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## Complete Summary

#### GUIDELINE TITLE

Pressure ulcer prevention and treatment following spinal cord injury.

#### BIBLIOGRAPHIC SOURCE(S)

Paralyzed Veterans of America. Pressure ulcer prevention and treatment
following spinal cord injury: A clinical practice guideline for health
care professionals. Washington (DC): Paralyzed Veterans of America; 2000
Aug. 94 p. \[448 references\]

Pressure ulcer prevention and treatment following spinal cord injury: a
clinical practice guideline for health-care professionals. J Spinal Cord
Med 2001 Spring;24(Suppl 1):S40-101. \[448 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11958176)

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline is still considered
to be current as of December 2005, based on a review of literature
published since the original guideline publication.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Pressure ulcers

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Rehabilitation\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Critical Care\
Dermatology\
Family Practice\
Internal Medicine\
Nursing\
Nutrition\
Physical Medicine and Rehabilitation\
Plastic Surgery\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Plans\
Hospitals\
Managed Care Organizations\
Nurses\
Occupational Therapists\
Patients\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians\
Social Workers

#### GUIDELINE OBJECTIVE(S)

-   To provide guidance and assistance in the decisions required to
    restore health, independence, control, and self-esteem to people
    with spinal cord injury.

-   To provide a conceptual framework within which to develop effective
    strategies for preventing and treating pressure ulcers.

#### TARGET POPULATION

Adolescents and adults with spinal cord injury (SCI)

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Risk assessment and risk assessment tools

2.  Prevention strategies

3.  Nutrition assessment of the spinal cord injured patient and support
    measures for those who are nutritionally compromised

4.  Assessment of the individual with a pressure ulcer, including
    history; physical and laboratory tests; psychological status;
    availability and use of personal care assistance; and
    positioning/posture and related equipment

5.  Assessment of the pressure ulcer

6.  Nonsurgical treatment of pressure ulcers, including:

    -   Cleansing

    -   Debridement

    -   Dressings

    -   Electrical stimulation

    -   Continued assessment

7.  Surgical treatment of pressure ulcers, including excision and
    resurfacing

8.  Preoperative and postoperative care

9.  Surgical and nonsurgical management of complications of pressure
    ulcers

10. Support surfaces and positioning for managing tissue loads,
    including:

    -   Bed positioning

    -   Bed support surfaces

    -   Wheelchair positioning

    -   Wheelchair support surfaces

#### MAJOR OUTCOMES CONSIDERED

-   Prevention of pressure ulcers

-   Morbidity due to complications of pressure ulcers

-   Recurrence of pressure ulcers

-   Improvement in overall size and condition of pressure ulcer

-   Cost of treating pressure ulcers

-   Quality of life

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A preliminary search of the MEDLINE database from 1966 to 1998 was
conducted, the main issues associated with pressure ulcers were
identified, and the volume of literature available on the subject was
estimated. The literature search criteria included elderly as well as
nonelderly adults. Children under the age of 13 were excluded as were
articles involving nontraumatic paralysis. The search was limited to
articles published in English. Study designs employing clinical trials
(randomized and nonrandomized), cohort studies, case controls, case
series, and cross-over studies were included. Case reports and
\"n-of-one\" studies were excluded.

Review articles and overview articles examining pressure ulcers in
individuals with spinal cord injury were identified and retrieved if
pressure ulcers were the focus of discussion. It is important to note
that although review articles were included, they were not intended for
use as evidence for the guideline. Rather, they were used to identify
\"gray literature\" and to cross-reference with the literature search to
ensure that all relevant articles on the topic had been identified and
retrieved for analysis.

Appropriate key words and Index Medicus subheadings (MeSH subheadings)
identified by the panel were used to search the MEDLINE database
(1966-98) and the CINAHL nursing database (1982-98). These initial
literature searches concentrated on articles focusing on pressure ulcers
in individuals with spinal cord injury. A second search was conducted in
the MEDLINE database (1993-98), focusing on the general population with
pressure ulcers. The purpose of the second search was to identify
literature that had emerged since publication of the Agency for Health
Care Policy and Research (AHCPR) pressure ulcer guidelines. Whenever
possible, \"exploded\" Index Medicus subheadings were used, allowing the
inclusion of more relevant literature than would be discovered using
text word searches. Second-level searches were conducted using the major
ands minor Index Medicus subheadings retrieved from relevant articles.

