FOURTEENTH ANNUAL EUROPEAN PRESSURE ULCER ...

FOURTEENTH ANNUAL EUROPEAN 

PRESSURE ULCER 

ADVISORY PANEL MEETING 

Theme: 

Pressure ulcer achievements translated to clinical guidelines 

EXPONOR Congress Center, Oporto, Portugal 

31st August to 2nd September 2011

European Pressure Ulcer Advisory Panel 

Mission Statement 

The European Pressure Ulcer Advisory Panel’s objective is to provide the relief of 

persons suffering from, or at risk of pressure ulcers, in particular through research 

and education of the public. 

EPUAP Scientific Committee 

Trudie Young UK 

Amit Gefen Israel 

Paulo Alves Portugal 

Nils Lahmann Germany 

Marco Romanelli Italy 

Executive Committee 

Cees Oomens President,The Netherlands 

Michael Clark President-elect UK 

Trudie Young Recorder, UK 

Chair Scientific Committee 

Amit Gefen Deputy Recorder, Israel 

Vice-chair Scientific Committee 

George Cherry Treasurer, UK 

Christina Lindholm Chair PR Membership Committee Sweden 

Trustees 


Dan Bader UK 

Zita Kis Dadara Austria 

Eric De Laat The Netherlands 

Lena Gunningberg Sweden 

Jan Kottner Germany 


Jane Nixon UK 

Anna Polak Poland 


Jos Schols The Netherlands 

Geert Vanwalleghem Belgium 

EPUAP Office 

Administrative Staff 

Christine Cherry UK 

Margaret Hughes UK 

email: epuap@aol.com 

Address 14 Aston Street 

Oxford OX45 1EP 

Tel & Fax +44 (0)1865 791725 

www.epuap.org 

EPUAP Commercial Exhibitors and Sponsors 2011 

Advancis 

AOTI 

ArjoHuntleigh 

Care of Sweden 

Danone (Nutricia) 

EWMA 

FlenPharma 

Hartmann 

Hill-Rom 

Invacare 

KCI 

Molnlycke 

Polymem 

Redactron 

Sage Products 

Smith & Nephew 

Stryker Medical 

Wounds UK 

XSENSOR





















Trustees 


Dan Bader UK 






Jane Nixon UK 





EPUAP Office 







Tel & Fax +44 (0)1865 791725 

www.epuap.org

Dear conference Delegate, 

Welcome to Oporto 

It is with great pleasure on behalf of the European Pressure Ulcer Advisory Panel to welcome 

you to the 14th Annual Conference. This year’s theme is 

“Pressure Ulcer Research Achievements Translated to Clinical Guidelines” 

We are very pleased that you have chosen to join our conference, here in the extreme 

southwest of Europe, at Oporto - Portugal. Located along the Douro river estuary in northern 

Portugal, Oporto is one of the oldest European centres and it is a striking combination of 

the old and the new. Big lodges of port wine can be visited and delegates can enjoy a glass 

facing the sightseeing of the UNESCO World Heritage Site since 1996. 

During these three days, Oporto is the center of knowledge in pressure ulcers. Experts, 

clinicians and researcher’s from all over the world will be able to share their practice and new 

evidences in this field. As we gather people from many different countries, we hope to reflect 

multiple different perspectives to prevent and treat pressure ulcers. 

This year’s program was developed with the objective of correlating new achievements, 

implementation and how to translate them to clinical guidance, with speakers from 20 

different countries. The program contains a wide variety of themes; basic science and clinical 

practice are divided evenly throughout the program, topics such as scientific developments 

in pressure ulcers, pediatric population, and financial burden resurgence ulcer innovations, 

between others. 

In addition to the main program there will be 

three Pressure ulcer classification work shops, nine excellent free paper/oral sessions, a 

student paper competition and the new Novice and Established Investigator Award 

The role of industry in supporting this conference is very evident, with a wide variety of 

companies, allocated just in the center of the venue, in the center of all action. There will be 

four company symposia and for the first time “Meet the Industry Sponsors” a space for 

interaction between companies and delegates. 

To try to reduce the stress of our working days, the Gala Dinner will be served in a relaxed 

atmosphere on the waterfront, where you can enjoy the sunset, and magnificent views of the 

sea. Traditional Portuguese food and wine will be served, and music will be playing, during 

the dinner. 

We hope the scientific programme will increase your networking, your knowledge, and 

contribute to the improvement of the quality care. 

Enjoy your stay in Oporto. 

Paulo Alves, Local Organiser on behalf of the Scientific Committee 

1

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14th EPUAP 14th Open EPUAP Meeting, Open Meeting, Oporto, Porto, Portugal 

