2.
Background
Clinical
practice guidelines are systematically developed statements to
assist practitioner and patient decisions about
appropriate health care for specific clinical circumstances (www.nice.org.uk,
2005). Guidelines have become increasingly used in response to
concerns regarding wide variations in health care as well as the
suspicion that much of this care is of sub-optimal quality. An
appropriately developed guideline can serve as an authoritative
statement about best practice for providers and patients, an important
educational tool, and as a benchmark for use in assessing care.
The pressure ulcer prevention guideline developed by the European
Pressure Ulcer Advisory Panel in 1998 is now probably outdated
in terms of its content and fails to take account of significant
advances in the guideline development process that have been reported
in the past few years (www.agreecollaboration.org).
This scoping document sets out the limits of the revision required
of the initial EPUAP and NPUAP guidelines on pressure ulcer prevention.
3. Clinical need for the guideline
Pressure ulcers (also known as pressure sores, bed sores, pressure
damage, pressure injuries and decubitus ulcers) are areas of localised
damage to the skin and underlying tissue caused by pressure, shear
or friction, or a combination of these. They generally occur over
the bony prominences of the body of those who are very ill, neurologically
compromised or immobile are particularly vulnerable. A number
of countries have undertaken surveys to identify the numbers of
patients with pressure ulcers, examples are as follows:
Canada – overall prevalence rate of 26%
in all healthcare institutions; 25% in acute care, 30% in long
term / subacute care and 15% in the community (Woodbury &
Houghton, 2004)
Germany – point prevalence rates of 5.3–28.3%
in the hospital setting (Stausberg et al., 2005; Lahmann &
Dassen, 2001; Mertens et al., 2003)
Iceland – prevalence rate 8.9% (Thoroddsen, 1999)
Italy – prevalence rate of 8.3% in hospital setting
in 1996, but over 30% in home care setting (Bellingeri, 2002)
Japan – prevalence rate 5.1%
and incidence 4.4% (Hagisawa & Barbenel, 1999)
Netherlands – prevalence rate of 23.1%
(Bours et al., 2002)
Spain – overall prevalence rate – 8%, but
variation between different care settings (Torra et al., 2003).
A pilot survey undertaken by the EPUAP, which included 5,947 patients
located in Belgium, Italy, Portugal, Sweden and the UK, found
an overall prevalence 18.1%, although there was some variation
between countries (Clark et al., 2002). The National Pressure
Ulcer Advisory Panel (NPUAP) estimates that the pressure ulcer
prevalence in hospitals is 15% with an incidence of 7% (Ayello
et al., 2001). Unique populations such as those receiving palliative
care in home hospice report a pressure ulcer prevalence rates
of 15–27% and an incidence rate of 10% (Reifsnyder &Hoplamazian,
2005; Tippett, 2005; Reifsnyder & Magee, 2005). Pressure ulcer
prevalence among non-critical hospitalized pediatric patients
demonstrates significant variation from 0.47–13% (Baldwin,
2002 & Groenveld et al., 2004) While, incidence rates as high
as 27% among critical pediatric patients has been reported by
Curley (2003).
Pressure ulcers represent a major burden of sickness and reduced
quality of life for patients and their carers (Franks et al.,
1999). Increased morbidity and mortality associated with pressure
ulcer development in hospitalized patients is documented in multiple
studies (Kumar et al., 2004; Ducker, 2002; Davies, 1991; Khan
& Miller, 2003; Allman et al., 1999; Allman et al., 1986)
Among long term care residents who develop pressure, ulcers mortality
rates within six months have been reported of up to 67% (Brown,
2003). Additionally, hospitalized patients who develop pressure
ulcers are twice as likely to develop nosocomial infections and
to acquire other hospital complications (Allman et al., 1999).
Not surprisingly, hospital length of stay, readmis-sion rates
and hospital charges are greater in patients who develop pressure
ulcers than those remaining ulcer free (Strausberg et al., 2005;
Drucker, 2002; Allman et al., 1986; Allman et al., 1999; Zhan
& Miller, 2003). In fact, development of a single pressure
ulcer in US hospitals can increase a patient’s length of
stay five-fold and increase hospital
charges by $2,000–11,000 (Zhan & Miller, 2003; Allman
et al., 1999) Mean total direct care costs per in-hospital patient
associated with pressure ulcers in the New Mexico Medicaid system
was found to be $8,891 in 1995 (Kumar, 2004) In an Australian
study by Lapsley & Vogels (1996) among patients post-coronary
artery bypass grafting (n = 24) and post-hip replacements (n =
9) who developed pressure ulcers, the total excess hospital days
and costs were: 221.5 days at a cost of AU$106,984 and 49.5 days
at AU$ 23,098 respectively. Recent European cost-models to highlight
the cost of illness associated with pressure ulcers have indicated
that the total costs may consume between 1% (Netherlands, Severens
et al., 2002) and 4% (UK, Bennett et al., 2004) of health care
expenditure. Annual pressure ulcer treatment costs in the US range
from $9.1–11.6 billion, with cost per pressure ulcers ranging
from $21,000– 152,000 (Zulkowski et al., 2005).
