Supporting Pressure Injury Healing
Published online: 29 August 2026
Suggested citation
National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Supporting Pressure Injury Healing. In: Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline: Fourth Edition. Emily Haesler (Ed.). 2026. [cited: download date]. Available from: https://internationalguideline.com.
Introduction
Category/Stage 3 and 4 pressure injuries (PIs) are considered hard-to-heal/chronic wounds. Unlike acute wounds, which typically progress through the normal stages of healing in a timely manner, hard-to-heal/chronic wounds become stalled in one or more phases of the healing process, most commonly the inflammatory phase. Wounds are considered to be hard-to-heal/chronic if they have not started to heal within 4 to 12 weeks (1).
Individuals who are at higher risk of PIs very often are also at risk of delayed healing as a consequence of the same risk factors. Mechanical boundary conditions (i.e., the magnitude, duration and type of load) that lead to internal strain and stresses and increase the risk of PI can also reduce the ability of tissues to heal. Perhaps more significantly, factors that influence the susceptibility and tolerance of the individual to pressure, including perfusion, circulation and oxygenation factors, nutrition indicators, temperature, aging and general clinical status, are all factors that can contribute to delayed wound healing and increase the risk of wound infection (1, 2). Once a PI occurs in a vulnerable individual, factors such as malnutrition, poor circulation, diabetes, infection, moisture, and reduced immune function further delay healing and contribute to the chronic nature of the wound (3). Chronic inflammation within the wound also increases the production of destructive enzymes and microbial burden, which can damage healthy tissue and prolong recovery. Because healing is often slow and complex, PIs are classified as hard-to-heal/chronic wounds that require long-term management strategies and specialised treatment to promote tissue repair and prevent further complications.
As noted in the good practice statements, establishing the goal of care is an important step to determining treatments for a hard-to-heal/chronic wound. This includes evaluating what is possible, what is feasible, and the individual’s priorities. The good practice statements in this chapter are designed to support healing when the PI is healable (i.e., healing is possible and feasible) and the individual and healthcare team agree that healing is the goal of care.
Some PIs are non-healable for a range of reasons. For example, the underlying etiology cannot be corrected; impediments to healing cannot be reversed, preferences of the individual with a PI, or the resources required to heal the PI are not available in the healthcare system (especially in low resource settings). In many (but not all) end-of-life situations a PI may be non-healable due to the underlying health status or the anticipated time healing would take. When healing is possible, in theory, but may not be feasible in practice, a maintenance approach is recommended (4). The maintenance approach has a dual focus on symptom management (as discussed below for palliative wound care) while still supporting the possibility of wound healing.
For non-healable wounds, a palliative (symptom control) approach is often the best option (4). Note that palliative care is not restricted to the end-of-life. Palliative wound care includes regular monitoring of the wound (especially for infection and other treatable complications); however, the primary focus is on symptom management. Wound-related symptoms of greatest concern include pain, infection, odor and exudate. Holistic care goals should address emotional and psychological impact of the wound, limited access to resources, quality of life concerns; family and caregiver challenges and economic burden (5).
There are evidence-based guidelines/resources available on chronic wound management (see below). The general recommendations in these guidelines apply to PIs as well as other hard-to-heal/chronic wounds. Very little PI-specific research on wound treatment has been published since the last edition of the International Guideline. When available, this literature was analysed using the GRADE process. Much of the guidance in this International Guideline chapter is based on previous guidelines with pressure injury specific implications included when appropriate.
Wound Assessment
WC1: Good Practice Statement
It is good practice to:
Assess the individual, including risk factors for poor healing and any underlying causes of the PI,
Assess the individual, including risk factors for poor healing and any underlying causes of the pressure injury,
Assess the existing pressure injury prevention planning and implementation, especially in relation to pressure redistribution and nutrition,
Assess the wound bed and edge, periwound and surrounding skin and soft tissue,
Select a uniform, consistent method for measuring pressure injury size and surface area,
Assess for signs and symptoms of wound infection,
Set goals of care with the individual and their carer,
Develop a management plan to address modifiable factors that impact healing, and
Regularly reassess the individual and the pressure injury and then adjust management accordingly. See WC5 for additional information on frequency of reassessment.
The above practice should be implemented within frameworks and practices outlined in clinical guidelines for management of hard-to-heal/chronic wounds, using valid and reliable wound assessment tools and clinical judgement.
More information
Clinical question: What should be included in a comprehensive assessment of the individual and their PI(s) to inform goals of care and development of a comprehensive management plan?
Implementation considerations
Assess the individual for risk factors associated with poor healing and wound infection. Risk factors are extensive and relate to the individual’s clinical history, the wound history and clinical environment (2, 10, 11, 12). Tools that have been tested for this purpose are accessible in clinical guidelines for hard-to-heal/chronic wound assessment and management (2, 10).
Assess the individual’s psychosocial status, health literacy, cognitive ability and other factors that influence their quality of life and ability to heal (2, 11, 12). Tools that have been tested for this purpose are accessible in clinical guidelines for hard-to-heal/chronic wound assessment and management (2).
