The Emperor’s New Pressure Ulcer Dressing Protection Status
Blog Category: 
the emperor's new clothes

by Thomas E. Serena MD, FACS, FACHM, FAPWCA

The Emperor's New Clothes was one of my favorite childhood stories. In this Hans Christian Anderson tale, two weavers clothe the emperor in what today would be referred to as "virtual finery." All of his ministers, advisers, factotums and subjects praise the beauty of the unseen linens until a small boy states the obvious truth, "Look, the Emperor is naked."

I must admit that since I joined the ranks of the woundologists, I find myself frequently sans vetements. When I stand at the podium I pray I will not catch sight of a small person running toward the stage shouting, "You're naked, Doctor! There's no evidence for that therapy at all!!"

Standards of Wound Care: Is it Based on Evidence or Opinion?

Our specialty has so many times substituted opinion for evidence, which when repeated frequently enough becomes the standard of care. Recently I found myself again bare and embarrassed. The American College of Physicians (ACP) published their guidelines for the prevention and treatment of pressure ulcers earlier this year.1,2 The authors exposed the utter paucity of evidence in both prevention and treatment for this condition, which affects more than 3 million Americans. For years we have pushed our recommendations and guidelines for healing and preventing pressure ulcers, but the naked truth is we are naked before our critics.

An entire industry emerged based on our recommendations for the use of alternating air and low air loss mattresses and overlays with meager evidence to support these support services. As a result, the cost of treating these ulcers continues to increase and the legal exposure escalates for clinicians who choose to follow the evidence rather than the dogma. In addition, in the absence of standardized clinical trials and registries, the adverse events for these devices remain largely unknown. At this time, the ACP can only recommend the use of advanced static mattresses or advanced static overlays for patients at risk for pressure related skin breakdown.

However, I do not want to focus solely on mattresses. We are all uncovered! The review fails to find support for the use of heel boots, wheelchair cushions, repositioning, sundry skin care products and the vast majority of interventions which I prescribe for pressure ulcer prevention.

The treatment guidelines are no less scathing. The ACP concluded that studies performed to date are of low quality and represent "weak" evidence. They suggest that there is low level evidence for protein/amino acid supplements, hydrocolloids, foams and electrical stimulation, but not much else.2

The Need for Diagnostic Tools for Pressure Ulcer Detection

Although not specifically addressed in the ACP guidelines I have personally struggled with the lack of diagnostic tools for early detection and treatment of pressure ulcers. Making treatment decisions and conducting clinical trials without objective diagnostic tools is "flying blind."

We are exposed. We can no longer praise our fine garments. If we hope to gain respect and status as a medical specialty, we must clothe ourselves in evidence. We must strive to compare and contrast the various treatments for pressure ulcers. We must base our treatment decisions on clinical efficacy and fiscal responsibility. We must demand that manufacturers produce evidence before adopting their devices. We must join together and cooperate in comparative effectiveness studies on a large scale.

We don't need a few good tailors; we need a few dedicated physicians.

1. Qaseem A, Mir TP, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162:359-69. doi:10.7326/M14-1567.
2. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162:370-9. doi:10.7326/M14-1568.

About The Author
Dr. Thomas Serena has published more than 75 peer-reviewed papers and has made in excess of 200 presentations worldwide. He has been elected to the Board of Directors of both The Wound Healing Society and the American College of Hyperbaric Medicine (ACHM), the leading academic society in the field of Hyperbaric Medicine. In 2014 Dr. Serena was elected president of the American Professional Wound Care Association (APWCA). Dr. Serena has opened and operates Wound Care and hyperbaric oxygen treatment clinics across the United States.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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I did review the ACP guidelines and found them seriously lacking...and disturbing. If you want the definative word on Pressure Ulcer prevention & treatment I highly reccommend going to the NPUAP website (National Pressure Ulcer Advisory Panel), , which is a multidisciplinary panel of experts that have evidence based recommendations for prevention & treatment. This is the organization that is the recognized authority on the subject of pressure ulcers and has been for over 20 years!

Your best defense against pressure sores it's not pressure relieving devices it is the team that you put together.
My first line of defense is my nurses aids. Then dietary, therapy, all the way to house keeping.
As a wound nurse and charge nurse I rewarded aids for spotting safety issues to showing me a pin prick. Even though we gave away thousands in rewards and raises we saved tens of thousands more in lawsuits.
Furthermore my staff was happy knowing they were valued and respected.
Wound Care is a team effort. Todd Basnight Wound Nurse and team player

The way to stop pressure injuries is simple if a patient cannot reposition themselves then we need to provide a good alternating pressure air matttess asap. Happy to supply more information.

I am impressed by your statement and the way you show the frustration of a true physician soul.
This is quite uncommon; only a true born doctor feels that way and admits the reality of some tragic inadequacies.
I will write to you again with something interesting in the field of DFU and PAD where ischemia is the problem.
Something that has been around for very long time, at hand and still unrecognized.

Thank you, Dr Serena, for this editorial. Those of us who practice wound care with lots of experience but far too little science long for the day when "evidence-based wound care" is no longer an oxymoron. Until that happens, may we always remember to be humbled by how much we don't really know even as we continue to seek the best for our patients based on the best data we have thus far.

I know how so many are taught to think...but is the thinking wrong? Is our thinking the problem? The emperor thought he was dressed, common sense said no!
If we simply started looking at medicine and treatments from a simple and direct "mechanism of action" stand point...We could save even more money, time and effort on studies, that don't really provide any more answers, and then those will need to be studied! The study mechanism has it's place, but it needs to be fixed too! Talk about expensive!
Question: What causes the pressure sore injury
Answer: Pressure, reducing capillary blood supply
Fix that and you solve the problem, simple!
We don't need more support of basic mechanisms of action, any more than we need a placebo, double blind study, proving parachutes work! If you can prove common sense, then you will have proved something!

Pressure injuries are caused by unrelieved pressure. Therefore we must concentrate on relieving the pressure. The sicker the patient the quicker the injuries can occur. (Kosiac. Bliss) Nurses are run of there feet with so many clinical tasks that they often do not get time to reposition the patient therefore I believe that all patients 'at risk' should be on a good alternating pressure air mattress with regular skin checks and repositioning. If the patient cannot reposition themselves this should be done asap. Stopping pressure injuries is not that hard we have the knowledge. Its to late putting them on apam when the damage is done. Happy to discuss more.

Thank you for the thoughtful input. However, there is little evidence that pressure alone is the culprit here therefore simply turning and repositioning will not prevent all pressure ulcers as the literature has clearly demonstrated. In fact there is a growing body of evidence that in certain patients the real etiology of pressure ulcers is ischemia reperfusion injury. We need better diagnostics and a great deal more research.

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