Approximately, 1,800 abstracts from the literature searches were
reviewed, using the inclusion and exclusion criteria for relevance to
the prevention and treatment of pressure ulcers. Nearly 350 articles
were deemed relevant to the guideline and were retrieved. Of these
articles, more than 200 clearly met the criteria and were slated for
data extraction. Another 23 articles did not have abstracts, or their
relevance was unclear, so they were retrieved for further evaluation.
Approximately 50 articles were identified that did not have valid study
designs but were worthy of retrieval for education and orientation
purposes. Finally, relevant review articles (approximately 45 in number)
were retrieved.

#### NUMBER OF SOURCE DOCUMENTS

More than 200 source documents were selected from the primary and
secondary literature searches.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Hierarchy of the Levels of Scientific Evidence**:

I.  Large randomized trials with clear-cut results (and low risk of
    error)

II. Small randomized trials with uncertain results (and moderate to high
    risk of error

III. Nonrandomized trials with concurrent or contemporaneous controls

IV. Nonrandomized trials with historical controls

V.  Case series with no controls

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Standardized data extraction forms were used to extract relevant
information from the articles found to meet the inclusion and exclusion
criteria. Extracted information was compiled into evidence tables
according to subject area. The methodologists categorized the articles
into topic areas and disseminated relevant articles and evidence tables
to panel members for study and consideration. Articles identified as
relevant by panel members were extracted, and supplemental evidence
tables were created and disseminated.

The methodologists employed the hierarchy of the levels of scientific
evidence first discussed by Sackett (1989) and later enhanced by Cook et
al. (1992) and the U.S. Preventive Health Services Task Force (1996).
Each of the guideline recommendations was classified, according to the
level of scientific evidence used in the development of the
recommendation. Additionally, each study was evaluated for internal and
external validity.

Statistical meta-analyses or other specialized studies were conducted,
as needed.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The guideline development process adopted by the Spinal Cord Medicine
Consortium consists of 12 steps, leading to panel consensus and
organizational endorsement. After the steering committee chooses a
topic, a panel of experts is selected. Panel members must have
demonstrated leadership in the topic area through independent scientific
investigation and publication. Following a detailed explication and
specification of the topic by select steering committee and panel
members, consultant methodologists review the international literature,
prepare evidence tables that grade and rank the quality of research, and
conduct statistical meta-analyses and other specialized studies, as
needed. The panel chair then assigns specific sections of the topic to
the panel members, based on area of expertise. Writing begins on each
component using the references and other materials furnished by the
methodology support group.

After the panel members complete their sections, a draft document is
generated during the first full meeting of the panel. The panel employs
an iterative process in document preparation to incorporate new
literature citations or other evidence-based information not previously
available.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Categories of the Strength of Evidence Associated with the
Recommendation**:

A.  The recommendation is supported by scientific evidence from properly
    designed and implemented controlled trials providing statistical
    results that consistently support the guidelines statement

B.  The recommendation is supported by scientific evidence from properly
    designed and implemented clinical series that support the guidelines
    statement

C.  The recommendation is supported by expert opinion

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

After legal review to consider antitrust, restraint-of-trade, and health
policy matters, the draft document was reviewed by clinical experts from
each of the consortium organizations plus other select clinical experts
and consumers. The review comments were assembled, analyzed, and entered
into a database, and the documents revised to reflect the reviewers\'
comments. Following a second legal review, the draft document was
distributed to all consortium organization governing boards. Final
technical details were negotiated among the panel chair, members of the
organizations\' boards, and expert panelists. If substantive changes
were required, the draft received a final legal review.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*The following provides a summary of the recommendations presented in
the guideline document. The reader is directed to the original guideline
for a detailed discussion of each of the following topics.*

The levels of evidence (I-V), grades of recommendations (A-C), and
strength of panel opinion (low, moderate and strong) are repeated at the
end of the Major Recommendations.

