Prevention And Treatment Of Pressure Ulcers: Quick .
Prevention andTreatment ofPressure Ulcers:Quick ReferenceGuidePAN PACIFICPressure Injury Alliance NPUAP/EPUAP/PPPIA
Copyright National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Paneland Pan Pacific Pressure Injury AllianceISBN-10: 0-9579343-6-XISBN-13: 978-0-9579343-6-8First published 2009Second edition published 2014Published by Cambridge Media on behalf of National Pressure Ulcer Advisory Panel, EuropeanPressure Ulcer Advisory Panel and Pan Pacific Pressure Injury AlliancePAN PACIFICPressure Injury AllianceAll rights reserved. Apart from any fair dealing for the purposes of private study, research orreview, as permitted under the Copyright Act, no part may be reproduced or copied in any formor by any means without written permission. Requests to reproduce information can be emailed toadmin@internationalguideline.comSuggested citation:National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan PacificPressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. EmilyHaesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014.Disclaimer:This quick reference guide was developed by the National Pressure Ulcer Advisory Panel, the EuropeanPressure Ulcer Advisory Panel and the Pan Pacific Pressure Injury Alliance. It presents a comprehensivereview and appraisal of the best available evidence at the time of literature search related to theassessment, diagnosis, prevention and treatment of pressure ulcers. The recommendations in thisquick reference guide are a general guide to appropriate clinical practice, to be implementedby qualified health professionals subject to their clinical judgment of each individual case and inconsideration of the patient consumer’s personal preferences and available resources. The guideshould be implemented in a culturally aware and respectful manner in accordance with the principlesof protection, participation and partnership.Printed copies of the English version of this quick reference guide can be ordered, and PDFsdownloaded, from the following websites:NPUAPnpuap.orgEPUAPepuap.orgAustralian Wound Management Association (AWMA)awma.com.auHong Kong Enterostomal Therapists Association Societywww.etnurse.com.hkNew Zealand Wound Care Society (NZWCS)nzwcs.org.nzWound Healing Society Singaporewoundhealingsociety.org.sgInternational Pressure Ulcer Guidelineinternationalguideline.com NPUAP/EPUAP/PPPIA
INTRODUCTIONQUICK REFERENCE GUIDEINTRODUCTIONForewordThis Quick Reference Guide presents a summary of the recommendations and excerpts of the supporting evidencefor pressure ulcer prevention and treatment. The more comprehensive Clinical Practice Guideline version of theguideline provides a detailed analysis and discussion of available research, critical evaluations of the assumptions andknowledge of the field, and description of the methodology used to develop guideline. This Quick Reference Guideis intended for busy health professionals who require a quick reference in caring for individuals in the clinical setting.Users should not rely on excerpts from the Quick Reference Guide alone.The first edition of the guideline was developed as a four year collaboration between the National PressureUlcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP). In this second edition ofthe guideline, the Pan Pacific Pressure Injury Alliance (PPPIA) has joined the NPUAP and EPUAP. The goal of thisinternational collaboration was to develop evidence-based recommendations for the prevention and treatment ofpressure ulcers that could be used by health professionals throughout the world. An explicit scientific methodologywas used to identify and critically appraise all available research. In the absence of definitive evidence, expertopinion (often supported by indirect evidence and other guidelines) was used to make recommendations. Drafts ofthe recommendations and supporting evidence were made available to 986 invited stakeholders (individuals andorganizations) around the world. The final guideline is based on available research and the accumulated wisdomof the NPUAP, EPUAP, PPPIA and international stakeholders. In this edition of the guideline, a consensus votingprocess (GRADE) was used to assign a strength to each recommendation. The strength of recommendation identifiesthe importance of the recommendation statement based on potential to improve patient outcomes. It provides anindication to the health professional of the confidence one can have that the recommendation will do more goodthan harm, 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 on thefollowing websites:NPUAP website:www.npuap.orgEPUAP website:www.epuap.orgAustralian Wound Management Association (AWMA) website:www.awma.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, national and locallevel. We request citation as the source, using the following format:National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance.Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: OsbornePark, Western Australia; 2014. NPUAP/EPUAP/PPPIA1
