Prevention And Treatment Of Pressure Ulcers: Clinical Practice Guideline
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
CLINICAL PRACTICE GUIDELINEINTRODUCTIONStrengths of Evidence and Strengths of RecommendationsFull explanation of the methodology is available in Appendix 1: Guideline Methodology. Individual studieswere assigned a ‘level of evidence’ based on study design and quality. The body of evidence supporting eachrecommendation was given a ‘strength of evidence’. A consensus voting process (GRADE) involving all theexperts formally engaged in the guideline development was used to assign a ‘strength of recommendation’that indicates the confidence the health professional can have that the recommended practice will improvepatient outcomes (i.e., do more good than harm). The overall aim of the ‘strength of recommendation’ is tohelp health professionals to prioritize interventions.Strengths of EvidenceThe recommendation is supported by direct scientific evidence from properly designed andAimplemented controlled trials on pressure ulcers in humans (or humans at risk for pressureulcers), providing statistical results that consistently support the recommendation (Level 1studies required).BThe recommendation is supported by direct scientific evidence from properly designed andimplemented clinical series on pressure ulcers in humans (or humans at risk for pressure ulcers)providing statistical results that consistently support the recommendation. (Level 2, 3, 4, 5studies)CThe recommendation is supported by indirect evidence (e.g., studies in healthy humans,humans with other types of chronic wounds, animal models) and/or expert opinionStrengths of Recommendation Strong positive recommendation: definitely do it Weak positive recommendation: probably do it No specific recommendation Weak negative recommendation: probably don’t do it Strong negative recommendation: definitely don’t itGuideline Websitehttp://www.internationalguideline.comThe guideline website will remain accessible during the interim period until the next guideline revision. TheQuick Reference Guideline, sponsor acknowledgement, and supportive documents to the guideline areavailable from the website.3
INTRODUCTIONCLINICAL PRACTICE GUIDELINETABLE OF CONTENTSForeword Suggested Citation .Limitations and Appropriate Use of this Guideline .Abstract .Strengths of Evidence and Strengths of Recommendations Guideline Website .Guideline Developers Acknowledgements .Sponsor Acknowledgements .Executive Summary 11223366910BackgroundThe Etiology of Pressure Ulcers .Prevalence and Incidence of Pressure Ulcers .International NPUAP/EPUAP Pressure Ulcer Classification System . .192644Prevention of Pressure UlcersRisk Factors and Risk Assessment Skin and Tissue Assessment .Preventive Skin Care .Emerging Therapies for Prevention of Pressure Ulcers 46687581Interventions for Prevention and Treatment of Pressure UlcersNutrition for Pressure Ulcer Prevention and Treatment .Repositioning and Early Mobilization .Repositioning to Prevent and Treat Heel Pressure Ulcers .Support Surfaces .Medical Device Related Pressure Ulcers .88102115118134Treatment of Pressure UlcersClassification of Pressure Ulcers Assessment and Monitoring of Healing . .Pain Assessment and Treatment .Wound Bed Preparation .Wound Care: Cleansing Wound Care: Debridement .Assessment and Treatment of Infection and Biofilms . .Wound Dressings for Treatment of Pressure Ulcers Biological Dressings for Treatment of Pressure Ulcers .Growth Factors for Pressure Ulcer Treatment Biophysical Agents in Pressure Ulcer Treatment Surgery for Pressure Ulcers .142148158169170173181195205206209223Special PopulationsBariatric Individuals Critically Ill Individuals .Older Adults .Individuals in the Operating Room . .Individuals In Palliative Care .Pediatric Individuals Individuals with Spinal Cord Injury .2362422482542602682764
CLINICAL PRACTICE GUIDELINEINTRODUCTIONImplementing the GuidelineFacilitators, Barriers and Implementation Strategy .Health Professional Education . .Patient Consumers and Their Caregivers . Quality Indicators for this Guideline .Further Research Needs .Glossary of Terms 286294299303313316AppendicesAppendix 1: Guideline Methodology .3325
