EUROPEAN PRESSURE ULCER ADVISORY PANEL

Sylvie Meaume
Hôpital Caries Foix, Ivry Sur Seine, France

Background
To meet the challenge of an ageing population, providers and payers must optimise chronic wound care outcomes and contain costs.

Objective
To use a consensus approach to develop protocols of care and cost effective models for the treatment of pressure ulcers and venous leg ulcers in France.

Methods
A pooled analysis of the international literature, supplemented by consensus opinion from French experts provided data to develop 3 protocols of care for the management of pressure ulcers and venous leg ulcers in France. Protocols of care with a composite sample size in the literature of less than 100 pressure ulcers or leg ulcers were excluded. In the pressure ulcer model, all protocols of care involved saline cleansing, debridement, wound fillers and adjunctive therapies and differed only with respect to the cover dressings used (saline gauze, Granuflex®, Comfeel®). In the venous leg ulcer models, protocols of care involved saline irrigation, debridement, wound fillers and compression bandages and differed only with respect to the dressings used (saline gauze, Granuflex®, Apligraf). Clinical outcomes and some treatment patterns were culled from the literature. Treatment patterns specific to France were included based on the consensus of the expert panel. The information was used to develop cost-effectiveness models, which measured cost (in French Francs) per healed ulcer in a French patient cohort over a 12-week period.

Results
Costs per healed ulcer for managing pressure ulcers and venous leg ulcers in France using the different protocols of care will be presented and discussed.

ACHIEVING REDUCTIONS IN PRESSURE ULCER PREVALENCE WITH EDUCATION AND CLINICAL PRACTICE GUIDELINES: AN AUSTRALIAN EXPERIENCE

Prentice JL and Stacey MC
University Department of Surgery, Fremantle Hospital, Perth, Western Australia.

Introduction
Whilst reductions in prevalence have been reported retrospectively the expected overall national decrease in prevalence was not realised immediately in the USA and Holland when their clinical practice guidelines for pressure ulcers were first released 10 and 15 years ago.
The prevalence of pressure ulcers in Australia ranges between 2.7 and 19%. Comparatively few prevalence studies have been conducted however, and none nationally. The Australian Wound Management Association has developed 'Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers'. Prior to public release these guidelines have been evaluated for their effectiveness in reducing pressure ulcer prevalence. A critical concept of this evaluation was an intensive education program to assist with their introduction and implementation. An aim of this first national study on pressure ulcers was to prospectively evaluate whether or not Australian guidelines for predicting and preventing pressure ulcers, in conjunction with an education program, does reduce pressure ulcer prevalence.

Methods
Ten major teaching hospitals participated in this Study in 2000. Five hospitals were surveyed for pressure ulcer prevalence, using the same methodology. A structured education program to introduce the guidelines into these hospitals was implemented over a six-month period. An Education Manual was provided to each hospital to assist with guideline implementation. Over 3,000 full copies and 7,000 pocket versions of the guidelines were distributed to clinicians. The hospitals were then re-surveyed for pressure ulcer prevalence. The prevalence survey tool contained 24 variables. Data captured included patient demographics, number and stage of pressure ulcers found, number of hospital acquired pressure ulcers, use of formal risk assessment tools, and type of support surface in use. Documentation and management of pressure ulcers was also reviewed. The other five hospitals not surveyed for prevalence received the guidelines, but no other interventions, acted as a form of control.

Results
In the first survey 453 of 1707 patients examined had a pressure ulcer; a prevalence of 26.5%. There were 884 ulcers found with 63% being Stage 1, 31% Stage 2, 2% Stage 3, and 4% Stage 4. Over 60% of ulcers were hospital acquired. Only 59% of patients with an ulcer had a support surface in place. The average age of patients with pressure ulcers was 65.8 years. In the second survey 397 patients from 1807 were affected; a prevalence of 22%. On chi-squared analysis this reduction is statistically significant p<0.0 1. The number of ulcers overall dropped to 655 in the second survey. Other differences in relation to the above variables will also be discussed.

Summary
This Study's hypothesis that the introduction and effective use of the 'Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers' can reduce the prevalence of pressure ulcers within Australian teaching hospitals has been proven correct. Other clinical outcomes, such as an increase in the use of risk assessment tools and the use of support surfaces have also occurred.
This Study also suggests that an education programme that has organisational support is a key element to achieving successful implementation of clinical practice guidelines for pressure ulcers.

THE EFFECTS OF INTRA-OPERATIVE WARMING THERAPY ON THE INCIDENCE OF POST-OPERATIVE PRESSURE ULCERS: A RANDOMISED CLINICAL TRIAL

Eileen M Scott
Research & Development Co-ordinator, North Tees and Hartlepool NHS Trust, Stockton-on-Tees, England, UK

Introduction
Post-operative pressure ulcers are a common and expensive problem. Intra-operative hypothermia is also a common problem and may have a connection with impaired tissue viability. It was hypothesised that intra-operative prevention of hypothermia may reduce the incidence of post-operative pressure ulcers. A randomised clinical trial (n = 338) tested the effects of using a forced air blanket versus standard care.

Methods
Patients scheduled for orthopaedic, vascular, urological, or general abdominal surgery, where the normal hospital stay was expected to be at least five days, were admitted to the study. Exclusions were patients under 40 years of age and those for whom intra-operative warming therapy was standard practice. The elimination of bias was ensured through a concealed randomisation protocol and the measurement of outcomes by a researcher who was unaware of the treatment group to which each patient had been assigned.

Results
Pressure ulcers were reduced by almost half (10.4%: control; 5.6%: treatment; p = 0.109). The absolute risk reduction of 4.8% (95% confidence interval: no reduction to 11%) converts to a relative reduction of 46%. The number necessary to treat (NNT) is 21 patients (95% confidence interval: no effect to 10 patients). Contrary to what may have been expected, duration of surgery was not a factor there being no significant differences. Low body mass index (BMI) was related to pressure ulcer development (p = 0.009) and an inability to maintain core temperatures. The grading system used to categorise patient health status and anaesthetic risk (American Society of Anaesthesiologists, ASA grade) may also be an indictor of pressure ulcer risk. It appeared that the greater the anaesthetic risk, the greater the likelihood of developing pressure ulcers post-operatively.

Summary
Intra-operative forced air warming should become standard practice for all patients having major surgery, regardless of its expected duration. This is especially the case for patients who have additional risk factors, such as a low BMI or a high ASA grading, who may also benefit from pre-induction warming to supplement intra-operative therapy.
This research has important implications for the development of perioperative practice. The study was part of a doctoral programme with the University of Teesside and funded through a Research Training Fellowship awarded by the Northern & Yorkshire Region of the NHS Executive.

EDUCATION PROGRAMME IN PRESSURE ULCER CARE

Sally Rees Matthews
The Medi Centre, Heath Park, Cardiff, Wales CF14 4UJ

The occupational therapist is part of the multi-professional team that cares for patients who experience pressure ulcers. The occupational therapist is able to provide education where this equipment is best used. The health care professionals who seek advice and education include nursing staff, medical staff, patients and their carers and other colleagues (e.g., physio and OT).
The role of the occupational therapist as part of the team will be explained and will include liaison with other agencies.
Case histories will be used to illustrate how the occupational therapist functions as part of the multi-professional when managing patients with pressure ulcers. This will include discussing the use of equipment for beds, chairs, feet and other devices.
In this vulnerable group of patients who experience pressure ulcers the occupational therapist has a flexible and challenging role as part of the multi-professional team.

Note:
Further abstracts from the Le Mans meeting will be published in the next issue of the EPUAP Review.