For PI’s that are healable, it is important to remove any necrotic tissue. Necrotic tissue may harbor bacteria and facilitate infection, or produce a prolonged inflammatory response (Sibbald et al., 2021). Methods of debriding are reviewed in Chapter 1. For patients with decreased sensation to the wound, adequate pain control is still an essential component of sharp debridement to prevent adverse effect of the central nervous system eg. autonomic dysreflexia in a patient with a spinal cord injury.
For PI’s that are considered non-healable or maintenance, conservative debridement may occur to manage symptoms and decrease bacteria in the wound. For PI’s occurring on the lower legs and feet, debridement should only be considered if tissue perfusion is adequate (EPIAP, NPIAP, PPPIA, 2019).
Any debridement should only be performed by a skilled clinician who has the supports in place and when the skill is within their scope of practice.
Assess for infection and inflammation
NERDS and STONEES criteria have been detailed in previous chapters and are useful in guiding the assessment and treatment of infection and inflammation in PIs. Superficial swabs are not recommended to guide the diagnosis of infection in a PI. If deep and surrounding tissue infection is suspected with three or more of the STONEES criteria, identification of the organism requires tissue biopsy and culture or semi-quantitative swab technique e.g. Levine method (Angel et al., 2006).
Deep and surrounding tissue infection may extend to bone and cause osteomyelitis in some PIs. Seventeen to 43% of Stage 4 sacral PIs had histologic evidence of osteomyelitis (Turk et al., 2003). A bone biopsy is recommended (if feasible) to diagnose osteomyelitis if there is clinical suspicion as superficial cultures are not always reliable and imaging is limited by variable specificity (Hatzenbuehler et al., 2011). A comprehensive discussion of osteomyelitis is beyond the scope of this chapter but this is an active area of research in wound management (Wong et al., 2019).
A moist wound environment is ideal for cells to grow in a healable PI. For a PI that is considered non-healable or maintenance, the goal is to keep the wound bacteria free and stabilize the wound environment. It is appropriate to use antiseptic solutions to maintain a dry wound environment, especially for PI’s that occur on the feet or heels (EPIAP, NPIAP, PPPIA, 2019).
Evaluate Rate of Healing
A 20% to 40% reduction in size is expected by week 4, if not then the wound is unlikely to heal by week 12. If the wound is classed as healable but has stalled then referral for comprehensive interprofessional wound assessment is suggested. Also, be aware of atypical transformation in chronic wounds (Day & Chakari, 2018).
Refer for consultation for surgical correction if all contributing factors have been corrected, recognizing that there is a high risk of recurrence of PIs particularly if the patient has scoliosis, an oblique pelvis, diabetes, BMI<18.5 or an ischial PI. Recurrence risk ranges from 28.6 to 58.7%. (Schryvers et al., 2000; Bamba et al. 2017) For PIs that do not meet the expected rate of closure, a comprehensive reassessment of the individual including the PI, their environment and all potential causative factors are warranted.
It is essential to address the cause and contributing factors that delay healing prior to treating a PI with adjunctive therapies. Electrical stimulation has been proven (level A evidence (EPIAP, NPIAP, PPPIA, 2019)) to support accelerated healing in stage 2, 3, and 4 PIs (RNAO, 2016; EPIAP, NPIAP, PPPIA, 2019).
Other active therapies (ultrasound, electromagnetic therapy, hyperbaric oxygen and topical oxygen) have lower levels of evidence, but may support healing of PI (RNAO, 2016).
PI prevention and treatment cannot be performed by one individual healthcare profession alone. Interprofessional teams are necessary for optimal outcomes. The person with the PI along with family involvement is essential in PI prevention and treatment. Facilities and agencies need to allot resources to support effective PI prevention strategies. These may include organizational leadership, resources for prevalence and incidence surveillance, education for staff and sustainability strategies for such initiatives.