Auditorium Exhibition 

area 

Opening session and 

Pressure Ulcers the 

clinical and financial 

problem 

Investigator awards - 

Established 

investigator and 

Novice Investigator 

Awards 

Programme at a glance 

Lunch 

Programme at a glance 

Wednesday August 31st 

Poster viewing 

Coffee 

Drinks 

Reception 

Room A4 Room B4 Room HT 

Registration and Poster set-up 

End of Day 1


area 

0830 Coffee 

0900 

0930 

1000 

1030 

Pressure ulcers - 

scientific developments 

1100 Coffee 

1130 

1200 

1230 

1300 

1330 

1400 

1430 

1500 

Pressure ulcer 

assessment and 

treatment 

Lunch 

1530 Coffee 

1600 

1630 

1700 

1730 

Pressure ulcers in the 

paediatric population 

Free papers IV 

Thursday September 1st 


KCI Symposium 

Meet the Industry 

Sponsors 

HillRom 

symposium 

Stryker 

symposium 

Student paper 

competition I 

Free Papers I Pressure ulcer 

classification 

workshop 

EPUAP AGM 

Free papers II RCT workshop 

Student paper 

competition II 

1800 End of Day and Conference Dinner at 2000 

Free papers III

0900 

0930 

1000 


area 

Pressure ulcers - 

repositioning 

1030 Coffee 

1100 

1130 

1200 

1230 

1300 

1330 

1400 

1430 

1500 

1530 

1600 

1630 

1700 


debridement 

revisited 


innovations and 

guideline 

implementation 


innovations - the 

future 

Lunch 

Coffee 

Friday 2nd September 


Free papers V Oral poster 

session I 

Smith & 

Nephew 

symposium 

Oral poster 

session II 

Pressure ulcers 

quality of life 

1730 Presentation of EPUAP 2012 and Close of conference 

Free papers VI 

Free papers VII 



workshop

Programme 

Fourteenth Annual European Pressure Ulcer Advisory Panel Meeting 

31st August - 2nd September, 2011 

Exponor Congress Centre, Oporto-Portugal 

Theme: Pressure Ulcer Research Achievements 

Translated to Clinical Guidelines 

Wednesday, August 31st 

9.00 – 13.00 Registration - ground floor 

Exhibition Hall area 

9.00 – 13.00 Setting up of posters 

Sala A7 

9.00 – 13.00 Check in Powerpoint presentations to Audio Visual staff 

12.00 – 13.00 Lunch 

Auditorium 

13.00 – 13.15 Opening ceremony 

Chair - Professor Cees W.J. Oomens, The Netherlands, 

President of EPUAP 

Theme - Pressure ulcers the clinical and financial problem 

13.15 – 13.45 Epidemiology of pressure ulcers in Portugal – the current position 

Mr Paulo Alves, Gaia, Portugal 

13.45 – 14.15 Pressure ulcers: the economic impact 

Professor Jose Verdu Soriano , Spain 

14.15 – 14.45 Economic evaluation of prevention of pressure ulcers in intensive 

care units. 

Dr Melanie Andrade, Portugal 

11

Wednesday, August 31st 

14.45 – 15.15 The economic impact of repositioning to prevent pressure ulcers 

Dr Zena Moore, Dublin, Ireland 

15.15 – 16.00 Poster viewing in Exhibition area 

16.00 – 16.45 Coffee and exhibition viewing, Exhibition area 

16.45 – 17.15 Introduction to the investigator awards 

Professor Amit Gefen, Israel (Chair) 

17.15 – 17.45 EPUAP Established Investigator Award Lecturer 

Pressure Ulcers - Can biomechanical research inform 

clinical practice? 

Professor Dan Bader, Southampton, UK 

17.45 – 18.15 EPUAP Novice Investigator Award: 

Pressure Ulcer Prevention: Evidence-Based tool development and 

tailored protocol implementation to improve clinical practice 

Dr Dimitri Beeckman, London, UK 

18.30 – 19.30 Welcome drinks reception and official exhibition opening 

Exhibition area 

13

Morning sessions 

Thursday, September 1st 

08.30 Coffee and exhibition viewing 

Auditorium 

Theme – Pressure ulcers – scientific developments 

Chair – Mr Geert Vanwalleghem, Professor Dan Bader 

9.00 – 9.40 Mathematical models to describe wound healing and wound contraction 

Professor Fred Vermolen, Delft, The Netherlands 

9.40 – 10.20 Wound models in monolayer cell cultures, quantitative analysis of 

cell kinematics 

Professor Amit Gefen, Tel Aviv, Israel 

10.20 – 11.00 Using MR elastography to map changes in muscle and other tissues due to 

mechanical loading and disease 

Professor Lynne Bilston, New South Wales, Australia 

Room A4 

9.00 – 10.30 KCI Symposium 

A new chapter in pressure ulcer prevention and treatment; 

the Skin IQ microclimate manager 

Chairs: Professor Joyce Black, Professor Michael Clark, 

09.00 – 09.10 An introduction to skin-microclimate and how it influences skin integrity 

Michael Clark 

9.10 – 9.30 Negative airflow technology for microclimate management; pre-clinical data 

Joyce Black 

09.30 – 09.50 Skin IQ Microclimate Manager, results of a pilot study on 43 hospital 

patients with moisture issues in Germany 

Nils Lahmann 

09.50 – 10.05 Skin IQ microclimate management in pressure ulcer prevention 

and treatment 

Eddy Koopman: 

10.05 – 10.20 Beyond pressure ulcers; the beneficial effects of moisture contro in 

vulnerable patients 

Jacques Neyens: 

10.20 – 10.30 Interactive discussion and Q and A 

Closure 10.30 

11.00 – 11.30 Coffee and exhibition viewing 

15


Parallel sessions 

Room A4 

Chairs Ms Zita Kis Dadara, Ms Trudie Young 

11.30 – 12.30 Brief Industrial introductions 

Hill-Rom 

Stryker 

Ferris (Polymem) 

Sage Products 

Invacare 

Nutricia 

Molnlycke 


Flen Pharma 

ArjoHuntleigh 

Room A4 

12.30 – 14.00 Hill Rom Workshop 

Developments in microclimate management 

Room B4 

Chair – Dr Anna Polak, Professor Marco Romanelli 

12.30 – 13.30 Free papers 1 

Care of Pressure Ulcers in Palliative Care Individuals 

Diane Langemo, USA 

Pressure Ulcers in a Post Disaster Setting: Benefits of Advanced 

Wound Care Techniques 

Joanna Cherry and Jason Miller, Haiti 

Epidemiology, diagnosis and management of infected chronic wounds 

Armand Rondas, The Netherlands 

Characterization of patients with pressure ulcers of the neurological 

clinical: a path to prevention 

EEC Moura, Brazil 

Room Henry Tillo (HT) 

Chair Mr Paulo Alves 

12.30 – 13.30 Pressure Ulcer Classification workshop (Portuguese) 

