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A New Evidence-Based Practice Guideline
on Pressure Ulcer Prevention and Management
In 2002 new guidelines on pressure ulcer prevention and
management were released in the Netherlands. These evidence-based guidelines
built upon the literature review conducted during the development of the
United States Agency for Health Care Policy and Research (AHCPR) pressure
ulcer guidelines issued in the early 1990s. As such the new Dutch guidelines
offer new insights into the management of pressure ulcer prevention and
management given their foundation upon new research studies and an awareness
of literature published in languages other than English. The European
Pressure Ulcer Advisory Panel would like to acknowledge CBO, Dutch Institute
for Quality in Health Care (Kwaliteitsinstituut voor de Gezond-heidszorg)
CBO, PO Box 20064, 3502 LB Utrecht, the Netherlands for their kind permission
to present an edited version of these new guidelines within the EPUAP
Review. In this issue we cover the methodological issues related to the
development of the new guidelines.
Why was the new guideline developed?
Recent years have seen greater focus upon the problem of pressure ulcers
in the Netherlands at a political and economic level. For example political
initiatives have included a report on pressure ulceration to the Secretary
of Health and the Health Council.1 This report was followed by a written
reply to the report’s conclusions submitted by the Health Minister
to the Dutch House of Commons. In parallel with these political issues
there has been a growth in the availability of national epidemiological
data2 along with a stronger awareness of the economic impact of pressure
ulcers.3–18 In the Netherlands approximately 13% of all patients
in teaching hospitals have pressure ulcers, the prevalence then rises
in home care (17%), general hospitals (23%) and to about 30% in nursing
homes2 while the annual spend on pressure ulcer care is about 600 million
Euros with a total population of 16 million.16–17 These developments
have not occurred in a vacuum; Dutch demography has changed over the past
ten years with greater numbers of elderly people, while the scientific
basis for pressure ulcer prevention and management has also advanced.
Taken together there was perceived to be a need to revise earlier consensus
texts developed in the Netherlands during the mid 1980s, and to update
the US AHCPR guidelines that date from 1992. This update of the guideline
was commissioned by the CBO (Dutch quality organization for health care)
with all relevant interest groups represented in the working group established
to direct the guideline update.
What is the purpose of the new guideline?
Essentially the guideline must be appropriate for use in daily medical,
nursing and paramedical practice giving sound recommendations and practical
advice. All patient groups and care settings are to be covered by the
guideline’s recommendations – both those with an elevated
risk of developing pressure ulcers and those with established pressure
ulcers. One important consideration was that the guideline should seek
to facilitate the co-ordination of care both within and between institutions.
Definition of pressure ulceration used throughout
the guideline:
In this guideline, ‘pressure ulcer’ should be considered to
refer to any tissue damage caused by mechanical loading (pressure, shear
and friction alone or in combination).
Developing the guideline:
In 2000 a Working Group was formed to lead the development of the new
guideline (See Appendix 1 for composition of the group) formed of society
representatives and active researchers. In particular this latter group
comprised of post-doctoral fellows drawn from the Netherlands and Belgium
and collectively known as the European Pressure Ulcer Research Interest
Group (EPURIG).
The working group first met on 11 May 2000 and separated the guideline
development into two phases – development of the recommendations,
and commentary from appropriate stake-holders. The EPURIG members were
tasked to identify the relevant literature, review it and form draft recommendations.
The primary role of the scientific society representatives was to provide
comment upon these draft recommendations. Studies to be included in the
review were to have been published since the AHCPR pressure ulcer prevention
guideline issued in 1992. Initially it was anticipated that the latest
date of publication to be covered by the review was Summer 2000 but this
process extended to include new publications for a further twelve months
(Summer 2001). Throughout the review process close co-operation was sought
with relevant Dutch steering committees and European and North American
pressure ulcer organizations (EPUAP and NPUAP).
During the initial meeting, the chair of the working group proposed the
guideline be divided into five sections covering:
• risk assessment
• prevention
• pressure ulcer assessment
• treatment and complications
• organizational issues and specific care-setting
situations
This structure was subsequently adopted during the development of the
guideline.
Search strategy:
Relevant literature was identified through a combination of searches of
electronic data bases and hand-searching of reference lists and other
available evidence-based guidelines. The electronic search covered four
key data-bases – the Cochrane Library, CINAHL, EMBASE and MEDLINE.