INTRODUCTIONCLINICAL PRACTICE GUIDELINEGUIDELINE DEVELOPERSGuideline Development Group (GDG)NPUAPPamela Mitchell, MN, RN, PGDipWHTR (Wales)Clinical Nurse Consultant, Wound Management,Christchurch Hospital, Christchurch, New Zealand.Professor Emeritus, University of North Dakota Collegeof Nursing, Grand Forks, ND, USASiu Ming Susan Law, BScN, MScN, RN, RM,ETNurse Consultant (Wound Management), PrincessMargaret Hospital, Lai Chi Kok, Kowloon, Hong Kong.Janet Cuddigan, PhD, RN, CWCN, FAANAi Choo Tay, BN, Oncology Nursing, CWSDiane Langemo, PhD, RN, FAAN (NPUAP Chair)Associate Professor, University of Nebraska MedicalCenter College of Nursing, Omaha, NE, USASenior Nurse Clinician, Singapore General Hospital,Singapore, Republic of Singapore.Laurie McNichol, MSN, RN, GNP, CWOCN,CWON-APJapanese Society of Pressure Ulcers ObserverClinical Nurse Specialist/WOC Nurse, Cone Health,Greensboro, North Carolina, USAAssociate Professor, Department of Surgical Science,University of Tokyo, Tokyo, JapanJoyce Stechmiller, PhD, ACNP-BC, FAANMethodologist and Editor-in-ChiefAssociate Professor and Chair, Adult and ElderlyNursing, University of Florida, College of Nursing,Gainsville, FL, USAEPUAPLisette Schoonhoven, PhD (EPUAP Chair)Senior Researcher Nursing Science, Radboud UniversityMedical Center, Scientific Institute for Quality ofHealthcare, Nijmegen, The NetherlandsAssociate Professor, University of Southampton,Faculty of Health Sciences, UKTakafumi Kadono, MD, PhDEmily Haesler, BN, PGDipAdvNursingHonorary Associate, Department of Nursing andMidwifery, La Trobe University, Victoria, AustraliaVisiting Fellow, Academic Unit of General Practice,Australian National University, Canberra, AustraliaSmall Working Group (SWG) MembersBackgroundProfessor in Tissue Viability, Birmingham CityUniversity, Birmingham, UKDirector, Welsh Wound Network, Welsh WoundInnovation Centre, Pontyclun, Wales, UKEtiology: Cees Oomens (Leader), David Brienza,Laura Edsberg, Amit Gefen & Pang Chak Hau Prevalence and Incidence of Pressure Ulcers:Catherine Ratliff (Leader), Yufitriana Amir,Margaret Birdsong, Chang Yee Yee, Emily Haesler,Zena Moore & Lin PerryJan Kottner, PhDPrevention of Pressure UlcersMichael Clark, PhDScientific Director Clinical Research, Clinical ResearchCenter for Hair and Skin Science, Department ofDermatology and Allergy, Charité-UniversitätsmedizinBerlin, GermanyCees Oomens, PhD, IrAssociate Professor, Biomedical EngineeringDepartment, Eindhoven University of Technology,Eindhoven, The NetherlandsPPPIAKeryln Carville, PhD, RN (PPPIA Chair)Risk Factors and Risk Assessment: Jane Nixon(Leader), Katrin Balzer, Virginia Capasso, JanetCuddigan, Ann Marie Dunk, Claudia Gorecki, NancyStotts & Aamir Siddiqui Skin and TissueAssessment: Emily Haesler (Leader), Carina Bååth,Margaret Edmondson, Emil Schmidt & Ai Choo Tay Preventive Skin Care: Emily Haesler EmergingTherapies for Prevention: Kerrie Coleman(Leader), Teresa Conner-Kerr, Susan Law, AnnaPolak, Pamela Scarborough & Jakub TaradajProfessor, Primary Health Care and CommunityNursing, Silver Chain Group and Curtin University,Western Australia, Australia6
CLINICAL PRACTICE GUIDELINEInterventions for Prevention and Treatmentof Pressure UlcersINTRODUCTIONSpecial PopulationsNutrition in Pressure Ulcer Prevention andTreatment: Jos Schols (Leader), Mary EllenPosthauer, Merrilyn Banks, Judith Meijers, NancyMunoz & Susan Nelan Repositioning and EarlyMobilization: Zena Moore (Leader), BarbaraBraden, Jill Trelease & Tracey Yap Repositioningto Prevent and Treat Heel Pressure Ulcers: ZenaMoore (Leader), Barbara Braden, Jill Trelease &Tracey Yap Support Surfaces: Clarissa Young(Leader), David Brienza, Joyce Black, Sandra Dean,Liesbet Demarré, Lena Gunningberg & Cathy Young Medical Device Related Pressure Ulcers: Jill Cox(Leader), Liesbet Demarré, Tracy Nowicki & RaySamuriwoBariatric Individuals: Mary Ellen Posthauer(Leader), Jeannie Donnelly & Tracy Nowicki Critically Ill Individuals: Jill Cox (Co-leader), AngShin