13.30 – 14.30 Lunch and exhibition viewing 

17


Room HT 

13.30 – 13.45 EPUAP Annual General Meeting 

Afternoon sessions 

Auditorium 

Announcement of poster winner 

Theme – Pressure ulcer assessment & treatment 

Chair – Professor Christina Lindholm, Professor Jos Schols 

14.30 – 15.00 Pressure ulcer assessment 

Professor Marco Romanelli, Pisa, Italy 

15.00 – 15.30 Tissue engineered skin for pressure ulcer treatment and repair 

Dr Christianne Reijnders, Amsterdam, The Netherlands 


Room HT Chair – Professor Jane Nixon 

14.30 – 15.30 Randomised controlled trial workshop: Design considerations in RCTs 

and case study series 

Professor Jane Nixon, Leeds, England 

Room A4 

14.30 – 16.00 Stryker symposium 

Is it a pressure ulcer? SCALE & SOPE: Consensus & Cases 

Room B4 

14.30 – 15.30 Free papers 2 

Chair – Dr Lena Gunningberg, Dr Jan Kottner 

A 3-in-1 perineal care washcloth impregnated with dimethicone 3% 

vs. water and pH neutral soap to prevent and treat incontinenceassociated 

dermatitis: a randomized controlled clinical trial 

Dimitri Beeckman, UK 

Moisture Related Skin Excoriation: a retrospective review of 

assessment and management across 5 Glasgow hospitals 

Janice Bianchi, UK 

14.30 – 15.30 Skin the Greatest Organ. Back to the Essentials Using Millennium 

Technology 

Tracy Nowicki, Australia 

Pressure ulcers: damned by the data, 

Jacqui Fletcher, UK 


19



Auditorum 

Chair – Professor Marco Romanelli, Dr Anna Polak 

Theme – Pressure ulcers in the paediatric population 

16.00 – 16.20 From the neonate to the young person – the development of the skin. 

Dr Ana Garrido, Portugal 

16.20 – 16.40 Prevention of pressure ulcers in paediatric care 

Dr Guido Ciprandi, Rome, Italy 

16.40 – 17.00 Validation and implementation of Braden Q 

Mrs Cristina Miguens, Portugal 

Room A4 

Chair Professor Amit Gefen , Professor Christina Lindholm 

17.00 – 18.00 Student Paper competition 1 

Pressure ulcer prevalence in critically ill patients: Nursing care, 

Hospital facilities, and the prevalence of pressure ulcers in Jordanian 

Intensive Care Units 

Rana Al Awamleh, UK 

Heel Pressure Ulcers: a study of wound healing 

Elizabeth McGinnis, UK 

Relationship Between “Tilt in Space” Wheelchair Function and Risk of 

Pressure Ulcer Development 

Christian Olesen, Denmark 

Room B4 


Chair – Professor Michael Clark, Ms Zita Kis Dadara 

Pressure ulcer prevention in Ghana – What is the nurses’ knowledge? 

Amanda Jonsson, Sweden 

With or without a risk assessment scale? An evaluation of the Impact 

of the Braden Scale on allocation of preventive interventions to 

traumatological patients 

Sylvia Mallison, Germany 

21


Room HT 

17.00 – 18.00 Free papers 3 

Chair – Dr Elia Ricci, Dr Lisette Schoonhoven 

TexiSense « Smart Sock » - Textile Pressure Sensor and 3D Realtime 

Finite Element Model of the Diabetic Foot for a Daily Prevention 

of Pressure Ulcers 

Marek Bucki, France 

Energy expenditure and balance in pressure ulcer patients: a 

systematic review and meta-analysis of observational studies 

Emanuele Cereda, Italy 

A Different Type of Expertise; patient and public involvement in 

pressure ulcer research 

Delia Muir, UK 

Auditorium 

Chair – Professor Jos Schols, MsTrudie Young 

17.00 – 18.00 Free papers 4 

System for pressure sore prevention: a user-centered design 

Yohan Payan, France 

The first national pressure ulcer prevalence study in Sweden 

Ami Hommel, Sweden 

Preventable hospital-acquired pressure ulcer prevalence in Western 

Australian Public Hospitals: Serial data 2007 – 2009 

Jenny Prentice, Australia 

Pressure Ulcer Prevalence Reductions Seen from the International 

Pressure Ulcer Prevalence Survey 

Charlie Lachenbruch, USA 

20.00 Conference dinner with entertainment and dancing, presentation 

of poster winner, novice and established investigator awards by 

the President of EPUAP. Coach transportation will be provided 

from the Congress Centre from 19h30 to the dinner, and for 

return afterwards 

23

Morning sessions 


Friday, September 2nd 

Auditorium 

Chair – Dr Lisette Schoonhoven, Professor Michael Clark 

Theme – Pressure ulcers - repositioning 

09.00 – 09.15 Biomechanics of the heel 

Professor Amit Gefen, Israel 

09.15 – 9.35 Pressure ulcer prevention: Different lying positions and their effects on 

tissue blood flow and skin temperature in elderly patients while lying 

on a pressure reducing mattress. 

Dr Ulrika Kallman, Boras, Sweden 

09.35 – 10.05 Repositioning the clinical perspective 

Mr Paulo Alves, Gaia, Portugal 

10.05 – 10.20 The effectiveness of repositioning in preventing pressure ulcers 

Dr Katrien Vanderwee, Belgium 

Room B4 

Chair – Dr Erik Delaat, Professor David Gray 

9.00 – 10.15 Oral poster session 1 

Poster #1 Incidence of Pressure Ulcers in a unit of clinical surgery after 

establishment of a prevention protocol 

Cleide Baptista, Brazil 

Poster #2 Evaluation of the implementation of Braden scale agreement between 

observers 

Cleide Baptista, Brazil 

Poster #3 Wound bed preparation with an enzyme alginogel in the treatment of 

pressure ulcers category 4 

Kris Bernaerts, Belgium 

Poster #6 Wound dressing shear test method (bench) providing results 

equivalent to Humans 

Evan Call, USA 

Poster #7 An instrumental indenter for measurement of pressure distribution in 

wheelchair cushions 


Poster #27 Clinical cases evaluation of a continuous and reactive pressure range 

of mattesses in the prevention of pressure ulcers in pediatric patients 

Leticia Munoz, 

25


Poster # 8 Wound Commission of Oporto’s Centro Hospitalar do Porto – What 

we do and how we do it 

Rui Morais Carvalho 

Poster # 11 Vacuum Therapy on Sacral pressure ulcer – case study 

Rui Pedro Da Silva, Portugal 

Room A4 

Chair – Professor Jane Nixon, Professor Dan Bader 

9.00 – 10.15 Free Papers 5 

Development and Effectiveness of a Pediatric Pressure Ulcer 

Prevention Bundle 

Ann-Marie Nie, USA 

Factors Influencing the Development of Pressure Ulcers in Neonatal 

and Pediatric Patients 


Effective pressure ulcer care in a specialized spinal cord injury 

rehabilitation department 

Ora Pilo, Israel 

The incidence rate of occipital pressure ulcers in adults at 5 intensive 

care units 

Nancy Van Genechten, Belgium 

Room HT 

Chair – Ms Trudie Young 

9.00 – 10.15 Pressure Ulcer Classification workshop (English) 