Each data-base was searched using the following key-words; pressure ulcer,
pressure ulcers, pressure sore, pressure sores and decubitus. Studies
retrieved with the last key-word were rejected from the review if they
referred to the decubitus position. The search was refined using a variety
of study designs as additional key-words; randomized clinical trials,
cohort studies, retrospective studies, prospective studies, case control
studies and case studies. Eligible studies had to be published between
1992 until July 2001. Members of the working group also submitted publications
out with those included on the electronic data-bases while further publications
were identified from reference lists and other evidence-based guidelines.
In total over 400 publications were considered in this review. Each publication
was then reviewed and graded using the following criteria:
Where publications reported the use of interventions for either pressure
ulcer prevention or treatment;
A1 systematic reviews that included some studies of A2 level, with consistent
results across the individual studies,
A2 appropriately designed and conducted randomized controlled trials,
B low quality randomized controlled trials or non-randomized comparative
cohort studies or patient-controlled studies,
C non-comparative studies,
D expert opinion.
And in cases where publications reported upon diagnostic procedures for
example risk assessment;
A1 several prospective studies (including some at A2 level) with minimal
loss to follow-up within specified patient groups that reported clinical
outcomes achieved after implementing a specified diagnostic procedure,
A2 studies comparing the results from a diagnostic procedure against previously
agreed ‘gold standard’ reference procedure, with appropriate
statistical analyses,
B studies comparing the results from a diagnostic procedure against a
reference procedure, may not have appropriate statistical analyses,
C non comparative studies,
D expert opinion.
Throughout the process of reviewing and grading studies the working group
would like to thank the Belgian Pressure Ulcer Guideline Committee for
the assistance they provided.
Having graded the sources of evidence, the recommendations
in the new guideline were also weighted as follows:
1 Recommendation based on one systematic review (A1), or at least two
independent studies on level A1 or A2,
2 Based on at least two independently executed studies on level B,
3 Based on one study at level A2 or B, or studies on level C,
4 Based on expert opinion.
Each recommendation is supported by its scientific basis, representing
a summary of the studies that underpin the recommendation. The key studies
and weighting (level 1 to 4) are illustrated for each of the given recommendations.
Where recommendations were in part based on information outside the scientific
studies (for example patient preferences, cost, equitable access throughout
all care settings) the non-scientific aspects are listed as ‘other
considerations’. Adopting this procedure for presenting recommendations
was considered to increase the transparency and implementation of the
guideline while also facilitating discussion within the working group!
Legal implications of the guideline:
Clinical guidelines are not laws, but rather offer insights based on the
available evidence that would assist caregivers to deliver ‘good’
care. These insights are based on the average or typical patient and when
faced with a heterogeneous patient population it is likely that caregivers
may exercise their professional judgement and decide to deviate from the
guideline. Such deviations should be noted in the patients medical record.
Updating the guideline:
The CBO will update the guideline no later than 2007 although earlier
review may be required dependent upon advancves in scientific knowledge
and clinical practices.
References:
1. Gezondheidsraad: Decubitus.Den Haag: Gezond-heidsraad, 1999. Publicatie
nr 1999/23, blz.13.
2. Bours, G. and Halfens R. ‘Decubitus komt nog veel te veel voor.’
TVZ 1999; (20): 608–611.
3. Hey, S. Pressure sores care and cure (letter). Lancet 1996; 348: 1511.D
4. Haalboom JRE. Pressure Ulcers. Lancet 1998; 352: 581.
5. Hu TW, Stotts NA, Fogarty TE and Bergstrom B. Cost analysis for guideline
implementation in prevention and early treatment of pressure ulcers. Decubitus
1993; 6: 42–46.
6. Frantz R, Bergquist S and Specht J. The cost of treating pressure ulcers
following implementation of a research-based skin care protocol in a long
term care facility. Adv Wound Care 1995; 8: 36–45.
7. Lapsley HM and Vogels R. (1996) Cost and prevention of pressure ulcers
in an acute teaching hospital. Int J Qual Health Care 8: 61–66.
8. Haalboom JRE. (1991) De kosten van decubitus. Ned Tijdschr Geneesk
135: 606–609.
9. Xakellis GC, Frantz R and Lewis A. Cost of pressure ulcer prevention
in long term care. J Am Geriatr Soc 1995; 43: 496–501.