Yuh (Co-leader), Maarit Ahtiala, Paulo Alves, &Alison Stockley Older adults: Tracey Yap (Leader),Jill Campbell , Emily Haesler & Susan Kennerly Individuals in the Operating Room: David Huber(Leader), Steven Black, Ray Samuriwo, Susie ScottWilliams & Geert Vanwalleghem Individuals inPalliative Care: Trudie Young (Leader), WayneNaylor & Aletha Tippett Pediatric Individuals:Emily Haesler, Mona Baharestani, Carmel Boylan,Holly Kirkland-Walsh & Wong Ka Wai Individualswith Spinal Cord Injury: Emily Haesler (Leader),Amy Darvall, Bernadette McNally & Gillian PedleyTreatment of Pressure UlcersImplementing the GuidelineClassification of Pressure Ulcers: Emily Haesler(Leader), Carina Bååth, Margaret Edmondson, EmilSchmidt & Ai Choo Tay Assessment of PressureUlcers and Monitoring of Healing: Kerrie Coleman(Leader), Elizabeth Ong Choo Eng, Michelle Lee,Amir Siddiqui, Mary Sieggreen Pain: Assessmentand Treatment: Carrie Sussman (Leader), JaneNixon & Jan Wright Wound Care: Cleansing:Nicoletta Frescos (Leader), Mona Baharestani,Catherine Ratliff, Sue Templeton, Martin van Leen& David Voegeli Wound Care: Debridement: SueTempleton (Leader), Mona Baharestani, NicolettaFrescos, Catherine Ratliff, Martin van Leen & DavidVoegeli Assessment and Treatment of Infectionand Biofilms: Judith Barker (Leader), VirginiaCapasso, Erik de Laat & Wan Yin Ping WoundDressings for Treatment of Pressure Ulcers: Erik deLaat (Leader), Michelle Deppisch, MargaretGoldberg, Yanting Quek, Jan Rice & Quek Yan Ting Biological Dressings: Laura Edsberg (Leader),Kumal Rajpaul & Colin Song Growth Factors:Laura Edsberg (Leader), Kumal Rajpaul & Colin Song Biophysical Agents for Treatment: KerrieColeman (Leader), Teresa Conner-Kerr, Anna Polak,Pamela Scarborough, Maria ten Hove & JakubTaradaj Surgery for Pressure Ulcers: AamirSiddiqui (Leader), Emily Haesler & Kok Yee OnnFacilitators, Barriers and ImplementationStrategy: Dimitri Beeckman (Leader), NancyEstocado, Morris Magnan, Joan Webster, DorisWilborn & Daniel Young Heath ProfessionalEducation: Dimitri Beeckman (Leader), NancyEstocado, Morris Magnan, Joan Webster, DorisWilborn & Daniel Young Patient Consumers andTheir Caregivers: Nancy Stotts (Leader), Winnie SiuWah Cheng, Michael Clark, Liesbet Demarré,Rebekah Grigsby & Emil Schmidt QualityIndicators: Ruud Halfens (Leader), Anne Gardner,Heidi Huddleston Cross, Edel Murray, Lorna Semple& Mary SieggreenFurther Research NeedsKeryln Carville, Michael Clark, Janet Cuddigan,Emily Haesler, Jan Kottner, Diane Langemo, SusanLaw, Laurie McNichol, Pamela Mitchell, CeesOomens, Lisette Schoonhoven, Joyce Stechmiller,Ai Choo Tay7
INTRODUCTIONCLINICAL PRACTICE GUIDELINEACKNOWLEDGEMENTSAcknowledgement & In Kind SupportTranslationSpecial acknowledgement and thanks to the 2009Guideline Development Group and Small WorkingGroup members from NPUAP and EPUAP whodeveloped the first edition of this guideline. Thework in this second guideline edition builds onresearch that was appraised and summarized bythe 2009 guideline development team.The following experts from the Clinical ResearchCenter for Hair and Skin Science, Department in Berlin, Germany completedtranslation and data extraction for papers inlanguages other than English:Claudia Richter, MAVera Kanti, MDEva Katharina Barbosa Pfannes, PhDJan Kottner, PhDJanet Cuddigan, PhD, RN, CWCN, FAAN, InterimMethodologist (literature update, review andanalysis during the interim between formalguideline development activities [2009 to 2012])Lisette Schoonhoven, PhD (lead organizer andconvener of the Guideline Development Group)Kandis McCafferty, PhD, RNC-OB (preliminaryevidence tables)Paul Haesler, BSc(Hons) (web development and ITsupport)College of Nursing, University of Nebraska MedicalCenter, Omaha, NE, USA (professional,organizational and IT support)StakeholdersSpecial thanks to the many stakeholders whoreviewed the guideline processes and drafts. Allstakeholder comments were reviewed by theGuideline Development Group and revisions weremade based on the comments received. Weappreciate the investment of health professionals,researchers, educators