Parallel Sessions 

Auditorium 

Chair – Dr Lena Gunninberg, Mr Geert Vanwalleghem 

Theme – Pressure ulcer debridement revisited 

11.00 – 11.15 Debridement revisited 

Ms Trudie Young, UK 

11.15 – 11.30 Debridement and biofilms 

Professor Christina Lindholm, Sweden 

11.30 – 11.45 Debridement with larval therapy 

Dr Gwendolyn Cazander, The Netherlands 

11.45 – 12.15 Mechanical and ultrasonic debridement 

Professor David Gray, Scotland 

27


Room B4 

11.00 – 12.00 Free Papers 6 

Chair – Dr Dimitri Beeckman , Professor Jose Verdu Soriano 

Wound Dressings, Measuring the Microclimate they Create 


Body weight and pressure ulcer occurrence 

Jan Kottner, Germany 

Role of Mechanical Loading in the Aetiology of Deep Tissue Injury 

Cees Oomens, Netherlands 

Wound bed preparation with an enzyme alginogel in the treatment of 



Room A4 

11.00 – 12.30 Smith & Nephew Symposium 

Reducing the human and economic cost of pressure ulcers 

Chair – Kátia Furtado 

Reducing the human impact and the economic cost in prevention 

and treatment 

Joan Enric Torra I Bou, Spain 

Infection Control in pressure ulcers 

Paulo Alves, Portugal 

Skin care and negative pressure wound therapy 

Ester Malcato 

12.00 – 13.30 Lunch and exhibition viewing 

Friday, September 2nd. Afternoon sessions 


Auditorium 

Theme - Pressure ulcer innovations and guideline implementation 

Chair Professor Jose Verdu Soriano, Dr Erik Delaat 

13.00 – 13.30 The implementation of innovation in clinical practice 

Dr Lisette Schoonhoven, The Netherlands 

13.30 – 14.00 Pressure ulcer prevention and treatment guideline 

implementation process 

Dr Betsie van Gaal, The Netherlands 

14.00 – 14.30 The implementation of NPUAP/EPUAP guidelines on a national level 

in Sweden 

Dr Lena Gunningberg, Sweden 

29


Room A4 

Chair – Professor David Gray, Dr Elia Ricci 

13.00 – 14.00 Poster oral session 2 

Poster # 12 e-learning and PU: Supporting best practice development 

Wendy Davies, UK 

Poster # 15 Professional ethics in the treatment of pressure ulcers, a nursing work 

FJ Hernandez, Gran Canaria, Spain 

Poster # 19 The therapeutic use of Aloe Vera in pressure ulcers 

Juan Fernando Jimenez Diaz, Gran Canaria, Spain 

Poster # 28 Local Hyperbaric Oxygen therapy - Case study 

Rosa Maria Nascimento, Portugal 

Poster # 29 Prescribing beds: Electric profiling beds will reduce pressure injuries! 


Poster # 33 Is the education of the ‘informal caregiver’ necessary to prevent the 

appearance of pressure ulcers? 

MP Quintana, Spain 

Poster # 36 Multiple lesions in person with scleroderma and severe pulmonary 

hypertension: application of dressing with honey – Case study 

Cecilia Rodrigues, Spain 

Poster # 39 Pressure distribution properties of the cushions using shear-stress 

relief foam 

MakikoTanaka, Japan 


Room A4 Chair Dr Jan Kottner, Professor Katrien Vanderwee 

Theme - Pressure ulcers quality of life 

14.00 – 14.15 Final version of PU-QOL: a patient-reported outcome measure of 

health-related quality of life for patients with pressure ulcers 

Claudia Gorecki, UK 

14.15 – 14.30 Pressure ulcer pain prevalence in community populations 

prevalence survey 

Jane Nixon 

14.30– 14.45 Do organisations cause pressure ulcers 

Lisa Pinkney, UK 

14.45 – 15.00 A systematic review of pressure ulcer risk factors 

Susanne Coleman, UK 

31


Room B4 

Chair – Mr Geert Vanwalleghem, Dr Dimitri Beeckman, 

14.00 – 15.00 Free papers 7 

Pressure ulcer care in Dutch and German nursing homes: a 

comparison of nurses’ knowledge and patient characteristics 

Ruud Halfens, The Netherlands 

Collaborative working of providers and commissioners, in the 

development and delivery of an integrated healthcare economy wide 

pressure ulcer pathway 

Jacqueline Warner, UK 

Implementation of the German Expert Standard Pressure Ulcer 

Prevention and Nosocomial Pressure Ulcers – A Multi-Level-Analysis 

Doris Wilborn, Germany 

The development and re-development of an electronic Pressure Ulcer 

Notification Tool (PUNT) for use within an NHS Acute Healthcare 

setting. 

Mark Collier, UK 


Auditorium 

Theme - Pressure ulcer innovations – the future 

Chair Professor C Oomens 

15.30 – 16.00 The role of neuromuscular electrical stimulation in pressure 

ulcer prevention 

Dr Kath Bogie, Cleveland, USA 

16.00 – 16.30 The role of the microclimate in new innovations 

Professor Michael Clark, Wales, UK 

16.30 – 17.00 The role of stochastic resonance in wound healing 

Dr Elia Ricci, Italy 

17.00 - 17.30 Innovative textiles in pressure ulcer prevention 

Miguel Carvalho, Portugal, 

17.30 Presentation on 2012 conference, Cardiff, Wales 

Professor Michael Clark 

Close of conference 

Professor Michael Clark, President Elect of EPUAP 

33

Wednesday 

31st August 

ABSTRACTS 

35


Proceedings of the 14th Annual European Pressure Ulcer Meeting 

Oporto, Portugal 

Epidemiology of pressure ulcers in Portugal – the current position 

Alves, Paulo 1 , Neves-Amado, João 1 , Amado, João 1 , Vieira, Margarida 1 

1 Health Sciences Institute – Oporto – Catholic University of Portugal 

Pressure ulcers are a major and global health 

problem. The healing is difficult and complex; they 

bring with them great physical, psychological and 

social suffering, decreases the quality of life of the 

person and their family members, and a major 

economic burden. The most recent definition of 

Pressure Ulcers is the International NPUAP-EPUAP 

Pressure Ulcer Definition, defined as “A pressure ulcer 

is a localized injury to the skin and/or underlying tissue 

usually over a bony prominence, as a result of 

pressure, or pressure in combination with shear. A 

number of contributing or confounding factors are also 

associated with pressure ulcers; the significance of 

these factors is yet to be elucidated” [1]. 

