Dr Carol Dealey
Senior Research Fellow , University Hospital Birmingham NHS Foundation Trust , Birmingham, UK
On behalf of the EPUAP and NPUAP Guideline Development Group
The National Pressure Ulcer Advisory Panel (NPUAP) from the USA and the European Pressure Ulcer Advisory Panel (EPUAP) are organisations focused on pressure ulceration and its prevention and management. Both societies had produced guidelines in the 1990s, which, by 2004, were woefully out of date. Denis Colin, who was EPUAP president at that time, approached the NPUAP president to propose a joint collaboration on updating the guidelines.
This was received positively and, as a result, I was one of a small group of EPUAP board members to travel to Tampa, Florida, USA, in February 2005 to attend both the NPUAP conference and a meeting to discuss guidelines. We agreed to work together, but had no idea of the journey ahead of us.
Both societies formed a Guideline Development Group (GDG) to work separately and jointly on different parts of the work. NPUAP undertook a scanning exercise to identify all the pressure ulcer guidelines currently available and EPUAP prepared a draft methodology paper for the guideline development. Draft papers were then exchanged between the two associations until consensus was achieved. The methodology paper was placed on the joint guideline website, presented at both conferences and also published in a European journal.1
It was agreed that EPUAP would focus on the prevention guidelines and NPUAP would focus on treatment.
The methodology was the same for both prevention and treatment and draft statements were reviewed by the joint GDG.
Developing the guidelines
The main work was undertaken by small working groups (SWGs), who reviewed the literature on specific topics, developed evidence tables from the included papers and then drafted guideline statements with supporting text. Within EPUAP SWGs, there were 29 people from 11 European countries. A total of 31 people were involved in the NPUAP SWGs, but several of them worked in more than one group. This work involved a great deal of commitment from these people for which the joint GDG is most grateful.
The SWGs met together either in person or by teleconference to discuss the findings from the literature review and their draft statements. There was also a great deal of email communication. It soon became obvious that the timetable that we had originally set was not practical and we had quite a bit of slippage. One of the reasons for this was that most people were doing the work in their spare time and they were busy people.
‘Divided by a common language’
Another problem that arose was that of language. This might have been expected to be an issue among the European members – after all, they do not all speak English as a first language. However, the communication problems were actually because of the differences between UK English and American English and email writing style. Although there was much goodwill between NPUAP and EPUAP, we did not know each other very well when we started working together. Ultimately, we concluded that we needed to meet in person as often as possible to prevent miscommunication.
Undertaking international guidelines is a considerable responsibility because we wanted to develop guidance that both reflected the research evidence available and were also applicable across the world. It was important to recognise that resources are very limited in some countries.
It was by chance that I discovered that some common terminology was used differently in other countries.
I was teaching on a university course in Portugal when I realised that when I talked about an alternating air mattress (a common support surface to prevent pressure ulcers), the students were visualising something different. In Portugal, hospitals were still using an alternating air overlay on top of the normal mattress and these overlays had small-diameter cells that are no longer used in the UK or other parts of northern Europe or North America. Research has shown them to be ineffective. The alternating air mattress I was talking about is used to replace the normal mattress and has large-diameter cells.
To ensure that the guidelines were relevant to all and also that we had not missed any relevant literature, we invited as many people and societies as possible to register as stakeholders. When the draft guideline statements were completed, all the stakeholders were invited to comment on them and to propose any literature that they thought we had missed. Altogether, we had 903 individuals from 53 countries and 146 organisations from 32 countries. All the comments were reviewed by the joint GDG and the guideline statements were revised as appropriate.
The International Guidelines for the Prevention and Treatment of Pressure Ulcers were finally published in October 2009. There are two formats:
- Clinical Practice Guideline, which has the full details of the methodology and the underpinning evidence as well as the guidelines statements and references
- Quick Reference Guide, which has all the statements and some supporting text.
The project had taken nearly five years instead of the two that we had originally planned. However, we felt that we had produced a very worthwhile document. It is not possible to discuss the whole guideline, but I will endeavour to provide some insight.