Assess and document characteristics of the PI using a structured approach to wound assessment. Characteristics to consider in the assessment include, but are not limited to (2, 10, 11, 12, 16, 17, 18):
Category/Stage
Anatomical location
Size (length and width) and surface area
Tissue type(s)
Color
Wound edges
Sinus tracts, undermining, and tunneling
Periwound condition
Exudate and odor
Wound-related pain.
Assess for signs and symptoms of wound infection. Consider using a framework (see Figure 1) to facilitate an evaluation of the microbial burden to guide treatment decisions (2, 10, 13).
Consider using valid and reliable wound assessment tools/scales to guide and document the wound characteristics and other assessment findings (2, 11, 12, 18). Commonly used wound assessment tools that have been tested for this purpose are accessible in clinical guidelines for the management of hard-to-heal/chronic wounds (2, 12).
Develop a PI treatment plan that includes goals of care and strategies aimed at achieving these goals. These goals should be established in consultation with the individual and their carer (2, 11, 12, 13).
Consider goals of care beyond complete healing. Individuals with PIs place high value on care goals such as reducing the size of a PI (15), reduction in wound signs and symptoms (e.g., exudate and odor) (15), and reducing the impact of the PI to enhance quality of life (19).
Promote involvement of the individual and their carer in PI assessment, management and planning, particularly when the individual is self-caring. This includes providing ongoing education.
Additional implementation considerations for special populations
-
Traditional clinical signs and symptoms of infection (e.g. erythema) may not be identifiable in medium and dark skin tones. Evaluate other signs and symptoms including increasing warmth and pain.
-
Consider using a population-specific tool that has been tested for validity and reliability (e.g., Toronto Symptom Assessment System for Wounds) to identify concerns of the individual that impact on quality of life (e.g., pain, exudate, odor, itchiness and cosmetic appearance) (20).
Recognize that although PIs may heal in individuals in palliative and end-of-life care settings, wound maintenance and palliation (e.g., pain and symptom management) are equally important care goals, particularly for Category/Stage 2 or greater PIs, or PIs occurring less than two weeks before death.
Severe PIs may require a palliative wound care approach that includes a focus on managing wound-related symptoms (4, 5, 21, 22).
Supporting information
Effective assessment of the PI is underpinned by scientific principles that form the basis of evaluation for all types of hard-to-heal/chronic wounds. An assessment of the individual includes identification and assessment of comorbidities and other intrinsic factors that can influence ability to heal (e.g., medications, nutritional status, vascular status, mobility and activity, posture, continence status and psychosocial status).
Wound assessment techniques are consistent across all types of hard-to-heal/chronic wounds. Recommended techniques for performing different types of wound assessment (e.g., size, volume, tissue type, temperature, etc.) regularly change, especially as technology is becoming more advanced in this field.
Comprehensive clinical guidelines for assessment and management of hard-to-heal/chronic wounds and wound infection (see Figure 1 and Resources) provide overviews of the most valid and reliable methods to assess a PI, including evolving wound assessment technologies (6, 7, 8, 9) (e.g., digital technologies, thermography, pH evaluation, fluorescence, advanced imaging, etc.).
Figure 1: International Wound Infection Institute’s Wound Infection Continuum (IWII-WIC) (reproduced with permission) (2)
Establishing goals of care
When conducting a comprehensive assessment of the individual, it is good practice to set goals of care that will guide development of the PI management plan and evaluation of whether the plan is effective. In 2018, the Guideline Governance Group conducted an international survey of patient consumers and informal carers to identify their personal goals of care (14, 15). Of 1,233 respondents (n = 383 individuals with or at risk of PIs; n = 850 caring for such an individual) very few identified that they did not have a personal care goal. This highlighted that individuals have their own care goals, and it is important for health professionals to establish what these are in order to ensure the treatment plan is aligned with the individual’s goals. The survey results (see Figure 1) indicated that individuals with a PI were more likely to identify reducing the size of a PI as being important to them than achieving complete PI healing. Managing PI-related pain was identified as being as much of a focus as reducing the size of PI (14, 15).
Figure 2: Goals of care identified by individuals with a PI and their informal carers* (15)
(* Participants identified up to 3 goals of care they considered important)
Resources
A sample of clinical guidelines for hard-to-heal/chronic wound assessment and management
International Wound Infection Institute: Wound Infection in Clinical Practice (2)
International Wound Infection Institute: Therapeutic Wound and Skin Cleansing: Clinical Evidence and Recommendations (10)
Wounds Australia: Australian Standards for Wound Prevention and Management (11)
Wounds Canada: Best practice recommendations for the prevention and management of wounds: an overview (12)
World Union of Wounds Healing Societies, WUWHS International consensus document: Use of wound antiseptics in practice (13)
Wound Care to Support Pressure Injury Healing
WC2: Good Practice Statement
It is good practice:
Address wound-related and procedural pain,
Cleanse the surrounding skin,
Therapeutically cleanse the wound bed and wound edge and periwound,
Implement wound debridement when consistent with the condition of the pressure injury and the goals of the individual,
Manage wound infection as required,
Re-establish the ideal wound edge as needed,
Select wound dressings to promote an optimal wound healing environment based on the condition(s) of the wound (e.g., balance moisture, control infection and inflammation, control odor, support autolytic debridement, redistribute heat and pressure, and relieve pain) and
Consider advanced interventions to promote tissue repair.