The pathophysiology of pressure ulcers describes four 

mechanisms on the soft tissue in response to 

mechanical loading: localized isquemia, Impaired 

interstitial fluid flow and lymphatic drainage, 

reperfusion injury and sustained deformation of cells. 

Hospital Managers and Administrators are now giving, 

more attention to this problem. Some numbers show 

the extent of this issue, Pressure Ulcers are a major 

cause of morbidity in the population [2] and increased 

mortality [3]. 

The surgeon general’s Healthy People 2010 document 

has identified pressure ulcers as a national health 

issue for long-term care, and the Health Care 

Financing Administration (HCFA; in June 2001 

renamed the Centers for Medicare & Medicaid 

Services) has designated pressure ulcers as one of 

three sentinel events for long-term care [4]. 

Approximately 18% of hospitalised patients have a 

pressure ulcer [5]. 

Regular measurement of pressure ulcer prevalence is 

for many of health care institutions an action of 

evaluation of the quality of care. Compare data is 

difficult to achieve, related to methodology, sample 

selection, collecting data tool, between others, that´s 

why literature shows a large variety of figures from 

different countries and different care-settings. 

Some data of incidence and prevalence of Portugal 

demonstrates completely different figures, 

demonstrating diverse realities. This is important to 

reflect on contributing factors, preventive measures, 

prevention material available, location and categories 

of the population studied. 

In Portugal the first prevalence study on wounds 

(EPNFeridas)[6], started on March 2011 and some 

preliminary data is already available. This study and 

the most recent prevalence studies used the EPUAP 

collection form toll [7]. 

pjalves@porto.ucp.pt 

27 

In the year 2002 EPUAP, as published the results of 

the pilot study of prevalence [7], in hospital setting, 

from five European countries (Belgium, Italy, Portugal, 

United Kingdom and Sweden), with more than 5000 

patients. The median prevalence was 18,1%, in 

Portugal was 12.5%, there were evaluated 784 

hospitalized patients, of whom 98 had pressure ulcers. 

First study of prevalence and incidence of pressure 

ulcers, was conducted for the validation of the Braden 

Scale in Portugal [8], 9841 patients were evaluated, 

with a prevalence of 11,5%. The other study, the 

Project ICE [9], included hospitals, nursing homes and 

primary health care, the sample included 1,186 

individuals, with an overall prevalence of 14.2%, and 

the highest prevalence was found at the level of 

primary health care. The figures corresponding to the 

locations were similar, the same we cannot say about 

the categories of the pressure ulcers in Portugal. 

Professionals should be aware that most pressure 

ulcers can be prevented, and the approach with 

objective preventive measures, may be cheaper than 

the concern to treat this type of chronic wound 

[10,11,12]. It is known that the treatment and 

prevention of pressure ulcers is expensive for health 

services, yet there is little information on precise direct 

costs [2] 

The prevention and healing of pressure ulcers requires 

the cooperation and skills of the entire interdisciplinary 

health care team [4]. 

Conflict of Interest 

None 

References 

[1] NPUAP & EPUAP (2009). Prevention and treatment of pressure ulcers: 

clinical practice guideline. Washington DC: National Pressure Ulcer Advisory 

Panel. 

[2] Franks, P. (2007). The cost of pressure Ulceration. EWMA Journal , 15-17. 

[3] Allman, R. (1997). Pressure ulcer prevalence, incidence, risk factors and 

impact. Clinical Geriatric Medicine , 241-246. 

[4] Lyder, C ( 

[5] EPUAP, E. P. (2002). Summary report on the prevalence of pressure 

ulcers. EPUAP Review , 49-57. 

[6] Alves, P. Amado, J. Vieira, M (2011). Estudo Nacional de Prevalência em 

Feridas. Universidade Católica Portuguesa – Instituto Ciências da Saúde. 

[7] Clark, M. Bours, G. & Flour, T. (2002) Summary report on the prevalence 

of pressure ulcers. EPUAP Review 4. 

[8] Ferreira, L. Miguéns, C. Gouveia, J. Furtado, K. (2007) Risco de 

desenvolvimento de úlceras de pressão – Implementação Nacional da Escala 

de Braden. Lusociência. Loures 

[9] Grupo ICE (2008). Enfermagem e úlceras por pressão: Da reflexão sobre 

a disciplina às evidências nos cuidados. Imprenta Pelayo: Islas Canarias 

[10] Hopkins B, e. a. (2000). Reducing Nosocomial Pressure Ulcers in acute 

care facility. Journal of Nursing Care Quality , 28. 

[11] Whitefield, M. (2000). How effective are prevention strategies in reducing 

the prevalence of pressure ulcer? Journal Wound Care , 9: 261-266. 

[12] Lyder, C. (2006). Pressure Ulcer prevention and management. JAMA , 

August - Vol 296 nº8, 23-30. 

Copyright © 2011 by EPUAP




Pressure ulcers: the economic impact 

Verdú José 1* 

1* Community Nursing, Preventive Medicine, Public Health and History of Science Department. University 

of Alicante. Spain, pepe.verdu@ua.es 

Introduction 

Nowadays no one doubts that pressure ulcers are an 

important problem for all healthcare systems. Pressure 

ulcers are a serious and debilitating condition treated 

in all care settings, which have a significant impact on 

both patients and on health care resources. However, 

there are still few studies in the published literature 

aimed at measuring the economic impact of this 

condition and some of these studies are based on very 

general assumptions. 

