        JAMA. 2008; 300: 2647-2662
        • Sibbald R.G.
        • Williamson D.
        • Orsted H.L.
        • et al.
        Preparing the wound bed—debridement, bacterial balance, and moisture balance.
        Ostomy Wound Manage. 2000; 46: 14-37
        • Centers for Medicare and Medicaid Services
        State operations manual appendix PP—guidance to surveyors for long care facilities 483.25 (d). P. 246.
        (Available at:) (Accessed December 30, 2010)
        • Desai H.
        Ageing and wounds. Part 2: healing in old age.
        J Wound Care. 1997; 6: 237-239
        • Thomas D.R.
        The role of nutrition in prevention and healing of pressure ulcers.
        Med Clin North Am. 1997; 13: 497-511
        • Lown D.
        Wound healing.
        in: Matarese L.E. Gottschlich M.M. Contemporary nutrition support practice, a clinical guide. W.B. Saunders, Philadelphia1998: 583-589
        • Cullum N.
        • McInnes E.
        • Bell-Syer S.E.M.
        • et al.
        Support surfaces for pressure ulcer prevention.
        Cochrane Database Syst Rev. 1998; 1 (CD001735)
        • Corcoran P.J.
        Use it or lost it—the hazards of bed rest and inactivity.
        West J Med. 1991; 154: 219-223
        • Allen C.
        • Glasziou P.
        • Del Mar C.
        Bed rest: a potentially harmful treatment needing more careful evaluation.
        Lancet. 1999; 354: 1229-1233
        • Falanga V.
        Classification for wound preparation and stimulation of chronic wounds.
        Wound Repair Regen. 2000; 8: 347-352
        • Schultz G.S.
        • Sibbald R.G.
        • Falanga V.
        • et al.
        Wound bed preparation: a systemic approach to wound management.
        Wound Repair Regen. 2003; 11: 1-28
        • Panuncialman J.
        • Falanga V.
        The science of wound bed preparation.
        Clin Plast Surg. 2007; 34: 621-632
        • Hinman C.D.
        • Maibach H.
        Effect of air explosure and occlusion on experimental human skin.
        Nature. 1963; 200: 377-378
        • Bolton L.L.
        • Johnson C.L.
        • Van Rijswijk L.
        Occlusive dressings: therapeutic agents and effects on drug delivery.
        Clin Dermatol. 1991; 9: 573-583
        • Seaman S.
        Dressing selection in chronic wound management.
        J Am Podiatr Med Assoc. 2002; 92: 24-33
        • Sibbald R.G.
        • Woo K.
        • Ayello E.A.
        Increased bacterial burden and infection: the story of NERDS and STONES.
        Adv Skin Wound Care. 2006; 19: 447-461
        • Gardner S.E.
        • Frantz R.A.
        • Doebbeling B.N.
        • et al.
        The validity of clinical signs and symptoms used to identify localized chronic wound infection.
        Wound Repair Regen. 2001; 9: 178-186
        • James G.A.
        • Swogger E.
        • Wolcott R.
        • et al.
        Biofilms in chronic wounds.
        Wound Repair Regen. 2008; 16: 37-44
        • Black C.E.
        • Costerton J.W.
        Current concepts regarding the effect of wound microbial ecology and biofilms on wound healing.
        Surg Clin North Am. 2010; 90: 1147-1160
        • Jankicevic J.
        • Vesić S.
        • Vukićević J.
        • et al.
        Contact sensitivity in patients with venous leg ulcers in Serbia: comparison with contact dermatitis patients and relationship to ulcer duration.
        Contact Dermatitis. 2008; 58: 32-36
        • Saap L.
        • Fahim S.
        • Arsenault E.
        • et al.
        Contact sensitivity in patients with leg ulcerations: a North American study.
        Arch Dermatol. 2004; 140: 1241-1246
      3. National Guideline Clearinghouse (NGC). Guideline synthesis: management and treatment of pressure ulcers. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD); 2006 (revised 2008 July). Available at: Accessed January 10, 2011.

        • Gardner S.E.
        • Frantz R.A.
        • Saltzman C.L.
        • et al.
        Diagnostic validity of three swab techniques for identifying chronic wound infection.
        Wound Repair Regen. 2006; 14: 548-557
        • Gastmeier P.
        Healthcare-associated versus community-acquired infections: a new challenge for science and society.
        Int J Med Microbiol. 2010; 300: 342-345
        • Pineda C.
        • Vargas A.
        • Rodriguez A.V.
        Imaging of osteomyelitis: current concepts.
        Infect Dis Clin North Am. 2006; 20: 789-825
      4. (Available at:) (Website Accessed December 30, 2010)
        • Longe R.L.
        Current concepts in clinical therapeutics: pressure sores.
        Clin Pharm. 1986; 5: 669-681
        • Reddy M.
        • Sibbald G.
        Management of diabetic foot ulcers.
        Geriatr Aging. 2005; 8: 33-37
      5. Second European Consensus Document on chronic critical leg ischemia.
        Circulation. 1991; 84 (IV1–26)
        • Drosou A.
        • Falabella A.
        • Kirsner R.S.
        Antiseptics on wounds: an area of controversy.
        Wounds. 2003; 15: 149-166
        • Kapoor A.
        • Kader B.
        • Cabral H.
        • et al.
        Using the case mix of pressure ulcer healing to evaluate nursing home performance.
        Am J Med Qual. 2008; 23: 342-349
      6. Nursing Home Reform Amendments. US Code of Federal Regulations Title 42, Chapter 7, Subchapter XIX, Subpart 483.

        • Xakellis G.C.
        • Frantz R.A.
        The cost-effectiveness of interventions for preventing pressure ulcers.
        J Am Board Fam Pract. 1996; 9: 79
        • Baier R.R.
        • Gifford D.R.
        • Lyder C.H.
        • et al.
        Quality improvement for pressure ulcer care in the nursing home setting: the northeast pressure ulcer project.
        J Am Med Dir Assoc. 2003; 4: 291
        • Makai P.
        • Koopmanschap M.
        • Bal R.
        • et al.
        Cost-effectiveness of a pressure ulcer quality collaborative.
        Cost Eff Resour Alloc. 2010; 8: 11
        • Abel R.L.
        • Warren K.
        • Bean G.
        • et al.
        Quality improvement in nursing homes in Texas: results from a pressure ulcer prevention project.
        J Am Med Dir Assoc. 2005; 6: 181-188
        • Voss C.A.
        • Bender S.A.
        • Ferguson M.L.
        • et al.
        Long-term care liability for pressure ulcers.
        J Am Geriatr Soc. 2005; 53: 1587-1592
        • Dimond B.
        Pressure ulcer care: making and handling a complaint in the NHS.
        Br J Nurs. 2006; 15: 1242-1243
        • American Medical Directors Association
        Pressure ulcers in long-term care setting: clinical practice guideline.
        AMDA, Columbia (MD)2008
        • Langemo D.
        • Brown G.
        Skin fails too: acute, chronic, and end-stage skin failure.
        Adv Skin Wound Care. 2006; 19: 206-211
        • Levine J.M.
        • Savino F.
        • Peterson M.
        • et al.
        Risk management for pressure ulcers: when a family shows up with a camera.
        J Am Med Dir Assoc. 2008; 9: 360-363