The above practice should be implemented within frameworks and practice outlined in clinical guidelines for management of hard-to-heal/chronic wounds.
More information
Clinical question: What are wound care considerations in promoting healing of pressure injuries?
Implementation considerations
Access relevant national and international clinical guidance on local wound care to maintain current knowledge and skills in treating hard-to-heal/chronic wounds.
Select an aseptic technique framework based on a risk assessment that considers the individual, the wound, the wound healing environment and local health service policies and procedures (2, 10).
Select a cleansing technique and solution based on the condition of the wound bed and wound edge, and the goals of care for the individual (2, 10, 37).
Select a method of debridement appropriate to the condition of the PI wound bed, if required. Consideration should be given to the need for rapid removal of non-viable tissue (especially with spreading or systemic infection), the extent of non-viable tissue requiring removal, whether the PI is healable, adequacy of blood supply to the debrided area, moisture and exudate level, the individual’s pain tolerance, the skills and training of the health professional and the resources available (2, 10, 13, 29, 31, 37, 38).
Consider the need for antimicrobial treatment based on the principles of antimicrobial stewardship, signs and symptoms of wound infection, the individual’s risk for wound infection, and the goals of care (2, 37, 39).
Select wound dressing products that support the need for autolytic debridement, exudate management, infection control, wound bed hydration, odor control and protection of epithelial tissue and periwound skin. Consider the comfort and preferences of the individual, and the resources available (2, 10, 16).
Additional implementation considerations for special populations
-
The European Wound Management Association has a series of educational material on management of wounds in the home setting.
Supporting information
Wound bed preparation (WBP) is a clinical concept encompassing a systematic and holistic approach to treatment that creates an environment that will promote wound healing. The overall goal of WBP is to promote a well-vascularized wound bed, free from non-viable tissue and excess exudate, and with a reduced microbial burden and reduced edema, that is optimal for development of healthy granulation tissue (23, 24). WBP incorporates several important factors, each of which should be evaluated and optimized (23, 24, 25, 26). These factors are outlined in a widely used framework, TIMERS and briefly described in Table 1 (1, 17, 27, 28):
tissue management,
infection and inflammation control,
moisture balance,
epithelial wound edge advancement,
repair and regeneration,
social factors and factors related to the individual (i.e. psychosocial factors).
Best practice in wound care is outlined in national and international guidelines for hard-to-heal/chronic wound care that are directly relevant to treating PIs (see Resources).
Components of WBP and their role in wound healing
| Components of WBP | Role in wound healing |
|---|---|
| Therapeutic wound cleansing (2, 10, 17, 23, 26, 29) |
|
| Debridement (1, 2, 10, 17, 23, 26, 29, 30, 31) |
|
| Infection and inflammation management (2, 10, 17, 23, 26) |
|
| Re-establish the ideal wound edge (10, 17, 32) (also referred to as re-fashioning or remodelling) |
Promotes epithelial advancement by:
|
| Repair and regeneration (27,33) |
|
| Address clinical status and modifiable PI risk factors(27) |
|
| Adress psychosocial status, pain status, knowledge and education, and social support (1, 2, 10, 27, 34, 35) |
|
Wound dressings play an important role in promoting a wound healing environment that is optimal to healing. Wound dressings have various characteristics that promote moisture balance, treat infection and inflammation, control signs and symptoms (e.g., odor and pain), support autolytic debridement and redistribute heat and pressure. Careful selection of a wound dressing that is appropriate to the wound presentation and goals of care is required.
Figure 3: Guidance on selecting a wound dressing appropriate to moisture balance requirements (36)
N.b: With low levels of wound exudate, the wound needs moisture from the wound dressing. With high exudate, the wound needs a dressing with high absorptive properties.
Resources
Wound care
European Wound Management Association: Wound debridement (e-learning module)
European Wound Management Association: Wound debridement pathway
European Wound Management Association: Recognising Infection in Pressure Ulcers
European Wound Management Association: Management of wound related pain at home
European Wound Management Association: Wound management at home
International Wound Infection Institute: Wound Infection in Clinical Practice (2)
International Wound Infection Institute: Therapeutic Wound and Skin Cleansing: Clinical Evidence and Recommendations (10)
World Union of Wounds Healing Societies: Use of wound antiseptics in practice (13)
Melnychuk, I. (2025). Wound remodelling: Approaches and techniques aimed at closure of wounds with unfavorable base or edges. Wounds International, 2025; 16(1): 8–11.
Ousey, K. Maceration in Wound Care: Towards a Standardised Assessment Scale. Wound International, 2026. 17(2): 9-15.
Biophysical Agents to Support Pressure Injury Healing
Biophysical agents deliver specific treatment directly to the wound bed, to support healing including oxygen (positive hyperbaric or hyper atmospheric pressure), electromagnetic, acoustic waves and mechanical energy. Biophysical agents that are commonly used in management of hard-to-heal/chronic wounds are outlined in Table 2.