The cost is combined by direct high drug costs (as 

cleansing materials, dressings, treatment of 

complications, surgical and diagnostic interventions, 

pain management, nursing time increases, increased 

hospital stays and so on) and other indirect costs 

(costs related to quality of life and help to perform 

activities of daily living, including litigation expenses, 

related Springs...). 

Perhaps, the more accurate study of costs associated 

with pressure ulcers, performed in Europe, was 

undoubtedly discussed by Bennet, Dealey and Posnett 

in the UK [1]. The authors, using an inductive 

methodology, determined treatment costs. Finally, 

estimated costs of treating a pressure ulcer could 

range from 1080 pounds for stage I up to 15,000 for 

stage IV, emphasizing that the cost increases with the 

stage, because it increases the healing time and 

incidence of complications. the estimated total cost for 

the health care and social system was around 2000 

million pounds per year (representing about 5.1% of 

gross expenditure of the British Health Service in the 

year 1999/2000). 

In Spain, the Prevalence Study of Pressure Ulcers in 

Rioja (1999) [2], with estimates clearly downward, 

allowed a first global approach to the annual cost of 

treatment across the country, reaching it over the 

seventy billion of pesetas. More recently, in 2007, 

GNEAUPP conducted a new study to estimate the 

national costs [3]. This study shows that the cost to 

heal a pressure ulcer increases substantially with the 

severity of the ulcer, ranging from 24€ (grade I) to 

6,802€ (grade IV) for patients treated in hospital. Costs 

increase with ulcer severity because the time to heal is 

longer and because the incidence of complications is 

higher in more severe cases. The total cost of 

pressure ulcer treatment in Spain is approximately 461 

million € (around 5% of total annual health care 

expenditure). Of this, 15% represents the cost of 

38 

dressings and other materials, 19% is the cost of 

nurse time and 45% is the cost of ulcer-related 

hospital stays. 

Historically, pressure ulcers have not been regarded 

as an important public health issue in Spain as well as 

other countries. However by comparing their cost with 

the costs associated with other indications considered 

key targets for any developed healthcare system (such 

as AIDS or type II diabetes), we can gain a better 

understanding of the true dimensions of the problem. 

In addition to the cost to the healthcare system, many 

published papers have shown that pressure ulcers 

present a significant associated morbidity and 

mortality, diminishing the quality of life of those who 

suffer from them. 

Clinical relevance 

This conference Highlight the high impact that 

pressure ulcer have on national health costs. 


José Verdú is co-author of several papers related to 

the title of this piece of work. 

References 

[1] Bennett G, Dealey C, Posnett J. The cost of 

pressure ulcers in the UK. Age and Ageing. 2004; 

33:230-235 

[2] Soldevilla JJ, Torra JE. Epidemiología de las 

úlceras por presión en España. Estudio piloto en la 

Comunidad Autónoma de la Rioja. Gerokomos. 1999; 

10(2):75-87 

[3] Soldevilla JJ, Torra JE, Posnett J, Verdú J, San 

Miguel L. The Burden of Pressure Ulcers in Spain. 

Wounds. 2007; 19(7):201-206 



39 

14th Annual European Pressure Ulcer Meeting 


ECONOMIC EVALUATION OF PREVENTION OF PRESSURE ULCERS IN INTENSIVE CARE UNITS 

Andrade, Melanie 1* , Nogueira, Fernanada 2 , Morais, Ernesto 3 

1* CHVNG/E, Portugal, andrade.melanie@gmail.com 

2 UTAD,Portugal 3 ESEP, Portugal 

Introduction 

The prevention of pressure ulcer assumes a fundamental role 

in health services economics and management, requiring the 

mobilization of material and human resources translated into 

significant costs for the institutions involved. 

As its aim this study had the determination and comparison 

of the costs and direct effects of pressure ulcer prevention 

with patients at risk of developing these ulcersm, admitted 

to two samples of an intensive care from different hospitals. 

Methods 

The methodology of this study was an economic evaluation, 

cost-effectiveness (CE), from the health institution view 

analysis, with patients admitted in intensive care units in 

two different hospitals CHVNG and in the HPH, between 

May and September 2009. The study population was 132 

patients (CHVNG) and 162 (HPH). The sample present 

inclusion criteria: patient without UP in admission moment 

and at risk of UP developing, with nursing intervention 

planed to prevent PU developing. The variables were related 

to the socio-biographical characteristics of patients, the costs 

of material and human resources recruited from the 

prevention PU programs and their direct effects (number of 

new cases, incidence and incidence density). 

Results 

The professional more important in prevention PU plan was 

the Nurse. We found that the samples had similar sociobiographical 

characteristics. They were hospitalized in ICU 

for around 6,7 days (CHVNG) and 5,9 (HPH). Diabetes is 

the predominant comorbidity in both samples. The patients’ 

risk PU development was evaluated by Braden scale 

(CHVNG) and Norton scale (HPH). Considering the 

different risk PU development degree in each population, 

the difference between the averages of the daily frequency 

of the interventions for prevent PU development is not 

statistically significant. But, considering the two hospitals, 

the difference between the averages of daily frequency 

interventions was statistically significant - in the HPH, 

interventions were more frequently. Patients weren’t 

evaluated (using the scales) every days. The time of witch 

interventions, in the CHVNG was, for Position (position the 

patient, bed linen care) - 15 minutes, and in HPH - 19. For 

Monitoring scale was estimated 1,8 min in the CHVNG and 

5,87 min in HPH. Application of cream and massage was 

similar in both hospitals, 5,5 min in CHVNG and 5,9 in 

HPH. 

