EUROPEAN PRESSURE ULCER ADVISORY PANEL

Andrew J.M. Boulton and Loretta Vileikyte, Departments of Medicine and Behavioural Sciences, Manchester Royal Infirmary, University of Manchester, Manchester, England

Foot complications remain the commonest cause for hospital admission amongst diabetic patients in most European countries at the beginning of the 21st century. A number of well recognized risk factors predispose patients to foot ulceration; most important amongst these are neuropathy (leading to reduced pain sensation, altered joint position sensation, dry skin, altered blood flow, peripheral vascular disease and abnormalities of pressures an loads under the feet during standing and walking). Neuropathic ulcers remain the most preventable of the diabetic foot problems and can be divided into intrinsic and extrinsic lesions. In both of these abnormalities of pressures and loads are involved; intrinsic foot ulcers result from a combination of peripheral insensitivity, and altered foot shape leading to high pressures under the metatarsal heads during walking. The combination of autonomic neuropathy and high pressures results in callus formation. Several studies have now confirmed the importance of both abnormally high metatarsal head pressures and callus (hard skin) formation in the genesis of ulceration. Extrinsic ulcers result from neuropathy leading to insensitivity and some form of extrinsic pressure which may be from ill fitting footwear (a common cause) or a foreign body in the shoe. As can be seen, it is a combination of risk factors, most commonly neuropathy, altered foot shape and trauma, that results in foot ulceration. Of paramount importance, therefore, is the correct identification of the at-risk foot from systemic and regular screening of all diabetic patients and providing appropriate foot care, together with education and treatment to those identified as ‘at risk’. The major problem has been that, despite education, foot ulcers remain common. Surprisingly, until recently, research into the psychosocial variables that might influence adherence or non-adherence to preventative foot care has not been driven by any integrated theory, and therefore has lacked explanatory power as to how behavioural decisions are made. There is now some evidence of progress in this area, with a new generation of measures being developed, such as a neuropathy specific quality of life measure. Current research that is guided by the illness perception approach appears promising in explaining adherence or non-adherence to preventative foot care. Newly emerging, patient centred, neuropathy focuses, theoretically based approaches to adherence behaviours and quality of life should increase the clinicians’ understanding as to how diabetics experience and deal with their neuropathy.

Mrs Jacqui Fletcher, Hertford University, England

A pressure ulcer grading system should provide a means of describing the severity of tissue damage directly attributable to pressure (or a combination of pressure, friction and shear). Although a number of grading systems have been developed to help practitioners achieve consistency in their definition and description of pressure damage there is no agreement about which tools should be used. Consequently problems of inter rater reliability are apparent (Healey, 1995). Some systems define intact skin with blanching hyperaemia as a pressure ulcer (Torrance, 1983) whilst others record damage only if the hyperaemia does not resolve (i.e., is non blanching) (Reid and Morison, 1994, EPUAP, 1998). The tools are based on numerical systems and generally classify the depth of damage based on the layers of the skin involved. Problems occur when the same numerical rating is used to indicate differing degrees of damage in individual tools. Other problems identified include difficulties in determining redness in darker coloured skin and how to classify damage where a blister is present or where necrotic tissue masks the true extent of the underlying damage. The aim of these two workshops is to discuss some of the more commonly used pressure ulcer grading tools and by use of photographic examples provide a forum to discuss some of the common inconsistencies in clinical usage.

References:

• European Pressure Ulcer Advisory Panel (1998) Pressure Ulcer Treatment Guidelines, Oxford, EPUAP.
• Healey F. (1995) The reliability and utility of pressure sore grading systems. J of Tissue Viability 5, (4) 111–114.
• Reid J and Morison M. (1994) Towards a consensus: Classi-fication of pressure sores. J of Wound Care 3, (3) 157–160
• Torrance C. (1983) Pressure Sores: Aetiology, treatment and prevention, Beckenham, Croom Helm

Joan-Enric Torra i Bou, Interdisciplinary Chronic Wounds, Consorci Sanitari de Terrassa, Hospital de 08277 Terrassa, Barcelona, Spain

A comprehensive approach of the treatement of pressure ulcers is based on three main aspects:

• The control of pressure and friction forces,
• The approach of the general condition of the patient,
• And the local treatment of the wound.