**[Prevention]{.underline}**

**Risk Factors, Risk Assessment, and Risk Assessment Tools**

1.  Conduct comprehensive, systematic, and consistent assessment of
    pressure ulcer risk factors in individuals with spinal cord injury.

    -   Assess and document risk on admission and reassess on a routine
        basis, as determined by the health-care setting, institutional
        guidelines, and changes in the individual\'s health status.

    -   Use clinical judgment as well as a risk assessment tool to
        assess risk. Assess demographic, physical/medical, and
        psychosocial risk factors associated with

    -   pressure ulcer prevention.

> Scientific evidence: I, II, III, V; Grade of recommendation: A, B, C;
> Strength of panel opinion: Strong

**Prevention Strategies**

2.  Implement pressure ulcer prevention strategies as part of the
    comprehensive management of acute spinal cord injury and review all
    aspects of risk when determining prevention strategies.

    -   Avoid prolonged positional immobilization whenever possible.

    -   Institute pressure relief as soon as emergency medical condition
        and spinal stabilization allow.

    -   Initiate intraoperative pressure reduction strategies.

> Scientific evidence: III, V; Grade of recommendation: C; Strength of
> panel opinion: Strong

3.  Conduct daily comprehensive visual and tactile skin inspections,
    with particular attention to the areas most vulnerable to pressure
    ulcer development, including, but not limited to:

    -   Ischii

    -   Sacrum/coccyx

    -   Trochanters

    -   Heels

> Scientific evidence: V; Grade of recommendation: C; Strength of panel
> opinion: Strong

4.  Turn or reposition individuals with spinal cord injury initially
    every 2 hours in the acute and rehabilitation phases if the medical
    condition allows.

    -   Eliminate stretching and folding of soft tissues and prevent
        shearing when individuals are repositioned.

    -   Avoid positioning individuals who are side-lying in bed directly
        on their trochanter.

> Scientific evidence: V; Grade of recommendation: C; Strength of panel
> opinion: Strong

5.  Evaluate the individual and his/her support environment for optimal
    maintenance of skin integrity.

    -   Apply pressure-reducing support surfaces preventively to protect
        soft tissues from bruise and injury.

    -   Prevent moisture accumulation and temperature elevation at the
        support surface-skin interface.

    -   Apply pillows and cushions to bridge contacting tissues and
        unload bony prominences; do not use donut-type devices.

    -   Establish a mechanism to follow up on equipment performance
        specific to pressure ulcer prevention (support surfaces for the
        bed and wheelchair) and determine if changes in medical or
        health status have altered the effectiveness of the support
        surface.

> Scientific evidence: II, III, V; Grade of recommendation: B, C;
> Strength of panel opinion: Strong

6.  Provide an individually prescribed wheelchair and pressure-reducing
    seating system.

    -   Establish and initiate a specific pressure relief regimen within
        the individual\'s capability.

    -   Employ a power weight-shift system when manual pressure relief
        is not possible.

> Scientific evidence: II, V; Grade of recommendation: B, C; Strength of
> panel opinion: Strong

7.  Implement an ongoing exercise regimen for the medically stable
    spinal cord injured individual to promote maintenance of skin
    integrity, increase strength of paretic and nonparalyzed muscles,
    improve cardiovascular endurance, and prevent fatigue and
    deconditioning.

> Scientific evidence: II, III, V; Grade of recommendation: B, C;
> Strength of panel opinion: Strong

8.  Provide individuals with spinal cord injury, their families,
    significant others, and health-care professionals with specific
    information on effective strategies for the prevention and treatment
    of pressure ulcers.

> Scientific evidence: V; Grade of recommendation: C; Strength of panel
> opinion: Strong

**[Nutrition]{.underline}**

9.  Assess nutritional status of all spinal cord injured individuals on
    admission and as needed, based on medical status, including:

    -   Dietary intake

    -   Anthropometric measurements

    -   Biochemical parameters (prealbumin, total protein, albumin,
        hemoglobin, hematocrit, transferrin, and total lymphocyte count)

> Scientific evidence: II, III, V; Grade of recommendation: B, C;
> Strength of panel opinion: Strong

10. Provide adequate nutritional intake to meet the individual\'s needs,
    especially:

    -   Calories (or Energy)

    -   Protein

    -   Micronutrients (zinc, vitamin C, vitamin A, and vitamin E

    -   Fluids

> Scientific evidence: II, III, V; Grade of recommendation: B, C;
> Strength of panel opinion: Strong

11. Implement aggressive nutritional support measures if dietary intake
    is inadequate or if an individual is nutritionally compromised.

