Prevention And Treatment Of Pressure Ulcers: Clinical .

Prevention andTreatment ofPressure Ulcers:Clinical PracticeGuideline

Copyright National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan PacificPressure Injury AllianceISBN-10: 0-9807396-5-9 (in print)ISBN-13: 978-0-9807396-5-7 (in print)ISBN-17: 978-0-6480097-1-9 (digital version)Published by Cambridge Media on behalf of National Pressure Ulcer Advisory Panel, European Pressure UlcerAdvisory Panel and Pan Pacific Pressure Injury AllianceAll rights reserved. Apart from any fair dealing for the purposes of private study, research or review, aspermitted under the Copyright Act, no part may be reproduced or copied in any form or by any means withoutwritten permission. Requests to reproduce information can be emailed to admin@internationalguideline.comafter reviewing the general statement on content use at sted citation:National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure InjuryAlliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.).Cambridge Media: Osborne Park, Western Australia; 2014Disclaimer:This guideline was developed by the National Pressure Ulcer Advisory Panel, the European Pressure UlcerAdvisory Panel and the Pan Pacific Pressure Injury Alliance. It presents a comprehensive review and appraisalof the best available evidence at the time of literature search related to the assessment, diagnosis, preventionand treatment of pressure ulcers. The recommendations in this guideline are a general guide to appropriateclinical practice, to be implemented by qualified health professionals subject to their clinical judgment of eachindividual case and in consideration of the patient consumer’s personal preferences and available resources.The guideline should be implemented in a culturally aware and respectful manner in accordance with theprinciples of protection, participation and partnership.Printed copies of the English version of this guideline can be ordered, and PDFs downloaded, from the followingwebsites:NPUAPEPUAPWounds Australia (previously Australian Wound Management Association) website:Hong Kong Enterostomal Therapists Association SocietyNew Zealand Wound Care Society (NZWCS)Wound Healing Society SingaporeInternational Pressure Ulcer Guideline sginternationalguideline.com

CLINICAL PRACTICE GUIDELINEINTRODUCTIONINTRODUCTIONForewordThis Clinical Practice Guideline presents recommendations and summarizes the supporting evidence forpressure ulcer prevention and treatment. The first edition was developed as a four year collaborationbetween the National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer AdvisoryPanel (EPUAP). In this second edition of the guideline, the Pan Pacific Pressure Injury Alliance (PPPIA) hasjoined the NPUAP and EPUAP. This edition of the guideline has been developed over a two year period toprovide an updated review of the research literature, extend the scope of the guideline and producerecommendations that reflect the most recent evidence. It provides a detailed analysis and discussion ofavailable research, critical evaluation of the assumptions and knowledge in the field, recommendations forclinical practice, a description of the methodology used to develop the guideline and acknowledgements ofthe 112 experts formally involved in the development process.A Quick Reference Guideline version that contains excerpts from the Clinical Practice Guideline is alsoavailable. The quick reference guideline is intended for busy health professionals who require a quickreference in caring for individuals in the clinical setting. Users should not rely on excerpts from the QuickReference Guideline alone.The goal of this international collaboration was to develop evidence-based recommendations for theprevention and treatment of pressure ulcers that could be used by health professionals throughout theworld. An explicit scientific methodology was used to identify and critically appraise all available research. Inthe absence of definitive evidence, expert opinion (often supported by indirect evidence and otherguidelines) was used to make recommendations. Drafts of the recommendations and supporting evidencewere made available to 986 invited stakeholders (individuals and organizations) around the world. The finalguideline is based on available research and the accumulated wisdom of the NPUAP, EPUAP, PPPIA andinternational stakeholders. In this edition of the guideline, a consensus voting process (GRADE) was used toassign a strength to each recommendation. The strength of recommendation identifies the importance ofthe recommendation statement based on potential to improve patient outcomes. It provides an indicationto the health professional of the confidence one can have that the recommendation will do more good thanharm, and can be used to assist in prioritizing pressure ulcer related interventions.Printed copies of the English version of the Clinical Practice Guideline are available through links provided onthe following websites:NPUAP website:www.npuap.orgEPUAP website:www.epuap.orgWounds Australia (previously Australian Wound Management Association) website: www.woundsaustralia.com.auHong Kong Enterostomal Therapist Society website:www.etnurse.com.hkNew Zealand Wound Care Society (NZWCS) website:www.nzwcs.org.nzWound Healing Society Singapore l Pressure Ulcer Guideline website:www.internationalguideline.comSuggested CitationThe NPUAP, EPUAP and PPPIA welcome the use and adaptation of this guideline at an international, nationaland local level. We request citation as the source, using the following format:National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan PacificPressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical PracticeGuideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.1