QUICK REFERENCE GUIDEINTRODUCTIONLimitations and Appropriate Use of This Guideline Guidelines are systematically developed statements to assist health professional and patient consumer decisionsabout appropriate health care for specific clinical conditions. The recommendations may not be appropriate foruse in all circumstances.The decision to adopt any particular recommendation must be made by the health professional with considerationto available resources and circumstances of the individual patient. Nothing contained in this guideline is to beconsidered medical advice for specific cases.Because of the rigorous methodology used to develop this guideline, the Guideline Development Group membersbelieve that the research supporting these recommendations is reliable and accurate. Every effort has been madeto critically appraise the research contained within this document. However, we do not guarantee the reliabilityand 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 technology changerapidly and the recommendations contained in this guideline may be inconsistent with future advances. The healthprofessional is responsible for maintaining a working knowledge of research and technology advances that mayaffect his or her clinical decision making.Generic names of products have been used. Nothing in this guideline is intended as endorsement of a specificproduct.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; howevercommonly available safety and usage tips have been included. Adverse events reported in the included researchhave been reported in the evidence summaries and caution statements. All products should be used according tomanufacturer’s directions.Purpose and ScopeThe goal of this guideline is to provide evidence based recommendations for the prevention and treatment of pressureulcers that can be used by health professionals throughout the world. The purpose of the prevention recommendationsis to guide evidence based care to prevent the development of pressure ulcers and the purpose of the treatmentfocused recommendations is to provide evidence-based guidance on the most effective strategies to promote pressureulcer healing.The guideline is intended for the use of all health professionals, regardless of clinical discipline, who are involvedin the care of individuals who are at risk of developing pressure ulcers, or those with an existing pressure ulcer. Theguideline is intended to apply to all clinical settings, including hospitals, rehabilitation care, long term care, assistedliving at home, and unless specifically stated, can be considered appropriate for all individuals, regardless of theirdiagnosis or other health care needs. The sections of the guideline for Special Populations add further guidance forpopulation groups with additional needs, including those in palliative care, critical care, paediatric and operatingroom settings; bariatric individuals; individuals with spinal cord injury; and older adults. Additionally, the guidelinemay be used as a resource for individuals who are at risk of, or have an existing pressure ulcer, to guide awareness ofthe range of preventive and treatment strategies that are available. Prevention and treatment of mucosal membranepressure ulcers are beyond the scope of this guideline.2 NPUAP/EPUAP/PPPIA
QUICK REFERENCE GUIDEINTRODUCTIONGuideline DevelopmentThe full methodological process is outlined in the full Clinical Practice Guideline. The US National Pressure UlcerAdvisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance(PPPIA) collaborated to update the guidelines on the prevention and treatment of pressure ulcers and amalgamatethe previous edition of two guidelines (prevention and treatment) into one comprehensive clinical practice guideline.The guideline was produced by an interprofessional guideline development group (GDG) and numerous small workinggroups (SWGs), each consisting of representatives of the three development organizations.The first step in the guideline development process was identifying the new evidence. The GDG commissioned acomprehensive review of the literature on pressure ulcer prevention and treatment in several electronic databasesusing a sensitive search strategy. All retrieved references were screened by the GDG and methodologist on predetermined inclusion criteria and preliminary data extraction tables were completed. In a second step, the retrievedevidence was evaluated, and thereafter the full texts were divided according to topic and provided to the relevantSWGs. With the assistance of the methodologist, the SWG members conducted critical appraisals of the evidence,assigned a level of evidence to each study using a classification system adapted from Sackett (1997)1, and refined theevidence tables.The next stage was drafting the recommendations. Each SWG formulated conclusions about the body of availableevidence and developed recommendations that emerged from the evidence. Recommendations from the 2009 guidelinewere reviewed and revised based on insights from new evidence and an analysis of the current cumulative body ofevidence. The strength of the body of evidence was determined. This rating identifies the strength of cumulativeevidence supporting a recommendation. The SWGs summarized the evidence supporting each recommendation.Recommendations and evidence summaries were reviewed by the GDG and international stakeholders with finaldrafts approved by the GDG.The final stage involved determining the strength of each recommendation statement. Each individual who wasinvolved in the guideline development process was invited to review every recommendation and participate in a webbased consensus voting process in which strength of recommendations were assigned. The recommendation strengthrepresents the confidence a health professional can place in each recommendation, with consideration to the strengthof supporting evidence; clinical risks versus benefits; cost effectiveness; and systems implications.Guideline RecommendationsRecommendations are systematically developed statements to assist health professional and patient consumerdecisions about appropriate health care for specific clinical conditions. The recommendations may not be appropriatefor the use in all circumstances.The recommendations in this guideline are a general guide to appropriate clinical practice, to beimplemented by qualified health professionals subject to their clinical judgment of each individual caseand in consideration of the patient consumer’s personal preferences and available resources. The guidelineshould be implemented in a culturally aware and respectful manner in accordance with the principles ofprotection, participation and partnership.The guidance provided in the guideline should not be considered medical advice for specific cases. This book and anyrecommendations within are intended for educational and informational purposes only. Generic names of productsare provided. Nothing in this guideline is intended as an endorsement of a specific product. NPUAP/EPUAP/PPPIA3