Table 2: Form of biophysical agents
| Category | Biophysical Agents |
|---|---|
| Electromagnetic Spectrum | Electrical stimulation (ES) |
| Electromagnetic fields (EMF) | |
| Pulsed radio frequency energy (PRFE) | |
| Phototherapy: laser, infrared, ultraviolet, light emitting diode | |
| Acoustic | Non-contact low frequency ultrasound (NC-LUFS) kHz |
| Low frequency ultrasound (LFUS) kHz | |
| High frequency ultrasound (HFUS) MHz | |
| Mechanical/Kinetic | Sub-atmospheric: negative pressure wound therapy |
| Kinetic: whirlpool, pulsatile lavage, vibration | |
| Atmospheric: hyperbaric oxygen therapy, topical oxygen |
The electromagnetic spectrum is an energy source that affects living systems. The electromagnetic spectrum comprises infrared (thermal radiation), ultraviolet light (invisible light), laser (coherent and monochromatic light) and electrical/electromagnetic stimulation. The various modalities of electromagnetic spectrum energy differ from each other only in their wavelength or frequency and often overlap with adjacent areas of the electromagnetic spectrum. Electrical and magnetic fields are two component properties of electromagnetic radiation that travel perpendicular to each other and are always present together. Their properties may be altered by the device design so that one is dominant; however, they induce similar physiological responses (40, 41) that are important for wound healing and are often evaluated together.
Other forms of biophysical energy used in the management of hard-to-heal/chronic wounds include acoustic, mechanical, and kinetic energy. Some delivery devices provide more than one form of biophysical energy. For example, megahertz (MHz) and kilohertz (kHz) ultrasound devices respectively transmit high and low frequency acoustic (sound) waves and kinetic energy (pressure waves). Negative pressure wound therapy is another commonly used wound treatment through which negative pressure (a vacuum) is applied to the wound bed to promote removal of third space edema and stimulate production of granulation tissue.
Many trials on biophysical agents are conducted in samples with wound of mixed etiologies, often with no or low proportions (or number) of individuals with PIs. It is uncertain whether the results can be extrapolated to PI healing given the underlying disease processes vary across different types of wounds. Therefore, the Guideline Governance Group limited analyses to studies in which treatment of PIs were the primary focus and there was sufficient evidence to conduct a GRADE analysis.
More information
WC3: Recommendation
We suggest using negative pressure wound therapy to promote healing for Category/Stage 3 and 4 pressure injuries.
Conditional recommendation; very low certainty of evidence
Clinical question: Should negative pressure wound therapy (NPWT) versus no standard wound therapy be used to promote healing of pressure injuries?
Implementation considerations
Follow comprehensive wound care clinical guidelines for and the manufacturer directions in applying and using NPWT, including in selection of an interface dressing. Review the product information on contraindications.
Rule out osteomyelitis before applying NPWT.
If active bleeding develops suddenly or in large amounts during NPWT, or if frank (bright red) blood is seen in the tubing or in the canister stop NPWT (e.g., stop the suction), take measures to stop the bleeding and seek immediate expert advice.
If the pressure injury is located on the heel or foot, establish the presence of adequate vascular blood supply to the lower limb before commencing NPWT (66).
Consider anatomical structures and their location when using NPWT.
Cautious use by an experienced health professional is recommended for individuals on anticoagulant therapy, in actively bleeding wounds, or where the wound is near major blood vessels.
Evaluate the pressure injury with each dressing change to determine response of the wound and appropriate intervals for wound dressing changes.
Position the individual off of the PI site. Pay attention to positioning of the NPWT tubing due to the risk of medical-device related pressure injuries. The guideline chapter Device Related Pressure Injuries provides relevant additional recommendations.
Implementation considerations for special populations
-
Provide the individual and their informal caregivers with instructions for managing the NPWT, especially for those residing in community settings.
Evidence Summary
Studies were available that reported four outcome measures considered to be of critical importance based on a review of the evidence (42, 43, 44, 45, 46, 47, 48, 49) on PI and wound healing outcome measures, and informed by a stakeholder survey conducted by the guideline Governance Group.[*] The outcome measures reported in the studies included time to healing, complete PI healing (total/percent healed), percent change in wound size and pain. The devices and regimens[**] used in the studies varied, and many studies used non-commercial NPWT.
A meta-analysis (50) of ten randomized controlled trials (RCTs) (51, 52, 53, 54, 55, 56, 57, 58, 59, 60) showed that NPWT was associated with faster healing for Category/Stage 3 and 4 PIs compared with standard wound treatment (debridement plus a wound dressing). The weighted mean difference in healing time was −16.47 days (95% CI −22.36 to −10.59 days). The evidence was downgraded for risk of bias and due to high heterogeneity across the study results.
We updated a Cochrane review (61) comparing NPWT with standard wound treatment with complete PI healing as the outcome measure. The new meta-analysis included two RCTs (62, 63). The analysis indicated that NPWT was associated with a non-statistically significant greater percent of Category/Stage 3 and 4 PIs fully healing (25% versus 4.5%, relative risk [RR] 3.95, 95% confidence interval [CI] 0.74 to 21.20, p = 0.11). This translated to 134 per 1,000 more PIs healing (from 12 fewer to 918 more). There is very low certainty in this result; the certainty of evidence was downgraded due to risk of bias, and imprecision.