Prevention of pressure ulcers is an important goal for healthcare
professionals and there is a growing body of knowledge
to support the use of a range of prevention strategies.
4. The guideline
The guideline development process will broadly follow the methods
devised by the UK National Institute for Clinical Excellence for
guideline development with some modification in relation to the
international context. Full details of the process can be found
in Appendix 1. This document is the scope. It defines exactly
what this guideline will (and will not) examine, and what the
guideline developers will consider. The areas that will be addressed
by the guideline are described in the following sections.
4.1 Population
4.1.1 Groups that will be covered
The guideline recommendations will apply to adult patients and
vulnerable adults. The needs of specific groups, for example those
with spinal cord injury, will be addressed at a later date.
4.1.2 Topics that will not be covered
The guideline will not include recommendations on the treatment
of existing pressure ulcers as this will be the subject of a separate
guideline. Other wound types will not be included in this guideline
4.2 Healthcare setting
The guideline is intended for the use of health care professionals
who are involved in the care of patients and vulnerable people
that are at risk of developing pressure ulcers, whether they are
in hospital, long term care, assisted living (supported accommodation)
at home or any other care setting, and regardless of their diagnosis
or health care needs. It will also help to guide patients and
carers on the range of prevention strategies that are available.
4.3 Clinical management
The guideline will cover all aspects of pressure ulcer risk assessment
and prevention and include:
a) The current definitions of a pressure ulcer including underpinning
aetiology
b) Risk assessment including nutrition.
c) Skin inspection
d) The management of soft tissue loading. The guideline will include
evidence on the use of positioning and repositioning and on the
use of support surfaces including beds, mattresses, overlays (including
those for operating tables and trolleys), cushions and other pressure
redistributing aids. Devices that will be considered include:
• Air fluidised beds
• Alternating air mattresses, overlays and seating such
as cushions
• Bead-filled overlays and seating such as cushions
• Foam: block, cubed, layers of different densities –
mattresses, overlays and cushions, including ‘standard’
hospital mattresses
• Gel mattresses, overlays and seating such as cushions
• Fibre-filled overlays and cushions
• Low air loss beds and mattresses
• Static air-filled mattresses, overlays and cushions
• Turning beds
• Water-filled mattresses, overlays and cushions
Pressure redistributing aids will include genuine and synthetic
sheepskins, limb protectors, doughnut shaped devices and water-filled
cushions.
4.4 Audit support within guideline
Criteria for undertaking audits related to guideline implementation
will be included in the guideline. They will be linked to the
EPUAP position statement on prevalence and incidence measurement.
4.5 Status
4.5.1 Scope
This is the final version of the scoping document
4.5.2 Guideline
The development of the guideline recommendations will begin in
September.
5. References
Allman RM, Goode PS, Burst N, Bartolluci AA, Thomas
DR (1999) Pressure ulcers, hospital complications,
and disease severity: impact on hospital costs and
length of stay. Advances in Skin & Wound Care, 12 (1)
22–30.
Ayello, EA et al., ‘Methods for determining pressure ulcer
prevalence and incidence’ in Cuddigan. J et al., eds.
Pressure ulcers in America: Prevalence, incidence and
Baldwin KM (2002) Incidence and prevalence of pressure
ulcers in children. Advances in Skin & Wound Care, 15
(13) 121–124.
Bellingeri A. et al., (2002) Wound management in home
care in Italy. EWMA Journal, 2 (1) 27–30.
Bennett G, Dealey C, Posnett J (2004) The cost of
pressure ulcers in the UK. Age & Ageing, 33: 23–235.
Bours GJ, Halfens RJ, Abu-Saad HH, Grol RT (2002)
Prevalence, prevention and treatment of pressure
ulcers: descriptive study in 89 institutions. Research in
Nursing & Health, 25 (2) 99–110.
Brown G (2003) Long term outcomes of full-thickness
pressure ulcers: healing and mortality. OWM, 49 (10)
42–50.
Clark M, Bours G, Defloor T (2002) Summary report on
prevalence of pressure ulcers. EPUAP Review, 4 (2) 49–57.
Curley MAQ, Quigley SM, Lin M (2003) Pressure ulcers
in pediatric intensive care: incidence and factors.
Pediatric Crit Care Med. 4 284–384.
Ducker A (2002) Pressure ulcers: Assessment, prevention
and compliance. Case Manager, 13 61–65.
Franks PJ, Winterburg H, Moffatt C (1999). Quality of life
in patients suffering from pressure ulceration: a case
controlled study (abstract). Ostomy and Wound
Management, 45: 56.