INTRODUCTIONQUICK REFERENCE GUIDELevels of Evidence, Strengths of Evidence and Strengths ofRecommendationsFull explanation of the methodology is available in the full Clinical Practice Guideline. Individual studies were assigneda ‘level of evidence’ based on study design and quality, using a classification system adapted from Sackett (1989)2.Levels of EvidenceIntervention StudiesDiagnostic studiesPrognostic studiesLevel 1Randomized trial(s) with clearcut results and low risk of errorOR systematic literature reviewor meta-analysis according tothe Cochrane methodology ormeeting at least 9 out of 11quality criteria according toAMSTAR appraisal tool.Systematic review of high quality(cross sectional) studies accordingto the quality assessment toolswith consistently applied referencestandard and blinding.Systematic review of highquality (longitudinal)prospective cohort studiesaccording to the qualityassessment tools.Level 2Randomized trial(s) withuncertain results and moderateto high risk of error.Individual high quality (crosssectional) studies according tothe quality assessment tools withconsistently applied referencestandard and blinding amongconsecutive persons.A prospective cohort study.Level 3Non randomized trial(s) withconcurrent or contemporaneouscontrols.Non-consecutive studies, or studieswithout consistently appliedreference standards.Analysis of prognosticfactors amongst persons in asingle arm of a randomizedcontrolled trial.Level 4Non randomized trial(s) withhistorical controls.Case-control studies, or poor/ nonindependent reference standard.Case-series or case-controlstudies, or poor qualityprognostic cohort study,retrospective cohort study.Level 5Case series with no controls.Specify number of subjects.Mechanism-based reasoning, studyof diagnostic yield (no referencestandard).Not applicable.The full body of evidence supporting each recommendation was given a ‘strength of evidence’. A consensus votingprocess (GRADE) involving all the experts formally engaged in the guideline development was used to assign a ‘strengthof recommendation’ that indicates the confidence the health professional can have that the recommended practicewill improve patient outcomes (i.e., do more good than harm). The overall aim of the ‘strength of recommendation’is to help health professionals to prioritize interventions.Strengths of EvidenceAThe recommendation is supported by direct scientific evidence from properly designed and implementedcontrolled trials on pressure ulcers in humans (or humans at risk for pressure ulcers), providing statisticalresults that consistently support the recommendation (Level 1 studies required).BThe recommendation is supported by direct scientific evidence from properly designed and implementedclinical series on pressure ulcers in humans (or humans at risk for pressure ulcers) providing statisticalresults that consistently support the recommendation. (Level 2, 3, 4, 5 studies)CThe recommendation is supported by indirect evidence (e.g., studies in healthy humans, humans withother types of chronic wounds, animal models) and/or expert opinionStrengths of Recommendation 4Strong positive recommendation: definitely do itWeak positive recommendation: probably do itNo specific recommendationWeak negative recommendation: probably don’t do itStrong negative recommendation: definitely don’t it NPUAP/EPUAP/PPPIA
INTRODUCTIONQUICK REFERENCE GUIDETABLE OF CONTENTSForeword. 1Suggested Citation. 1Limitations and Appropriate Use of this Guideline. 2Purpose and Scope. 2Guideline Development. 3Guideline Recommendations. 3Levels of Evidence, Strengths of Evidence and Strengths of Recommendations. 4Guideline Developers. 7Acknowledgements. 9Sponsor Acknowledgements. 10BackgroundPrevalence and Incidence of Pressure Ulcers. 11International Npuap/Epuap Pressure Ulcer Classification System. 12Prevention of Pressure UlcersRisk Factors and Risk Assessment. 14Skin and Tissue Assessment . 15Preventive Skin Care. 17Emerging Therapies for Prevention of Pressure Ulcers. 18Interventions for Prevention & Treatment of Pressure UlcersNutrition in Pressure Ulcer Prevention and Treatment. 20Repositioning and Early Mobilization . 22Repositioning to Prevent and Treat Heel Pressure Ulcers. 26Support Surfaces.
The goal of this guideline is to provide evidence based recommendations for the prevention and treatment of pressure ulcers that can be used by health professionals throughout the world. The purpose of the prevention recommendations is to guide evidence based care to prevent the development of pressure ulcers and the purpose of the treatment
education on pressure ulcer prevention and treatment, Coloplast has published this quick-guide. This guide is intended for educational and informational purposes only. It contains key recommendations for the prevention and treatment of pressure ulcers, and will be helpful to health care professionals who are
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