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Treatment of Pressure Ulcers

IN RESPONSE: We agree with Dr. Cereda that nutrition is an important component of pressure ulcer treatment and found moderate-quality evidence that protein-containing nutritional supplements resulted in wound improvement. We are aware of the recent Annals article on arginine supplementation and, although it was not included in our evidence review because it was published after our literature search dates, it would likely be included in an update of the guideline. In response to Dr. Finucane's comments about nutritional data, although the protein supplementation studies used various formulations, these supplements overall showed benefits for pressure ulcer outcomes and are therefore a suitable treatment option in conjunction with other therapies. To address Drs. Monfre and Endo's concerns, we reiterate that the guideline is based on a systematic evidence review done by an experienced evidence-based practice center commissioned by the Agency for Healthcare Research and Quality. The reviewers used well-established methods for acquiring, summarizing, and grading the evidence and included experts in the field during the review's development, as well as during public comment and peer review periods. This guideline follows the recently published standards from the Guidelines International Network and Institute of Medicine (1, 2). As for donut cushions, no studies on these cushions met the inclusion criteria in the evidence review; thus, we did not discuss this intervention. Furthermore, identifying every available device that has or has not been studied for harm or benefit was beyond the scope of the guideline. Dr. Cuddigan and colleagues seek advice beyond what is available from direct evidence. However, a guideline, by definition, should be based on a systematic literature review and not expert opinion (1, 2), and the American College of Physicians' guidelines are always based on evidence from such reviews. Although we agree that clinicians need guidance even in the absence of direct evidence, such resources as point-of-care tools, as opposed to guidelines, are better suited to provide this advice.