A Cochrane review (61) included two RCTs (64, 65) that reported the impact of NPWT on change in PI size. The review reported that reductions in PI length, width and depth were significantly (p < 0.01) greater with NPWT compared to standard treatment. However, specific values were not available and change in surface area could not be calculated. There was very low certainty of evidence, with downgrading for risk of bias, indirectness of outcome measure and imprecision (61).
A meta-analysis (50)of three RCTs (52, 59, 60) reported evaluation of participants’ pain. The meta-analysis showed a statistically and clinically significant reduction in pain score associated with NPWT (weighted mean difference −2.39, 95% CI −3.47 to −1.30, p < 0.0001). There was very low certainty of evidence, with downgrading due to risk of bias and imprecision.
[*] More details available on the evidence-to-decision frameworks.
[**] Devices and regimens are described in the data extraction tables. Product names may have changed.
Certainty of Evidence for outcome 1 time to complete PI healing
| Certainty assessment | No of patients | Effect | Certainty |
Importance |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies |
Study design |
Risk of bias |
Inconsistency |
Indirectness |
Imprecision |
Other considerations |
Negative pressure wound therapy |
standard wound therapy |
Relative (95% CI) |
Absolute (95% CI) |
||
| 10 | RCTs | Very Serious [a] |
Serious [b] | Not serious |
Not Serious |
none | 2/30 (6.7%) |
17/27 (63%) |
(0.03 to 0.42) |
WMD [c] −16.47 days (95% CI −22.36 to −10.59 days) |
Very Low |
CRITICAL |
[a] Downgraded twice due to all studies have high risk of bias in two or more domains
[b] Downgrade once due to significant heterogeneity (I2=98.2%)
[c] WMD = weighted mean difference
Evidence to Decision Framework
Problem:
Desirable Effects:
Undesirable Effects:
Certainty of Evidence:
Values:
Balance of Effects:
Resources Required:
Certainty of Evidence of Required Resources:
Summary of Judgements
Cost Effectiveness:
Inequity:
Acceptability:
Feasibility:
Yes
Moderate
Trivial
Very low
No important uncertainty or variability
Probably favors the intervention
Varies
Low
No included studies
Varies
Probably yes
Probably yes
More information
WC4: Recommendation
We suggest using electrical stimulation therapy as an adjunct to standard wound care to promote healing for Category/Stage 2 to 4 pressure injuries, and unstageable pressure injuries.
Conditional recommendation; moderate certainty of evidence
Clinical question: Should electrical stimulation versus sham/no electrical stimulation be used to promote healing of pressure injuries?
Implementation considerations
Only use medical devices that meet local technical and legal requirements and as appropriate to the individual’s health and wound condition.
Use of electrical stimulation should be directed by and under the supervision/management of an appropriately licensed health professional educated and trained in safe and effective selection, application, and monitoring methods.
If used, electrical stimulation should be as an adjunct to standard wound management treatments.
Evidence Summary
The studies addressing this clinical question reported four outcomes measures considered to be of critical importance: time to healing, complete PI healing (total/percent healed), percent change in wound size and pain.
A meta-analysis (67) of eleven RCTs (68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78) reported on electrical stimulation for achieving complete PI healing. Regimens[*] included high voltage pulsed galvanic current electrical stimulation, transcutaneous electrical nerve stimulation (TENS), high voltage pulsed current (HVPC) electrical stimulation and pulsed low intensity direct current electrical stimulation. The regimens used different intensities, frequencies and polarity patterns, and included both pulsed and direct currents. Sessions were generally one hour in duration and performed once a day, either daily, or 3-5 times/week. Electrical stimulation was used as an adjunct to standard wound care (e.g., debridement, infection management and moist wound healing). Trial durations ranged from 20 days to 8 weeks. The studies variably included older adults, individuals with spinal cord injuries (SCI) and individuals in medical or surgical wards, but none of the studies included neonates or children. Electrical stimulation was associated with a significantly high proportion of PIs achieving complete healing (36.9% versus 14.9%, relative risk [1.99, moderate effect size] confidence interval [CI] 1.39 to 2.85). This translates to 297 more per 1,000 PIs completely healing (from 207 more to 425 more) when electrical stimulation is added to a standard wound care regimen. There is moderate certainty in this result. The certainty was downgraded for risk of bias (67).
Evidence from 12 RCTs (68, 69, 70, 71, 74, 76, 77, 78, 79, 80, 81, 82) was compiled in a systematic review (67)on the impact of electrical stimulation on PI surface area versus no electrical stimulation (either placebo/sham electrical stimulation or standard wound care).[**] The studies were highly heterogeneous, likely due to multiple reasons (e.g., differences in participants, length of intervention, duration of PIs and risks of bias) and the results were not suitable for pooling (67). The mean difference in PI surface area ranged from -0.90 cm2 to 10.37 cm2 across the studies. However, there is very low certainty in this result. The certainty of evidence was downgraded for risk of bias and for imprecision (67).