> Scientific evidence: II; Grade of recommendation: B; Strength of panel
> opinion: Strong

**[Assessment Following Onset of a Pressure Ulcer]{.underline}**

**Assessment of the Individual With a Pressure Ulcer**

12. Perform an initial comprehensive assessment of the individual with a
    pressure ulcer, to include:

    -   Complete history

    -   Physical examination and laboratory tests

    -   Psychological health, behavior, cognitive status, and social and
        financial resources

    -   Availability and utilization of personal care assistance

    -   Positioning, posture, and related equipment

> Scientific evidence: I, II, III, V; Grade of recommendation: A, B, C;
> Strength of panel opinion: Strong

**Assessment of the Pressure Ulcer**

13. Describe in detail an existing pressure ulcer. Include the following
    parameters:

    -   Anatomical location and general appearance

    -   Size (length width, depth, and wound area)

    -   Stage

    -   Exudate/odor

    -   Necrosis

    -   Undermining

    -   Sinus tracts

    -   Infection

    -   Healing (granulation and epithelialization)

    -   Wound margins/surrounding tissue

> Scientific evidence: I, II, V; Grade of recommendation: A, B, C;
> Strength of panel opinion: Strong

**[Treatment]{.underline}**

**Nonsurgical**

*Cleansing*

14. Cleanse pressure ulcers at each dressing change.

    -   Use minimum mechanical force when cleaning with gauze, cloth, or
        sponge.

    -   Use enough irrigation pressure to enhance cleansing without
        causing trauma to the wound.

    -   Use normal saline or wound cleansers.

    -   Avoid antiseptic agents.

    -   Consider hydrotherapy for ulcers containing large amounts of
        exudate and necrotic tissue.

> Scientific evidence: I, III, V; Grade of recommendation: A, C;
> Strength of panel opinion: Strong

*Debridement*

15. Debride devitalized tissue from pressure ulcers using a method
    appropriate to the ulcer\'s status and the individual\'s condition
    and goals.

    -   Debride areas in which there is eschar and devitalized tissue

> Scientific evidence: V; Grade of recommendation: C; Strength of panel
> opinion: Strong

*Dressings*

16. Use dressings that will keep the ulcer bed continuously moist and
    the surrounding intact skin dry.

    -   Use a dressing that controls exudate, but does not desiccate the
        ulcer bed or macerate surrounding tissue.

    -   Loosely fill pressure ulcer cavities with dressing material to
        avoid dead space; avoid overpacking the ulcer

    -   Monitor the placement of all dressings, especially those in
        anatomical areas in which they are difficult to keep intact

    -   Perform dressing changes on a specific schedule based on
        assessment of the individual, the ulcer, and the condition of
        the dressing. Consult the dressing manufacturer\'s package
        insert for general information and about the frequency of
        dressing changes.

> Scientific evidence: I, II; Grade of recommendation: A, B; Strength of
> panel opinion: Strong

*Electrical Stimulation*

17. Use electrical stimulation to promote closure of stage III or IV
    pressure ulcers combined with standard wound care interventions.

> Scientific evidence: I, II; Grade of recommendation: A; Strength of
> panel opinion: Strong

*Reassessment*

18. Monitor and assess the pressure ulcer on a consistent, ongoing basis
    to determine the adequacy of the plan of care.

    -   Monitor the pressure ulcer at each dressing change.

    -   Document ulcer assessment at least weekly and every time the
        condition of the pressure ulcer or the individual changes.

> Scientific evidence: None; Grade of recommendation: Expert consensus;
> Strength of panel opinion: Strong

19. Modify the treatment plan if the ulcer shows no evidence of healing
    within 2 to 4 weeks.

    -   Review individual risk factors when assessing the healing of
        pressure ulcers.

    -   Evaluate healing progress using an instrument or other
        quantitative measurements.