The total cost of PU prevention estimated was €20.915,36 in 

CHVNG and €42.100,69 in HPH. The cost of PU prevention 

per patient per day of hospitalization in ICU was €30,27 and 

€65,12, correspondingly. The human total cost represented 

almost 83% of the total cost, material/consumable (gloves, 

cream, apron and mask) 16% and material/equipment 

(mattress and pillows)




Repositioning for preventing pressure ulcers - an economic analysis 

Zena Moore 1* , Seamus Cowman 2 

1* Royal College of Surgeons in Ireland, Ireland, zmoore@rcsi.ie 

2 Royal College of Surgeons in Ireland, Ireland 

Introduction 

International best practice advocates the use of 

repositioning for the prevention of pressure ulcers, 

however, one must have cognisance of the economic 

implications of interventions used within the clinical 

setting, therefore, as one component of a larger RCT, 

economic analysis was conducted to explore the cost 

implications of repositioning. The aim of the study was 

to compare the cost implications of repositioning older 

individuals in long term care, using 2 different 

repositioning regimes - the experimental group (n=99) 

were repositioned 3 hourly at night, using the 30 

degree tilt; the control group (n=114) received 

standard care (6 hourly turning using the 90 degree 

lateral rotation). 

Methods 

Ethical approval was received. The cost analysis 

focussed on the cost difference between the two study 

groups (in terms of the number of nurses needed per 

turn, the time per turn, the cost of a nurse per minute 

and the cost of dressing treatments and nurse time for 

dressing changes for pressure ulcers that developed 

during the study period). Data were collected for a 4 

week period. 

Results 

The mean time per turn was 3.01 minutes 

(experimental), and 5.93 minutes (control). The mean 

number of nurses needed for each turn was 1.51 

(experimental), and 2.02 nurses (control). The mean 

daily nurse time was 18.5 minutes (experimental) and 

24.5 minutes (control) (p




Pressure Ulcers - Can biomechanical research inform clinical practice? 

Dan Bader 1,2* 

1* School of Health Sciences, University of Southampton, UK, D.L.Bader@soton.ac.uk 

2 Dept. of Biomedical Engineering, Eindhoven University of Technology, the Netherlands 

Introduction 

Biomechanical research has clearly been successful in 

many clinical fields, particularly those associated with 

orthopaedics and cardiovascular medicine. Indeed it 

can provide an objective differential diagnosis of a 

patient presenting at a clinic, and an assessment of 

the effectivenes of conservative and surgical 

management and rehabilitation strategies A similar 

biomechanical approach has also been envisaged in 

analysing the complex issues associated with pressure 

ulcers. As an example, for years the traditional 

mechanism associated with its aetiology was based on 

the concept of biomechanical-induced ischemia. 

However in the last decade we have been able to 

propose alternative mechanisms influenced by 

biomechanics, which evoke soft tissue breakdown, 

including cell and tissue deformation, ischaemicreperfusion 

injury and impaired interstitial and 

lymphatic flows [1]. This has necessitated an 

hierarchical approach from cell-based studies, to 

tissue and animal models [2] to human investigations. 

The former provide a means of examining specific 

biomechanical effects using controlled cell-based 

experiments [3]. However, it is still problematic to 

extrapolate these findings to a clinical setting. 

The presentation will evaluate what has been learned 

from these biomechanical approaches to inform 

clinical practice. In many cases, they have highlighted 

the need for caution, for example, in the use of 

pressure maps alone to evaluate the loaded interface, 

the establishment of a universal safe pressure levels 

and in the consideration of local tissue biomechanics. 

Nonetheless, there is considerable grounds for 

optimism that from a biomechanical point of view, we 

are now in a position to provide objective guidelines for 

the clinician who is directly involved in the prevention 

and treatment of pressure ulcers. Indeed the 

presentation will emphasize the importance of new 

biotechnologies, which could be adapted for use in 

identifying those patients at particular risk of 

developing pressure ulcers and providing them with 

personalized support systems. This can only be 

achieved by a multidisciplinary team involving 

scientists, clinicians and industry. 

Acknowledgements 

I gratefully appreciate the help of many collaborators 

that have shared my passion for pressure ulcer 

research over many years. Special thanks must go to 

41 

my long time colleague in Eindhoven, Dr Cees 

Oomens, the current president of EPUAP. 

References 

[1] Bouten et al. Archives Physical Medicine 

Rehabilitation 84: 616-619, 2003 

[2] Loerakker et al. Annals Biomedical Engineering. 

38(8):2577-87, 2010 

[3] Gawlitta et al. Annals Biomedical Engineering. 

35(2): 273-84, 2007 





Pressure Ulcer Prevention 

Evidence- Based tool development and tailored implementation to improve clinical practice 

Introduction 

Dimitri Beeckman 1,2,3* 

1* King’s College London, UK, Dimitri.Beeckman@UGent.be 

2 Ghent University, Belgium, 3 Artevelde University College, Belgium 

Pressure ulcers are a significant problem for patients 

and healthcare professionals in many different 

healthcare settings. Pressure ulcer prevention requires 

an interdisciplinary approach to care. Prevention 

guidelines are widely developed to reduce the 

variations in care, to improve patient outcomes, and to 

reduce costs. However, implementing these guidelines 

is complex and the use of guidelines is not always 

reflected in the actual care patients receive. 

Aim 

The first aim of this research was to study knowledge 

and attitudes of nurses regarding pressure ulcer 

prevention. The second aim was to get a more in 

depth understanding of the complexity of pressure 

ulcer classification and differentiation between 

incontinenceassociated dermatitis (IAD). The third 

aim was to study the effectiveness of a tailored 

implementation intervention to enhance pressure ulcer 

prevention in nursing homes. 

Overview of studies 

A cross-sectional multi-centre study was designed to 

explore the relation between knowledge, attitudes, and 

the application of adequate prevention in Belgian 

hospitals [1]. Previously developed and validated 

instruments were used in this study [2, 3]. The results 

showed that the knowledge of the participating nurses 

about pressure ulcer prevention was poor. Only half of 

the nurses showed satisfactory attitude scores. The 

application of adequate prevention was significantly 

correlated with the attitudes of the nurses. This study 

also indicated that pressure ulcer prevalence and the 

application of adequate prevention in patients at risk 

did not improve over the last years. 

A European study about the inter-observer reliability of 

the European Pressure Ulcer Advisory Panel 

classification system showed that pressure ulcers 

were often classified incorrectly [4]. Only a minority of 

nurses reached a substantial level of agreement. 

Problems were more obvious in superficial pressure 

ulcers. Furthermore, the differential diagnosis between 

IAD and pressure ulcers appeared to be complicated 

[5]. 