A meta-analysis (67)of two RCTs (68, 72)provided evidence on electrical stimulation’s impact on time taken for PIs to completely heal. There was a non-significant reduced time to complete PI healing compared to no electrical stimulation (either placebo/sham electrical stimulation or standard wound care); however, the evidence was very uncertain, and the difference might not be clinically significant. The certainty of evidence was downgraded due to risk of bias and imprecision (67).
One RCT (83)reported that individuals with a PI treated with electrical stimulation had small improvements in their pain scores while there was a very small worsening of pain for a conventional treatment group. It was unclear if the between group change score of –0.73 (–3.33 to 1.86) was clinically significant. There was low certainty in this result due to downgrading due to risk of bias (67) and imprecision.
The meta-analysis (67)reported that adverse events occurring in individuals treated with electrical stimulation across 13 RCTs (602 participants) included redness of the skin, itchy skin, dizziness and delusions, deterioration of the PI, limb amputation and occasionally death. It was unclear if the more severe adverse events were directly related to using electrical stimulation. The data was not appropriate for a quantitative analysis, and an effect size was not estimable. The evidence was of low certainty due to downgrading because of risk of bias and imprecision. However, electric burns have been reported (67).
The costs of using electrical stimulation are likely to vary by region and clinical setting. Electrical stimulation requires specialised equipment, training and daily application that can be inconvenient for individuals, especially when it is administered for longer durations (67). However, the certainty of the evidence on resource requirements is uncertain, and no cost-effectiveness trials in PIs are available (84).Practical training has been reported to improve the acceptability of the intervention to multidisciplinary health care providers (85).Feasibility of the intervention has been demonstrated, for example one study found positive outcomes were achieved with electrical stimulation delivered in community and home settings by individuals with PIs or their carers, without the direct oversight of health professionals, which can reduce the resource requirements (73). With reliable access to the equipment, electric source and adequate training in use of equipment, electrical stimulation may be an adjunct of benefit for some individuals.
[*] Devices and regimens are described in the data extraction tables. Product names may have changed.
[**] Devices and regimens are described in the data extraction tables. Product names may have changed.
Certainty of Evidence for Outcome 1 (Time to complete healing)
| Certainty assessment | No of patients | Effect | Certainty |
Importance |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies |
Study design |
Risk of bias |
Inconsistency |
Indirectness |
Imprecision |
Other considerations |
Electrical stimulation |
No electrical stimulation |
Relative (95% CI) |
Absolute (95% CI) |
||
| 2 | RCTs | Serious [a] | Not serious |
Not serious |
Not Serious |
none | 105/284 (36.9%) |
34/228 (14.9%) |
RR 1.99 (1.39 to 2.85) |
297 more per 1,000 (from 207 more to 425 more) |
Moderate |
CRITICAL |
[a] Downgrade once because a lot of the studies had either high or unclear risk of bias for performance bias and selective reporting (Arora, Harvey et al. 2020).
Evidence to Decision Framework
Problem:
Desirable Effects:
Undesirable Effects:
Certainty of Evidence:
Values:
Balance of Effects:
Resources Required:
Certainty of Evidence of Required Resources:
Summary of Judgements
Cost Effectiveness:
Inequity:
Acceptability:
Feasibility:
Yes
Moderate
Varies
Moderate
No important uncertainty or variability
Probably favors the intervention
Moderate costs
Low
No included studies
Probably increased
Probably yes
Probably yes
Monitoring Healing of Pressure Injuries
WC5: Good Practice Statement
It is good practice to:
Observe/inspect the physical characteristics of the PI and surrounding skin at each wound dressing change.
Follow-up with a more comprehensive wound assessment if signs of deterioration are observed during a wound dressing change (e.g., noticeable larger size, more exudate, more necrotic tissue or increased pain).
Use the last documented wound assessment as a baseline.
Assess the pressure injury initially and reassess at least weekly using a consistent technique.
Monitor pressure injury healing progress using a tool designed for this purpose..
More information
Clinical question: How should the healing of pressure injuries be monitored?
Implementation considerations
Observe the PI every time the wound dressing is changed for signs that indicate a change in treatment is required (e.g., wound improvement, wound deterioration, changes in exudate, signs of infection or other complications) (2, 10, 11, 12).
Conduct a comprehensive reassessment of the individual, the PI and the healing environment in the presence of signs of deterioration or stalled healing. Adjust the treatment plan accordingly (12).
Re-evaluate the PI management plan after two weeks. In general, expect some signs of healing within two weeks (103, 104); however, expectations should be adjusted in the presence of multiple factors that impair wound healing (103, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114). If there are no signs of healing within the expected timeframe despite appropriate pressure redistribution, nutrition and local wound care, re-assess the individual.
Use the same method to assess wound characteristics and pain at each assessment to facilitate monitoring of progress (11).
Document PI assessment in a manner that enables ongoing comparison to determine progress towards healing. Several PI-specific monitoring tools are provided in the supporting information (Table 4).
Consider using serial digital photography to document PI condition and to monitor healing progress.