> Scientific evidence: I, V; Grade of recommendation: A, C; Strength of
> panel opinion: Strong

**Surgical**

20. Refer appropriate individuals with complex, deep stage III pressure
    ulcers (i.e., undermining, tracts) or stage IV pressure ulcers for
    surgical evaluation. When surgery is indicated, include the
    following tenets of surgical treatment:

    -   Excising of ulcer, surrounding scar, bursa, soft tissue
        calcification, and underlying necrotic or infected bone

    -   Filling dead space, enhancing vascularity of the healing wound,
        and distributing pressure off the bone

    -   Resurfacing with a large regional pedicle flap, with suture line
        away from the area of the direct pressure, and one that does not
        encroach on adjacent flap territories

    -   Preserving options for future potential breakdowns

> Scientific evidence: V; Grade of recommendation: C; Strength of panel
> opinion: Strong

**Preoperative Care**

21. Assess, treat and optimize the following factors preoperatively:

    -   Local wound infection

    -   Nutritional status

    -   Bowel regulation

    -   Severe spasm and contractures

    -   Comorbid conditions

    -   Previous ulcer surgery

    -   Smoking

    -   Osteomyelitis

    -   Urinary tract infection

    -   Heterotopic ossification

> Scientific evidence: II, III, V; Grade of recommendation: B, C;
> Strength of panel opinion: Strong

**Postoperative Care**

22. Be cognizant of postoperative care procedures.

    -   Position the individual in a manner that keeps pressure off a
        fresh surgical site.

    -   Use an air-fluidized bed when pressure on the surgical flap is
        unavoidable.

    -   Progressively mobilize the individual to a sitting position over
        at least 4 to 8 weeks to prevent reinjury of the ulcer or
        surgical site.

    -   Provide subsequent patient education on pressure management and
        skin inspection.

> Scientific evidence: V; Grade of recommendation: C; Strength of panel
> opinion: Strong

**[Complications of Pressure Ulcers]{.underline}**

**Nonsurgical**

23. Identify the pressure of tissue and/or bone infection

    -   Obtain quantitative tissue and/or bone cultures in ulcers not
        responding to routine therapeutic measures.

    -   Obtain a tissue and/or bone biopsy to confirm infection, if
        necessary.

> Scientific evidence: III, V; Grade of recommendation: C; Strength of
> panel opinion: Strong

24. Identify the potential complications of immobility associated with
    pressure ulcer management and implement preventive and therapeutic
    measures for:

    -   Nutritional deficiencies and dehydration

    -   Decreased range of motion

    -   Deconditioning (cardiopulmonary, cardiovascular, and
        musculoskeletal)

> Scientific evidence: III, V; Grade of recommendation: C; Strength of
> panel opinion: Strong

25. Manage hypergranulation tissue that may impede ulcer healing.

> Scientific evidence: V; Grade of recommendation: C; Strength of panel
> opinion: Strong

26. Identify the potential psychosocial impacts of pressure ulcers and
    immobility and provide referral for therapeutic interventions based
    upon the individual\'s characteristics and circumstances. Refer to
    appropriate resources for problem resolution, including:

    -   Vocational rehabilitation services

    -   Peer counseling and support groups

    -   Formal psychotherapy and/or family therapy

> Scientific evidence: III, V; Grade of recommendation: C; Strength of
> panel opinion: Strong

**Surgical**

27. Identify potential complications of surgical intervention,
    including:

    -   Wound dehiscence/wound separation

    -   Delayed infection and abscess

    -   Hematoma and seroma

> Scientific evidence: None; Grade of recommendation: Expert consensus;
> Strength of panel opinion: Strong

**[Support Surfaces and Positioning for Managing Tissue
Loads]{.underline}**

**Bed Positioning**

28. Use bed-positioning devices and techniques to prevent and treat
    pressure ulcers. Use devices and techniques that are compatible with
    the bed type and the individual\'s health status.

    -   Avoid positioning individuals directly on a pressure ulcer.

    -   Avoid positioning individuals directly on the trochanter

    -   Use cushions and positioning aids to relieve pressure on
        pressure ulcers or vulnerable skin areas by elevating them away
        from the support surface.