The local treatment of the wounds has varied and improved a lot in the last forty years due to a better understanding of the healing process, as well as the developement of new dressings. Since the discovery by George Winter of the effect of moist environment in the healing of wounds, a great variety of dressings have been developed. The different types of dressings allow the clinician to address the different needs of the wounds: protection against pressure, exudate managing, odour managing, debridement, etc.

The Pressure Ulcer Treatement Guidelines of the European Pressure Ulcer Advisory Panel contain several general recomendations about the use of dressings:

• Use a dressing which maintains a moist environment at the wound/dressing interface [evidence A].
• Determine the condition of the wound and establish treatment objectives before selecting dressing, e.g.: grade, wound bed, infection, level of exudate, pain, surrounding skin, position, and patients preference [evidence C].
• Dressings should be maintained in situ as long as is clinically appropiate, and in line with manufacturers recommendations. Frequent removal could damage the wound bed. Dressings that harden should not be used since they may cause pressure injuries [evidence B].
• Dressings may need to be removed daily to ensure that the wound is not getting worse due to inadequate pressure relief. If there is leakage or strike through, it causes a break in the barrier that the dressing provides to external contamination, and so it should be changed. If this occurs frequently it may be appropriate to reconsider dressing choice [evidence C].
• The use of wound protocols based on good evidence will avoid unnecessary changes of dressing [evidence C].
• Regular observation will demosntrate the progress of healing and if there is need to change treatment objectives [evidence C].

Nowadays we have evidences about the action, indications and effectiveness of the different types of dressings. This information may be very useful in the choice of the appropiate dressing. We are going to update about the different moist environment dressings (Polyurethane films, polyurethane foams, hydrogels, hydrocolloids, alginates and hydrofibres) as well as other dressings such as silver, coal or collagen dressings.

Eileen Scott, Baqar Ali, Richard Buckland, Andrew Meiling and David Leaper. North Tees & Hartlepool NHS Trust, Professorial Unit of Surgery, North Tees General Hospital, Stockton-on-Tees, TS18 9HE, England

Introduction: Pressure ulcers are expensive to manage, with annual costs estimated at $750 million in the United States and £321 million in England; it has been suggested that up to 25% of hospital-acquired pressure ulcers may originate during surgery. Patients with femoral fractures tend to be elderly, have multiple health problems, and are particularly vulnerable to post­operative complications, and pressure ulcers incidence rates of over 60% have been recorded. Although the main causes of pressure ulcers are the intensity of the pressure and its duration, individual tolerance factors are also important.

Methods: Patients were selected for the study when they were scheduled for surgical intervention for a fractured neck of femur. Initially only patients who required the fixation of a dynamic hip screw (DHS) were selected. However, because of ethical considerations and the related difficulties in patient recruitment, selection criteria were extended to include all patients with such fractures regardless of the intended surgical approach. This decision can also be supported through the findings of related research, which will be discussed. This study aimed to quantify the variables in the pressure damage equation, as they are presented in the periop-erative period, and to correlate these measurements with the post-operative development of pressure ulcers. These objectives were achieved through:

• the measurements of microcirculatory tissue perfusion through the measurement of skin blood flow at intervals (laser doppler technology),
• the measurements of interface pressures (Force Sensing Array) during the perioperative period,
• skin assessments made during the first five days following surgery.

Results: Statistical analysis included paired sample t-test, repeated analysis of variance, and, for the dichotomous variable of pressure ulcer development, chi-square. Final results will be presented at this conference.

Discussion: Technological advances have been used to quantify the important variables in the pressure damage equation.

This study:

• has provided original knowledge about the pathophysiology of pressure ulcer development,
• has international implications in the prevention of pressure ulcers, and
• will inform the clinical management of the prevention of pressure ulcers in this vulnerable group of patients.

Acknowledgements:  The authors acknowledge the support of the EPUAP who provided funding for this study. We are also grateful to all of the members of the Orthopaedic Team at North Tees General Hospital for their valuable assistance, especially the Nursing Staff for assistance in data collection.