Groenveld A, Anderson M, Allen S et al., (2004) The
prevalence of pressure ulcers in a tertiary care
pediatric and adult hospital. JWOCN, 31 (3) 108–116.
Hagisawa S, Barbenel J (1999) The limits of pressure sore
prevention. J of the Royal Soc of Med, 92 (11) 576–78.
Lahmann N, Dassen T (2001) Prevalence of pressure
ulcers in eleven German hospitals in April 2001.
EPUAP Review, 4 (1) 17.
Lazarus GS, Cooper DM, Knighton DR et al., (1994)
Definitions and guidelines for assessment of wounds
and evaluation of healing. Arch Dermatol 130 489–493.
Mertens E, Dassen T (2003) Decubitus ulcer prevalence
in Germany: improvement by comparison. Pflege
Zeitschrift, 56 (2) 109–112.
Reifsnyder J, Hoplamazian L (2005) Incidence and
prevalence of pressure ulcers in hospice. J Palliat Med,
8 (1) 244.
Reifsnyder J, Magee HS (2005) Development of pressure
ulcers in patients receiving home hospice. WOUNDS,
17 (4) 74–79.
Severens JL, Habraken JM, Duivenvoorden S, Frederiks
CMS (2002) The cost of illness of pressure ulcers in
the Netherlands. Advances in Skin & Wound Care, 15
(2) 72–77.
Stausberg J, Kroger K, Maier I, Schneider H, Niebel W,
for the Interdisciplinary Decubitus Project (2005)
Pressure ulcers in secondary care: incidence, prevalence,
and relevance. Advances in Skin & Wound Care,
18 (3) 140–145.
Thoroddsen A (1999) Pressure sore prevalence: a
national survey. Journal of Clinical Nursing, 8 (2) 170–
179.
Tippett AW (2005) Wounds at the end of life. WOUNDS
17 (14) 91–98.
Torra i Bou J, Rueda López J, Soldevilla Agreda JJ,
Martínez Cuervo F, Verdú Soriano J (2003) First
National Study on Pressure Ulcer Prevalence in Spain.
Epidemiology and defining factors for lesions and
patients [Spanish]. Gerokomos, 14 (1) 37–47.
Woodburg MG, Houghton PE (2004) Prevalence of
pressure ulcers in Canadian healthcare settings. OWM
50 (10) 22–38.
Zulkowski K, Langemo D, Posthauer ME, the NPUAP
(2005) Coming to consensus on deep tissue injury.
Advances in Skin & Wound Care 18 (1) 28–29.
APPENDIX
1
GUIDELINE DEVELOPMENT PROCESS
Scoping 0–4months
1. Representatives of EPUAP and NPUAP meet to discuss possibility
of joint working (Feb 2005) – agree that each association
will discuss with their Board Members. EPUAP agree to produce
a draft scoping document.
2. EPUAP produce draft scoping document prior to conference in
Aberdeen and send to NPUAP
3. Finalise scooping document and guideline development process
at Aberdeen.
4. Final version of scoping document placed on both websites,
and Stakeholders invited to register their interest. (Stakeholders
can be wound-healing societies, healthcare professionals, healthcare
providers, charities, patient groups manufacturers or distributors).
Target date 20 June 2005.
Development 5–22 months
1. EPUAP and NPUAP nominate six representatives each to form the
Guideline Development Group (GDG) including a patient representative.
2. Budget to be prepared for 1 August 2005
3. Stakeholders are identified and invited to submit evidence
to the GDG.
4. Two centres are established, one in Europe and one in USA.
It is anticipated that each centre will be based within a university
and employ one person to undertake the work, including: literature
searches, utilising existing systematic reviews; review and summarise
literature; preparation of monthly reports for the GDG; collaboration
with international counterpart.
5. The GDG develops the guideline. This work will primarily be
undertaken by email and videoconferencing, although one full meeting
may be required. Such a meeting will be alongside conferences
held by one of the two associations in order to reduce travel
costs, if at all possible.
Validation 23–28 months
1. First consultation of draft guideline – guideline placed
on both websites and stakeholders and members of EPUAP, NPUAP
and other relevant associations invited to comment.
2. GDG addresses comments and develops 2nd draft of guideline.
3. Second consultation of draft guideline
4. Guideline finalised and a version produced for healthcare professionals
including a technical report, a ‘quick reference guide’
and also a version for patients and carers.
Publication and Dissemination 29–30 months
1. Final guideline (all versions) placed on both websites with
details for obtaining further copies.
2. Guideline presented at conferences for both associations and
other conferences as appropriate.
3. Translations of guideline made available for European countries.
Costs for Guideline Development
Costs to include:
• Two researchers/administrators for 24 months,
• Video-conferencing and two full meetings of the GDG,
• Facilitator for two GDG meetings,
• Printing and dissemination.