and manufacturers fromall over the world who took time to share theirexpertise and thoughtful critique.McGoogan Library, University of NebraskaMedical Center, Omaha, NE, USA (consultation ondatabase searches, journal access and interlibraryloan services)La Trobe University, Melbourne, Victoria, Australia(database and journal access and interlibrary loanservices)Academic Unit of General Practice, AustralianMedical School, Australian National University,Canberra (professional and IT support)Special thanks go to Emily Haesler who did anextraordinary job in managing the complexities ofan international, comprehensive, systematicreview of the research literature and developmentof this revised and expanded guideline on pressureulcer prevention and treatment.8
CLINICAL PRACTICE GUIDELINEINTRODUCTIONSPONSOR ACKNOWLEDGEMENTSThe National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) andthe Pan Pacific Pressure Injury Alliance (PPPIA) gratefully acknowledge the contributions of the followingindividuals and groups for financially supporting the presentation and dissemination of the guideline. Allfinancial contributions were made after the guideline development phase and in no way influenced thedevelopment of the guideline or its final content. Financial contributions are being used for the printing anddissemination of the guideline and associated educational products. The following companies providedunrestricted education grants:Diamond Level SponsorsEHOB, Inc.Smith & Nephew PLCPlatinum Level SponsorsArjoHuntleigh Inc.Mölnlycke Health CareGold Level SponsorsSage Products LLC9
EXECUTIVE SUMMARYCLINICAL PRACTICE GUIDELINEEXECUTIVE SUMMARYSignificancePressure ulcers are a frequently occurring health problem throughout the world. They are painful, costly, andan often preventable complication for which many individuals are at risk.Around the world, pressure ulcer prevalence in health care settings ranges from 0%1 to 72.5%,2 with largevariations observed between different countries and clinical settings (e.g., acute care, aged care andcommunity care). Average prevalence in acute care settings is cited as approximately 10%.3 In general acutecare, there appears to be a gradual and ongoing decline in pressure ulcer prevalence over the past decade,4driven in part by growing international health policy focus on prevention of pressure ulcers. However, thereare no clear trends in other clinical settings. Prevalence and incidence rates are generally higher in uniquepopulations who are at elevated risk, such as those receiving palliative care,3 those with spinal cord injuries,5neonates and infants,6, 7 and individuals in critical care.8, 9Pressure ulcers represent a major burden of sickness and reduced quality of life for patient consumers andtheir care givers.10-16 Increased morbidity and mortality associated with pressure ulcer development inhospitalized patients is documented in multiple studies.10, 11, 17 Hospital lengths of stay, readmission rates,and hospital charges are greater in individuals who develop a pressure ulcer than in those remaining ulcerfree.18-20 The development of a single pressure ulcer in hospitals in the United States (US) can increase thepatient’s length of stay five-fold.17 Additionally, the personal burden associated with a chronic wound,including pain and discomfort;21, 22 stress, anxiety and depression;10-12 lowered autonomy and security; andimpaired social functioning11 is immeasurable.Pressure ulcers increase hospital costs significantly. In the US, pressure ulcer care is estimated to approach 11 billion (USD) annually,23-25 with a cost of between 500 (USD) and 70,000 (USD) per individual pressureulcer.23, 25, 26 European cost models highlight that the cost of illness associated with pressure ulcers consumesup to 1.4% of health care expenditure in the Netherlands27, 28 or between 362 million and 2.8 billionannually.28 In the United Kingdom (UK) pressure ulcers cost up to 4% of the annual health care budget 29 (or 750 million annually26) with expenses estimated at 30,000 per individual pressure ulcer.26 Whencommunity