10. Xakellis GC and Frantz R. The cost of healing pressure ulcers across
multiple health care settings. Adv Wound Care 1996; 9: 18–22.
11. Allman RM, Damiano AM and Strauss MJ. Pressure ulcers, hospital complications,
and disease severity: impact on hospital costs and length of stay. Adv
Wound Care 1996; 9: 22–30.
12. Allman RM, Damiano AM and Strauss MJ. Pressure ulcer status and post-discharge
health care resource utilization among older adults with activity limitations.
Adv Wound Care 1996; 9: 38–44.
13. Richardson GM, Gardner S and Frantz RA. Nursing assessment: impact
on type and cost of interventions to prevent pressure ulcers. J WOCN 1998;
25: 273–280.
14. Xakellis GC, Frantz RA, Lewis, A and Harvey P. Cost-effectiveness
of an intensive pressure ulcer prevention protocol in long term care.
Adv Wound Care 1998; 11: 22–29.
15. Severens JL. A Kosten van decubitus in Nederland. Afdeling MTA, Universitair
Medisch Centrum St. Radboud, Nijmegen. 1999.
16. Severens JL Habraken JM, Frederiks CMA, Duivenvoorden S van. Kosten
van decubitus in Nederland; een inventarisatie op basis van expert-opinion.
Woundcare Consultant Society Nieuws 2000; 16: 20–25.
17. Severens JL, Habraken JM, Duivenvoorden S van, Frederiks CMA. The
cost-of-illness of pressure ulcers in the Netherlands. Adv Skin &
Wound Care (2001).
18. Rutten FFH, Ineveld BM van, Ommen R van, Hout BA van and Huijsman
R (1993). Kostenberekening bij gezondheidszorgonderzoek; richtlijnen voor
de praktijk Utrecht: Uitgeverij Jan van Arkel.
Appendix I
Members of the Guideline Development Group:
JRE Haalboom MD PhD, University Hospital Utrecht, Royal
College of Physicians, president
R Ettema BSc, CBO Utrecht, recorder
FWA van Asbeck MD PhD, rehabilitation centre, De Hoogstraat, Utrecht,
Dutch Society for Rahabilitation and Physical Medicine
TA van Barneveld PhD, epidemiologist, CBO Utrecht
GJJW Bours BSc, Dept of Nursing Research, University of Maastricht
IC Buss, BSc, Dept of Nursing Research, University of Maastricht
FJ van Buuren, occupational therapist, Dutch Society for Occupational
Therapy
M Casteleijn RN, nurse-specialist, Dutch Organization for Home Care
B Derre RN BSc, nursing researcher, Dept of Nursing Research, University
of Gent (Belgium),
T Defloor RN PhD, nursing researcher, Dept of Nursing Research, University
of Gent (Belgium),
PH Germs MD, general practitioner, Dutch Society of General Practitioners
HW Groen MD, nursing home specialist, Dutch Society of Nursing Home Specialists
WM van Hengel, dietician, Dutch Society of Dieticians
BPJA Keller MD, physician-researcher, University Hospital Utrecht,
MNS Koek RN, dermatologic-nurse-specialist, Wound Consultant Society
BGM Kolnaar, general practitioner, Dutch Society of General Practitioners
HEW de Laat, BSc, Dept of Nursing Research, University of Nijmegen
MJ Lubbers MD, surgeon, University Hospital Amsterdam, Royal Dutch College
of Surgeons
RJ van Marum MD PhD, clinical geriatrician, Dutch Society for Clinical
Geriatry
E Mathus-Vliegen MD PhD, professor of clinical nutrition, University Hospital
Amsterdam
JCL Neyens, physiotherapist, Dutch Society for Physiotherapy
JU Piersma, pressure ulcer nurse, Dutch Network Decubitus Consultants
ME Pieterse PhD, senior researcher, Dutch Institute for Health Care Education
NIGZ
CJG Sanders MD, dermatologist, University Hospital Utrecht, Dutch Society
for Dermatology and Venereology
L Schoonhoven RN BSc, assistant researcher, University Hospital Utrecht
JTM Westsrate MSc, Erasmus University Rotterdam
JT Zeilstra, pressure ulcer nurse, University Hospital Groningen, Dutch
Society of Dermatology Nurses
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