Include an assessment of wound pain in every PI assessment using pain assessment tool that has been tested for validity and reliability (11, 12).
Address signs of wound deterioration immediately by escalating local wound management. Follow guidance in clinical guidelines addressing hard-to-heal/chronic wound management and wound infection management. Changes should be documented and communicated to the healthcare team.
Consider further diagnostic investigations of wound bed tissue when healing does not progress according to expectations (e.g., tissue biopsies) (12).
Implementation considerations for special populations
-
Teach individuals and their informal carers to monitor the condition of their PI and to identify signs and symptoms that should be reported to the health professional (e.g., signs of local wound infection, spreading infection and systemic infection).
-
For Category/Stage 2 to 4 and unstageable PIs in individuals with medium and dark skin tones, prioritize assessment of skin temperature (compared to surrounding skin), tenderness, changes in surrounding tissue consistency and pain. Strategies to assess skin and tissue are discussed in the guideline chapter Skin and Tissue Assessment.
-
Be aware that PIs can take significantly longer to heal in individuals with spinal cord injury (SCI) and adjust expectations accordingly (115).
Consider using a SCI-specific PI monitoring tool (115) .
Supporting Information
Ongoing monitoring of wound healing provides an evaluation of the PI treatment plan, as well as the overall management plan. It is most important to use consistent techniques to evaluate the PI, to enable a more accurate determination as to whether the PI is progressing towards healing.
Clinical outcomes for evaluating healing of pressure injuries
There are multiple outcome measures that can be used to evaluate healing of a PI. In determining the clinical questions for interventions designed to treat PIs, the Guideline Governance Group undertook a review of relevant literature (42, 43, 44, 45, 46, 47, 48, 49) and also conducted a survey of key stakeholders including clinicians, industry representatives, individuals with or at risk of a PI and their informal carers. In this survey, stakeholders rated how important the outcome measure is to them in making a decision about PI treatment.
Based on the literature and survey results, the GGG prioritized five outcome measures to use when research evidence for interventions to support healing in open PIs, and one outcome measure for evaluating treatments for closed PIs (i.e., Category/Stage 1 PIs and suspected deep tissue pressure injury [sDTPI]) (see Table 3). These clinical outcomes were supported by all surveyed stakeholder groups as being critically important to making decisions about the PI treatment, and are wound agnostic (48), frequently reported in PI research (49), and relevant to both clinical practice and quality of life for individuals with a PI (46, 47).
Table 3: Ouitcome measures to evaluate pressure injury treatment [*]
| Outcome measure | GGG stakeholder survey results for clinicians, educators, researchers, industry [**] |
|---|---|
| Category/Stage 2,3 and 4 and unstageable pressure injuries | |
| Time taken for the PI to heal | Median 7.00 IQR 4.00 |
| Complete PI healing | Median 8.00 IQR 3.00 |
| Complete PI healing | Median 8.00 IQR 2.00 |
| Wound-related pain | Median 8.00 IQR 3.00 |
| If infected at baseline, changes in signs and symptoms of infection | Median 9.00 IQR 2.00 |
| Category/Stage 1 and deep tissue pressure injuries | |
| Progression or resolution of discoloration | Not evaluated because this outcome was not envisaged at the time of the stakeholder survey |
|
[*] Outcome measures were identified for evaluating research on PI treatments but are directly relevant to clinical practice and the experience of individuals with a PI. [**] In the stakeholder survey, participants were asked to rate their opinion on the level of importance of each outcome measure. Median results are reported in the table. The results indicate:
|
|
Monitoring pressure injury healing
Experienced health professionals are often astute in monitoring the progress of a PI toward healing. However, there is room for variability when multiple health professionals (or those with less experience) are evaluating the PI over time. Tools and scales have been designed to facilitate a more consistent and accurate assessment of the PI. Commonly used PI-specific assessment and monitoring tools/scales that have been tested for validity and/or reliability are reported in Table 4. These tools/scales provide the basis for a structured PI assessment that includes a range of wound characteristics. All the tools include a calculation of an overall assessment score that can be used to monitor overall progress towards healing. Many of the tools, although developed for PIs, have been used to assess other chronic wounds (18, 86, 87).
Surgical Options for Supporting Pressure Injury Healing
Pressure injuries, especially Category/Stage 3 and 4 PIs, may take months to years to heal (104, 116), and they are a known cause of sepsis and death (117, 118, 119, 120, 121, 122). Surgical intervention is appropriate for some individuals and has been shown to contribute to improved functional capacity, psychological status and quality of life (123).
WC6: Good Practice Statement
It is good practice to obtain a surgical consultation for an individual with a pressure injury that:
Has advancing cellulitis or is a suspected source of sepsis,
Has undermining, tunnelling, sinus tracts and/or extensive necrotic tissue not easily removed by conservative debridement, and/or
Is Category/Stage 3 or 4 and not closing with standard wound management within a defined period of time.
More information
Clinical question: What indicators are appropriate when considering eligibility for surgical intervention for a pressure injury?
Implementation considerations
Surgical debridement
Refer individuals for a surgical review with consideration of the individual’s clinical condition, PI condition and the goals of care.