The contents of the guideline document are divided into prevention and treatment and then a number of subsections that can be seen in Tables 1 and 2. The following statements demonstrated how the guidelines reflect the need for overall policy within a healthcare setting as well as specific patient care provision.
Examples of policy statements
‘Establish a risk assessment policy in all healthcare settings’
‘Ensure that a complete skin assessment is part of the risk assessment policy in place in all healthcare settings’
Such a policy should include a structured approach to risk and skin assessment that is relevant to the healthcare setting. It should include clear recommendations of the details of the assessment, timing of assessment and frequency of reassessment as well as documentation and methods of communication to the clinical team.
Examples of related patient-specific statements
‘Use a structured approach to risk assessment to identify individuals at risk of developing pressure ulcers’
‘Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition’
Risk and skin assessment are essential to determine the level of risk of individuals, thus allowing an individualized plan to be developed. In addition, skin assessment can detect early signs of pressure damage and ongoing skin assessment can assist in monitoring the effectiveness of the prevention plan.
Examples of education-related statements
The guidelines also include statements that address educational issues as can be seen in the statements below:
‘Educate professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localised heat, oedema, and induration (hardness).’
‘Education about the role of repositioning in pressure ulcer prevention should be offered to all persons involved in the care of individuals at risk of pressure ulcer development, including the individual and significant others (where possible).’
‘Educate the individuals, care-givers and healthcare providers about causes, assessment and management of pressure ulcer pain.’
‘Validate that family care-providers understand the goals and plan of care (taken from Palliative Care section)’
Education of healthcare professionals, patients, family and significant others is essential to ensure that they have the skills needed to participate in any pressure ulcer prevention and/or management plan.
Not all patients or their families will be able to actively participate, but they should be able to understand what is happening and why.
Two sections in the treatment part of the guidelines are pain and palliative care. Pain has been poorly recognised in relation to pressure ulcers in the past2 and has not been considered in other pressure ulcer guidelines. We believe this to be an important advance. In the same way, palliative care has not been considered in other guidelines and yet the management of pressure ulcers in this group is not necessarily the same as for other patient groups.
The goals for palliative care are much more about patient comfort and individual preferences rather than healing the pressure ulcer. Of course, it may be possible to achieve healing, but comfort has to be the priority.
Guidelines have no value unless they are available to be used. Both NPUAP and EPUAP were committed to ensuring that the guidelines were made widely available, but also had to recognise they had limited resources. In addition, they had made a considerable financial investment in developing the guidelines. It was therefore decided that the Clinical Practice Guideline (CPG) and printed versions of the Quick Reference Guide (QRG) would be available for purchase from the NPUAP website.
The QRG is also freely available on both websites (www.epuap.org and www.npuap.org) but separated into prevention and treatment documents.
EPUAP is a European organisation and very conscious of the need for the guidelines to be available in a wide range of languages. Members of the EPUAP Board and their colleagues have undertaken translations and more are in progress. Currently, the QRG for Prevention is freely available on the EPUAP website in: Finnish, German, Hebrew, Italian, Japanese, Polish, Portuguese, Spanish, and Swedish. In addition, translations are in progress into: Dutch, French, Greek, Hungarian, Slovenian, and Turkish.
So far, the QRG for Treatment is only available in Japanese, but translations into Dutch, German, Portuguese and Spanish are in progress. Very excitingly, the CPG is being translated into Dutch via a government-funded grant and there is a possibility of translation into Spanish. These translations have been considerable work for those undertaking them and each translation is checked for accuracy by independent verifiers.
Developing the International Pressure Ulcer Guidelines has taken considerable time, but we believe that the end result provides a succinct synopsis of existing research on pressure ulcers. It is an indispensable resource for clinicians providing evidence-based practice, educators presenting the latest research to their students, policy-makers shaping the future of healthcare, and researchers at the cutting edge of new discoveries.
- Vanderwee K. EWMA J 2007;7(3):44-46
- Hopkins A et al. J Adv Nurs 2006;56:345-353