health care costs are added to hospital costs, pressure ulcers consume up to 2.1 billion of theNational Health Service (NHS) budget.30 In Australia, associated opportunity cost related to increased hospitallength of stays arising from development of pressure ulcer is an estimated mean 285 million (AUD).26Purpose and ScopeThe goal of this guideline is to provide evidence based recommendations for the prevention and treatmentof pressure ulcers that can be used by health professionals throughout the world. The purpose of theprevention recommendations is to guide evidence based care to prevent the development of pressure ulcersand the purpose of the treatment focused recommendations is to provide evidence-based guidance on themost effective strategies to promote pressure ulcer healing.The guideline is intended for the use of all health professionals, regardless of clinical discipline, who areinvolved in the care of individuals who are at risk of developing pressure ulcers, or those with an existingpressure ulcer. The guideline is intended to apply to all clinical settings, including hospitals, rehabilitationcare, long term care, assisted living at home, and unless specifically stated, can be conside
INTRODUCTION CLINICAL PRACTICE GUIDELINE 2 Limitations and Appropriate Use of This Guideline Guidelines are systematically developed statements to assist health professional and patient consumer decisions about appropriate health care for specific clinical conditions. The recommendations may not be appropriate for use in all circumstances.
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
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
prevention of substance misuse. This "prevention set-aside" is managed by the Center for Substance Abuse Prevention (CSAP) in SAMHSA and is a core component of each state's prevention system. On average, SAPT Block Grant funds make up 68% of primary prevention funding in states and territories. In 21 states, the prevention set-aside .
Intrusion Prevention: Signature Policies 201 Intrusion Prevention: Signature Policies - New 203 Intrusion Prevention: Sensors 204 Intrusion Prevention: Sensor - New 205 Intrusion Prevention: Sensor - Associating Sensor to a Firewall Policy 206 Intrusion Prevention: Alerts and Reports 208 Intrusion Prevention: View Rule File 210
The sequence of treatment processes through which wastewater passes is usually characterized as: 1. Preliminary treatment 2. Primary treatment 3. Secondary treatment 4. Tertiary treatment This discussion is an introduction to advanced treatment methods and processes. Advanced treatment is primarily a tertiary treatment.
The sequence of treatment processes through which wastewater passes is usually characterized as: 1. Preliminary treatment 2. Primary treatment 3. Secondary treatment 4. Tertiary treatment This discussion is an introduction to advanced treatment methods and processes. Advanced treatment is primarily a tertiary treatment.
9 in 10 Canadians will develop high blood pressure or hypertension during their lives. One in three Canadians who have hypertension would have normal blood pressure if they consumed less sodium in their diets. Women with high blood pressure have a 3.5-times greater risk of developing heart disease than women with normal blood pressure.1File Size: 4MBPage Count: 28Explore further2017 Guideline for High Blood Pressure in Adults .www.acc.orgCombination Drug Treatment for High Blood Pressure - WebMDwww.webmd.comAntihypertensive Medication Chart: Drug Classes, List of .www.ezmedlearning.comList of 213 High Blood Pressure (Hypertension . - Drugs.comwww.drugs.comJNC 8 Hypertension Guideline Algorithm Initial Drugs of .www.umpquahealth.comRecommended to you b
Earth Pressure (P) 8 Earth pressure is the pressure exerted by the retaining material on the retaining wall. This pressure tends to deflect the wall outward. Types of earth pressure: Active earth pressure or earth pressure (Pa) and Passive earth pressure (P p). Active earth pressure tends to deflect the wall away from the backfill.File Size: 1MBPage Count: 55