    -   Avoid close cutouts or donut-type cushions

    -   Prevent contact between bony prominences.

    -   Limit the amount of time the head of the bed is elevated

    -   Develop, display, and use an individualized positioning regimen
        and repositioning schedule.

> Scientific evidence: II, V; Grade of recommendation: B, C; Strength of
> panel opinion: Strong

**Bed Support Surfaces**

29. Use pressure-reducing bed support surfaces for individuals who are
    at risk for or who have pressure ulcers.

    -   Select a static support surface for individuals who can be
        positioned without weight bearing on an ulcer and without
        bottoming out on the support surface.

    -   Select a dynamic support surface if the individual cannot be
        positioned without pressure on an ulcer, when a static support
        surface bottoms out, if there is no evidence of ulcer healing,
        or if new ulcers develop.

    -   Use low-air loss and air-fluidized beds in the treatment of
        pressure ulcers if one or more of the following conditions
        exist:

    -   Pressure ulcers on multiple turning surfaces

    -   Compromised skin temperature and moisture control in the
        presence of large stage III or IV pressure ulcers

> Scientific evidence: I, II, V; Grade of recommendation: A, B, C;
> Strength of panel opinion: Strong

**Wheelchair Positioning**

30. Prescribe wheelchairs and seating systems according to
    individualized anthropometric, ergonomic, and functional principles.

    -   Obtain specific body measurements for optimal selection of
        seating system dimensions.

    -   Measure the effects of posture and deformity on interface
        pressure distribution.

    -   Prescribe a power weight-shifting wheelchair system for
        individuals who are unable to independently perform an effective
        weight shift.

    -   Use clinical judgment as well as objective data in determining
        the compatibility of the individual\'s shape with the seating
        system.

> Scientific evidence: II, III, V; Grade of recommendation: B, C;
> Strength of panel opinion: Strong

31. Evaluate the individual\'s postural alignment, weight distribution,
    balance, stability, and pressure reduction capabilities to establish
    a proper sitting schedule.

    -   Avoid positioning the wheelchair-seated individual directly on a
        pressure ulcer.

    -   Allow limited sitting in individuals capable of performing
        weight shifts every 15 minutes.

    -   Reposition the wheelchair-seated individual at least every hour;
        if this is not possible and the individual is unable to perform
        weight shifts, return the individual to bed.

> Scientific evidence: II, III; Grade of recommendation: B, C; Strength
> of panel opinion: Strong

**Wheelchair Support Surfaces**

32. Use appropriate wheelchair cushions with all individuals with spinal
    cord injury.

    -   Inspect and maintain all wheelchair cushions at regularly
        scheduled intervals.

> Scientific evidence: II, V; Grade of recommendation: B, C; Strength of
> panel opinion: Strong

**[Definitions]{.underline}**:

**Hierarchy of the Levels of Scientific Evidence**:

I.  Large randomized trials with clear-cut results (and low risk of
    error)

II. Small randomized trials with uncertain results (and moderate to high
    risk of error)

III. Nonrandomized trials with concurrent or contemporaneous controls

IV. Nonrandomized trials with historical controls

V.  Case series with no controls

**Categories of the Strength of Evidence Associated With the
Recommendations**

A.  The guideline recommendation is supported by one or more level I
    studies

B.  The guideline recommendation is supported by one or more level II
    studies

C.  The guideline recommendation is supported only by level III, IV, or
    V studies

**Levels of Panel Agreement with the Recommendation**

*Based on a 5-point scale (1 corresponding to neutrality; 5 representing
maximum agreement)*

Low\
Mean agreement score of 1.00 to less than 2.33\
Moderate\
Mean agreement score of 2.33 to less than 3.67\
Strong\
Mean agreement score of 3.67 to 5.00

*Note*: If the literature supporting a guideline recommendation came
from two or more levels, the number and the level of evidence supporting
the studies are reported (e.g., a guideline recommendation that is
supported by two studies, one a level III and the other a level V, the
scientific evidence would be indicated as III, V). Likewise, if a
guideline recommendation is supported by literature that crossed two
categories, both categories are reported (e.g., a recommendation that
includes both level II and III studies would be classified as category
B, C).

