EUROPEAN PRESSURE ULCER ADVISORY PANEL

UPDATING THE EPUAP PRESSURE ULCER PREVENTION AND TREATMENT GUIDELINES
Jacqui Fletcher

The EPUAP guideline on pressure ulcer prevention was published in 1998 (EPUAP, 1998) and was followed shortly afterwards by a second guideline upon pressure ulcer treatment (EPUAP, 1999). While these guidelines were strongly influenced by the US Agency for Health Care Policy and Research guidelines, the membership of the EPUAP were able to direct the content of each guideline through discussion sessions during EPUAP open meetings. Through this approach of engaging the membership, it was hoped that the guidelines would not only represent the most up-to-date practice but also be clinically relevant to a wide range of practitioners from different professional backgrounds.

In line with the recommendations of many authorities on guideline development (for example Field and Lohr 1992, SIGN 2001) the EPUAP now wishes to revisit and review the guidelines. This process is required to:

a) ascertain if the statements within each guideline remain valid;
b) to include new research findings which may strengthen individual statements; and
c) to determine if the guidelines remain clinically relevant.

Such a review obviously requires considerable effort on the part of the EPUAP and its members and would usually necessitate the completion of a systematic review to identify all new evidence. However, undertaking a formal review may represent considerable wasted effort if it reveals little or no new information, furthermore where guidelines were initially based on a properly performed and documented review any update may not need a completely new systematic review (Browman 2001). Given that the EPUAP guidelines were initially based on the reviews carried out by the Agency for Healthcare Policy and Research it was considered that a repeat of these systematic reviews was not required and a more practical method of guideline updating was sought.
Why should a guideline be updated? Shekelle et al (2001) identified six scenarios when a guideline may require revision, these were;

• Changes in evidence on the existing benefits and harms of interventions
• Changes in outcomes considered important
• Changes in available intervention
• Change in evidence that current practice is optimal
• Changes in values placed on outcomes
• Change in resources available for healthcare.

In a second publication, Shekelle and colleagues (2001) have reported a methodology allowing rapid updating of clinical guidelines that will be adopted by the EPUAP. Their approach combined limited literature searching with contact with the initial guideline developers (the 'experts') to determine if new research had been published or completed that would require the guideline to be updated or even rewritten. Shekelle et al. recommended that guidelines should be reviewed regularly with a recommended interval between reviews being in the region of three years. Such an interval would suggest that the EPUAP prevention guidelines are now be due for review, and perhaps updating.

At this time the EPUAP would like to invite members to participate in this process of identifying important new evidence and assessing whether the new evidence justifies updating the pressure ulcer prevention guideline. The guidelines (reprinted below) should be thoroughly reviewed and the following three questions addressed in relation to the scenarios described above.

1. Are you aware of new evidence or development in the field relevant to each guideline statement?
2. Is the new evidence or development of sufficient importance to invalidate any of the guideline statements?
3. Are there new guideline statements (within the scope of the original guideline) that should be included given the existence of new research or clinical developments?

It should be borne in mind that the guidelines were developed to be useful to countries across Europe working in many different healthcare settings with differing levels of resources. The words chosen were selected very carefully to allow for direct translation into the many European languages and the purpose of this review is not to enter into lengthy discussion about the phrasing of individual statements unless a statement has led to particular confusion or difficulties in practice.
Suggestions for areas that require updating or review should be made in writing to Jacqui Fletcher, at:

j.fletcher@herts.ac.uk

and a copy of the supporting evidence provided. The deadline for return of this information is 28 March 2002.

References
Browman G.P. Development and aftercare of guidelines. The balance between rigor and pragmatism JAMA 2001 286 (12) 1509-1511.
EPUAP. British Journal of Nursing. 1998 7 (15 ) 888-889.
EPUAP. Guidelines on treatment of pressure ulcers EPUAP Review 1999 1 (2) 31-33.
Field M.J. and Lohr K.N. eds. Guidelines for Clinical Practice: From Development to Use. Washington DC National Academy Press 1992
Shekelle P., Eccles M.P., Grimshaw J.M. and Woolf S.H. When should guidelines be updated? BMJ 2001 323 155-157
Shekelle PG, Oritz E, Rhodes S, Morton SC, Eccles MP, Grimshaw JM and Woolf SH. Validity of the Agency for Healthcare Research and Quality Clinical Practice Guidelines. How quickly do guidelines become outdated? JAMA 2001 286 (12) 1461-1467.
SIGN. SIGN 50 A Guideline developers handbook. Available through http://www.show.scot.nhs.uk/sign/guidelines/fulltext/50/. 2001. Scottish Intercollegiate Guidelines Network Edinburgh.

View the EPUAP Guidelines on Pressure Ulcer Prevention
View the EPUAP Guidelines on Pressure Ulcer Treatment