Obtain an urgent surgical review when sepsis is suspected. When the individual experiences fever with no obvious other foci of infection, suspect bacteremia associated with the PI (118).
Obtain an urgent review by a medical practitioner/vascular surgeon for possible surgical sharp debridement in the presence of clinical signs of infection for a PI with dry, stable eschar (2, 128). Do not perform debridement without review by a medical practitioner/vascular surgeon when there is insufficient blood supply to support infection control or healing (11, 129, 130, 131).
Obtain a surgical referral for PIs requiring extensive debridement (11, 129, 130, 131). The rationale for a surgical review includes improved anesthesia, analgesia, clinical monitoring and access to instrumentation, equipment and ancillary staff.
Surgical repair (flaps or graft)
Obtain a surgical referral to evaluate the eligibility for surgical repair of a non-healing, severe PI (132).
Evaluate factors that may impair the individual’s ability to heal following surgery including nutritional status, smoking status, continence, co-morbidities, infection and psychosocial factors.
Undertake comprehensive discussion with the individual and their informal carer about the goals of care, expected outcomes from surgery, risks and benefits, pre- and post-surgery regimens, potential for healing and recurrence rates (especially for individuals with a high lifetime risk of PIs).
Implementation considerations for special populations
-
Evaluate psychosocial and educational needs of the individual and their informal carers (133).
Provide access to preoperative and ongoing education to individuals and their informal carers on the surgical procedure, the postoperative regimen and ongoing PI prevention (126, 133, 134, 135, 136).
Optimize control of comorbidities, including PI risk factors such as diabetes(137, 138) and incontinence prior to pressure injury surgery (139, 140). Manage signs and symptoms that may impact suture line disruption (e.g., muscular spasms) and plan post-surgery management plans for factors that may impact healing or increase the risk of surgical site infection (e.g. urinary and/or fecal incontinence).
Optimize nutritional status prior to pressure injury surgery (133, 134, 140, 141, 142, 143, 144). The chapter Nutrition in Pressure Injury Prevention and Treatment provides guidance on nutritional optimization.
Select and procure appropriate support surfaces for the post-operative period, (126, 140), with input from an appropriately trained health professional (e.g., seating specialist, occupational therapist, physiotherapist and/or other trained professional). A support surface with envelopment, immersion and moisture management features will be required for at least 2–4 weeks following surgery (126, 127, 139, 145, 146, 147, 148). Refer to the guideline sections Support Surfaces and Seating for recommendations and implementation considerations for selecting support surfaces.
Assess the individual’s living environment and commence procurement of support surfaces and other equipment that will be required on discharge.
-
Optimize healthy lifestyle choices and a supportive social network preoperatively and prior to discharge.(126, 136)
Regularly monitor the wound(127, 133, 140, 149) and report signs of flap failure to the surgeon immediately, including:(150)
Pallor of poor arterial supply
Slow capillary refill
Mottling
Bluish-purple tissue of venous engorgement
Purple-maroon tissue of deep tissue injury.
Consider using advanced monitoring devices (e.g., Doppler systems, infrared spectroscopy, long wave infrared thermography with imaging and surface temperature monitoring) to evaluate the health of the flap following surgery.(150, 151, 152)
Position and transfer the individual in a way that avoids pressure on or disruption to the surgical site. This includes avoiding placing any pressure or body weight on the surgical site,(140, 147, 153, 154) maintain bed rest in a flat position as much as possible,(145, 148, 155, 156, 157) frequent repositioning,(147) minimizing truncal flexion to 30° to 40° until the surgical site is sufficiently healed to permit progressive sitting,(145, 148) using prone or lateral positions,(141, 154) and cautious use of equipment (e.g., bedpans, manual handling equipment, etc.).
Commence a progressive seating protocol when the surgical site is sufficiently healed. Progressive sitting using a pressure redistribution seating surface(126, 127, 139, 140) should be initiated according to the surgeon’s post-operative orders. Refer to the guideline sections Support Surfacesand Seating for recommendations and implementation considerations.
Supporting Information
A surgical consultation should also be requested to evaluate the need for surgical debridement for individuals with advancing cellulitis, suspected sepsis, undermining, tunneling, sinus tracts and extensive necrotic tissue not easily removed by conservative debridement. A surgical consult can also evaluate eligibility for surgical repair for individuals with Category/Stage 3 and 4 PIs with large amounts of missing skin, subcutaneous fat and muscle, or with exposed bone that presents a risk of osteomyelitis. Surgery may also be considered in palliative care for the treatment of pain and control of odor when the risk-benefit ratio is favorable (117).
Urgent surgical consultation is warranted in some clinical scenarios. This includes PIs with advancing cellulitis, abscess or gross infection, when sepsis is suspected, or when the PI would benefit from surgical sharp debridement.
When assessing eligibility for PI surgical repair, the surgical team should consider healing with conservative treatment versus surgical intervention, the individual’s goal of care, the individual’s overall clinical condition (124), motivation and ability of the individual to comply with the treatment regimen (125, 126, 127) and the risk of surgery for the individual.
Resources
European Wound Management Association in collaboration with Wounds Australia: Pressure Injury Recurrence Toolkit
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