INTRODUCTIONCLINICAL PRACTICE GUIDELINELimitations and Appropriate Use of This Guideline Guidelines are systematically developed statements to assist health professional and patient consumerdecisions about appropriate health care for specific clinical conditions. The recommendations may not beappropriate for use in all circumstances. The decision to adopt any particular recommendation must be made by the health professional withconsideration to available resources and circumstances of the individual patient. Nothing contained in thisguideline is to be considered medical advice for specific cases. Because of the rigorous methodology used to develop this guideline, the Guideline Development Groupmembers believe that the research supporting these recommendations is reliable and accurate. Everyeffort has been made to critically appraise the research contained within this document. However, we donot guarantee the reliability and accuracy of individual studies referenced in this document. This guideline is intended for education and information purposes only. This guideline contains information that was accurate at the time of publication. Research and technologychange rapidly and the recommendations contained in this guideline may be inconsistent with futureadvances. The health professional is responsible for maintaining a working knowledge of research andtechnology advances that may affect his or her clinical decision making. Generic names of products have been used. Nothing in this guideline is intended as endorsement of aspecific product. Nothing in this guideline is intended as advice regarding coding standards or reimbursement regulations. The guideline does not seek to provide full safety and usage information for products and devices;however commonly available safety and usage tips have been included. Adverse events reported in theincluded research have been reported in the evidence summaries and caution statements. All productsshould be used according to manufacturer’s directions.AbstractThis guideline is the result of a collaborative effort among the National Pressure Ulcer Advisory Panel(NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA).A comprehensive literature review was conducted on pressure ulcer prevention and treatment. A rigorousscientific methodology was used to appraise available research and make evidence-based recommendationsfor the prevention and treatment of pressure ulcers. Draft guidelines were made available to 986 invitedstakeholder individuals and organizations/societies and stakeholder feedback was considered by theguideline developers. In the final development process, the guideline development team used a consensusvoting process (GRADE) to assign strengths of recommendation. Strength of recommendations indicate theextent to which one can be confident that adherence to a recommendation will do more good than harm,and are indented to assist the health professional to prioritize interventions. The guideline includes 575explicit recommendations and/or research summaries for the following pressure ulcer topics: etiology;prevalence and incidence; risk assessment; skin and tissue assessment; preventive skin care; prophylacticdressings; microclimate control; fabrics and textiles; nutrition; repositioning and early mobilization; supportsurfaces; medical device related pressure ulcers; pressure ulcer classification; wound assessment; monitoringof healing; pain assessment and treatment; cleansing; debridement; wound dressings (including growthfactors and biological wound dressings); assessment and treatment of infection and biofilms; biophysicalagents (e.g. electrical stimulation, negative pressure wound therapy, electromagnetic field treatment); andsurgery. Additional sections address the specific needs of special populations including bariatric individuals,critically ill individuals, older adults, pediatric individuals, individuals in palliative care and individuals in theoperating room setting. The guideline includes sections to assist in implementing the guideline withinorganizations, including quality improvement strategies, quality indicators, health professional educationand recommendations to assist patient consumers. The guideline also includes the NPUAP/EPUAPInternational Pressure Ulcer Classification system, complete with full Category/Stage descriptions andillustrative photography.2