EUROPEAN PRESSURE ULCER ADVISORY PANEL

It is eight months now since we had our last conference in Amsterdam, and some four to go before we meet in Pisa. During the meeting we made many plans, imagined ourselves some years later in a world in which medicine and nursing were developed even further and in which, of course, the problem of pressure ulcers no longer existed. Pressure ulcers? They were seen around the millennium change, I think, or was it in the ’90s of the last century? Well, let’s be realistic; they still exist and there is nothing that convinces me that in a few years time they will not exist.

However, we have won on several fronts. There are working groups on registration and prevalence recordings, on the minimum data set needed when research is done in order that it can be compared with other studies. Very slowly there is a developing recognition of the need for a European quality mark for overlays and dressings. Politicians now know that pressure ulcers are are very costly and we know how to judge the literature. These facts will be the basis for action in the next few years. This policy is already paying off. EPUAP Officers have been invited to attend international meetings in Australia, Japan and the United States. The organisations are anxious to hear about our achievements in such a short time and which model we used for the development of our guidelines. They were also pleased to know that our research of the literature only started at 1992, the year that the NPUAP published their guidelines and extensive literature search. Why do it all over again when they did it so well? It seems this is a success story.

I am honoured, but rather worried that in June next year I have to present some ideas about pressure ulcers to the NPUAP conference in New York. The subjects are risk assessment, overlays, dressings and debridement – four presentations! I explained to them that I have some know-ledge of pressure ulcers but certainly not a large knowledge of dressings and debridement as I am a doctor and not a nurse or specialised tissue viability nurse. However, they were just interested in our discussions and how we came to make our guidelines. I am happy to describe the process of rough guidelines and how to discuss them in plenary sessions, which scientific standards we have used and how we implement the things we know.

At this point I realise that there are problems; we still do not know the cause of the development of pressure ulcers. We know or believe that pressure is important, but there is something called ‘tissue tolerance’ which we cannot define exactly. Also, we do not know how to evaluate risk assessment tools, simply because we do not know the impact of all these separate factors. It struck me that none of all the factors used in the various tools, by themselves, cause ulcers. Just look at the risk assessment tools used to predict who will get a myocardial infarct and you will understand what I mean: all those factors, cholesterol, hypertension, diabetes and smoking cause infarctions on their own, and much faster when there are several factors present in one patient. They simply all fit into the pathophysiological model of the development of atherosclerosis.

And now for pressure ulcers; can anyone explain how a depressed mood causes an ulcer, or decreased activity and mobility, or incontinence of urine (the Norton tool)? Certainly a moist skin increases friction and causes, perhaps, this phenomenon of ulcers eventually, but there are several extra steps needed before an ulcer occurs. There is no link with pathophysiology. We still do not know what we are talking about with regard to pressure ulcers. We desperately need to perform basic studies to understand what exactly pressure ulcers are, and what tissue tolerance means. Perhaps we should also understand why some overlays perform better than others and perhaps the manufacturers, as in the pharmaceutical trade, will perform rigorous, well thought out studies before they introduce the next device on a market without well defined criteria to judge them properly. There are exceptions of course, some work really well and all ethical aspects have been examined. It is the task of one of our working groups to make these criteria. It’s getting better, a little better all the time (Sgt. Pepper etc. 1967).

Jeen Haalboom
President EPUAP