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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 members based their recommendations on
expert consensus.

The type of supporting evidence is identified for each recommendation
(see \"Major Recommendations\").

In addition, the references list presented in the original guideline
document provides the \"scientific evidence (I-V)\" for each graded
article. The reference list also indicates which references were used,
including those that were not graded but were essential to the guideline
as whole.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

The benefits of clinical practice guidelines for the spinal cord
medicine practice community are numerous. Among the more significant
applications and results are the following:

-   Clinical practice options and care standards

-   Medical and health professional education and training

-   Building blocks for pathways and algorithms

-   Evaluation studies of clinical practice guidelines use and outcomes

-   Research gap identification

-   Cost and policy studies for improved quantification

-   Primary source for consumer information and public education

-   Knowledge base for improved professional consensus building

*Additional benefits include*:

-   Reduced incidence and recurrence of pressure ulcer in patients with
    spinal cord injury

#### POTENTIAL HARMS

Not Stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   This guideline has been prepared based on scientific and
    professional information known about outcomes following traumatic
    spinal cord injury and its treatment in 1999. Users of this
    guideline should periodically review this material to ensure that
    the advice herein is consistent with current reasonable clinical
    practice.

-   Since most pressure ulcer literature does not focus on persons with
    spinal cord injury, there were a number of instances where no spinal
    cord injury-specific literature existed with respect to a particular
    recommendation. In those instances, findings from studies of other
    populations were reported.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Paralyzed Veterans of America. Pressure ulcer prevention and treatment
following spinal cord injury: A clinical practice guideline for health
care professionals. Washington (DC): Paralyzed Veterans of America; 2000
Aug. 94 p. \[448 references\]

Pressure ulcer prevention and treatment following spinal cord injury: a
clinical practice guideline for health-care professionals. J Spinal Cord
Med 2001 Spring;24(Suppl 1):S40-101. \[448 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11958176)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2000 Aug (reviewed 2005)

#### GUIDELINE DEVELOPER(S)

Consortium for Spinal Cord Medicine - Private Nonprofit Organization\
Paralyzed Veterans of America - Private Nonprofit Organization

#### SOURCE(S) OF FUNDING

Paralyzed Veterans of America (PVA)

#### GUIDELINE COMMITTEE

Multidisciplinary Pressure Ulcer Clinical Practice Guideline Development
Panel

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Susan L. Garber, Chairperson, MA, OTR, FAOTA; Andrea K.
Biddle, PhD; Carla N. Click, RN, MSN, CWOCN, GNP; J. Fred Cowell;
Theresa L. Gregorio-Torres, MA, OTR; Nancy K. Hansen, PhD; Luther C.
Kloth, MS, PT, CWS; Daniel P. Lammertse, MD; David T. Netscher, MD;
Steven I. Reger, PhD, CP; Donna J. Rodriquez, MS, RD, CNSD; Gladys P.
Rodriquez, PhD; Susan Thomason, MN, RN, CS, CETN; Gary Yarkony, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### ENDORSER(S)

American Academy of Physical Medicine and Rehabilitation - Medical
Specialty Society\
American Association of Spinal Cord Injury Nurses - Professional
Association\
American Association of Spinal Cord Injury Psychologists and Social
Workers - Professional Association\
American Paraplegia Society - Disease Specific Society\
American Spinal Injury Association - Disease Specific Society

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline is still considered
to be current as of December 2005, based on a review of literature
published since the original guideline publication.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Paralyzed Veterans of America
(PVA) Web
site](http://www.pva.org/site/PageServer?pagename=pubs_generalpubs#cpg).

Print copies: Available from the Paralyzed Veterans of America, 801
Eighteenth Street, NW, Washington, DC 20006.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 12, 2001. The information
was verified by the guideline developer on March 27, 2001.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. The guideline was
developed and produced by the Consortium for Spinal Cord Medicine and is
owned and copyrighted by the Paralyzed Veterans of America (PVA). Any
use and distribution of the guideline must adhere to PVA copyright
restrictions as specified at the PVA Web site (see
[www.pva.org](http://www.pva.org/)).

### DISCLAIMER

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Date Modified: 11/10/2008