A randomized controlled trial was set up to evaluate 

the effectiveness of the Pressure Ulcer CLASsification 

education tool (PUCLAS) on classification and 

42 

differentiation skills by nurses [6]. PUCLAS is a tool to 

teach and learn about pressure ulcer classification and 

IAD differentiation. Attending PUCLAS improved 

pressure ulcer classification and IAD differentiation 

significantly. Furthermore, a study about the 

effectiveness of the ‘PUCLAS2’ e-learning program 

showed similar positive results [7]. 

The effectiveness of multi-faceted tailored made 

implementation of a computerized patient-tailored 

pressure ulcer prevention protocol was tested in a 

randomized-controlled trial. The tailor made strategy 

included interactive education, reminders, monitoring, 

feedback and the introduction of leadership [8]. During 

the 16 weeks of implementation, a significant positive 

effect was observed on the allocation of adequate 

pressure ulcer prevention in residents at risk when 

seated in a chair. There was no effect on the 

prevalence of pressure ulcers and on the knowledge of 

the professionals. While baseline attitude scores were 

comparable between both groups, the mean score 

after the intervention was significantly higher in the 

experimental group than in the control group. 

Conclusion 

The journey to Evidence- Based Practice in pressure 

ulcer prevention is long. Major efforts are made to 

develop practice guidelines. More effective 

implementation methods should be developed and 

based on the barriers experienced by clinicians trying 

to incorporate the guidelines into clinical practice. An 

intensive collaboration between policy makers at 

different levels, clinicians, researchers and the industry 

is needed to realize these goals. 


I would like to warmly thank Tom Defloor † and Katrien 

Vanderwee (Ghent University, Belgium) for 

supervising this research between 2006 and 2011. 

References 

[1] Beeckman D. et al., Worldviews Evid Based Nurs. 

doi: 10.1111/j.1741-6787.2011.00217.x., 2011 

[2] Beeckman D. et al., Int J Nurs Stud. 47:399-410, 

2010 

[3] Beeckman D. et al., Int J Nurs Stud. 47: 1432-41, 

2010 

[4] Beeckman D. et al., J Adv Nurs. 60: 682-91, 2007 

[5] Beeckman D. et al., J Adv Nurs. 65: 1141-54, 

2009 

[6] Beeckman D. et al., Qual Saf Health Care. 19:e3, 

2010 


Thursday 

1st September 

ABSTRACTS 

43




Mathematical models to describe wound healing and wound contraction 

Fred Vermolen 1 , Etelvina Javierre 2 , Amit Gefen 3 

1* Delft Institute of Applied Mathematics, Delft University of Technology, Delft, the Netherlands 

F.J.Vermolen@tudelft.nl 

2 University of Zaragoza, Zaragoza, Spain 

3 University of Tel-Aviv, Tel-Aviv, Israel 

Introduction 

Wound healing phenomena, either occuring in 

cutaneous wounds, or in trauma on organs or bone, 

are crucial biological processes for the viability of a 

living organism. These healing processes in general 

proceed by signaling processes from, for instance 

platelets, that trigger the cells in surrounding 

undamaged tissues to come into action. This action 

can be mobility, cell movement in the direction of a 

signaling or growth factor concentration gradient or by 

(biased) random motion, or the proliferation of cells 

(division and growth). The simulations were described 

in more detail in [1]. 

Methods 

In this talk, we will review some of the mathematical 

models we are working on. These models are 

predominantly based on systems of reaction-diffusionconvection 

equations and on the equations of viscoelasticity. 

Here, we show some results from finiteelement 

simulations and discuss some of the 

implications. This model is applied to simulation of 

wound contraction, angiogenesis and wound closure. 

The processes of wound contraction and angiogenesis 

take place in the dermis and are contain the ingress 

and proliferation of (myo-)fibroblasts, endothelial cells, 

and the regeneration of the capillary network. Wound 

closure takes place in the epidermis as a result of 

motility and proliferation of keratinocytes. Between the 

two mechanisms, there is interaction via the oxygen 

tension and secretion of signaling agents. This 

interaction is dealt with in the model. 

Besides the partial differential equations approach that 

we use to model wound healing and wound 

contraction, we will also discuss a brand new 

formulation of a semi-stochastic cellular based model 

on wound closure and growth of cell cultures. This 

model is based on the mechanical forces that are 

exerted and sensed by cells. Furthermore, the cellular 

motion contains a somewhat random component. Cell 

death and cell division are incorporated into this model 

as stochastic processes as well. It is possible to 

extend this formalism to chemical signaling. This semistochastic 

approach has been described in [2]. 

If time allows, we will also show the newest 

applications to modeling angiogenesis on fibrosis 

impaired areas on the surface of a heart. 

45 

Results 

We will show the results from simulations with input 

date that are as realistic as possible. The results are 

presented in terms of profiles of the various cell 

densities over the dermal and epidermal region. 

Furthermore, we show the contraction dynamics of a 

wound over time. 

Discussion 

There is a huge variety of mathematical models for 

wound healing. Most models are based on partial 

differential equations and therewith, they are 

continuum-based models. As soon as one arrives at a 

dimension that is comparable to a cell size, then these 

models will fail to predict the right behavior of the 

phenomenon. Therefore, we are also interested at the 

processes on a cellular level. It is one of our aims to 

link the cellular models with the continuum models. 

Furthermore, the value of the parameters is uncertain, 

as well as most of the data is patient-specific. These 

uncertainties introduce a certain randomness. We 

think that we will be able to deal with this degree of 

randomness by the use of stochastic finite-element 

methods. This will be done in future studies. 


The mathematical models will contribute in 

understanding the fundamental relations between the 

various subprocesses occurring in wound healing. This 

understanding can give guidelines to improve 

treatments such as preventing the formation of 

hypertrophic scars, which is a mayor undesired sideeffect 

during the healing of burns. 


We are grateful for the financial support from 

Agenschap.nl for funding the collaboration between 

the Delft University and University of Zaragoza. 

There is no Conflict of Interest 

References 

[1] F.J.Vermolen. et al., J. Tissue Viability. 19(2):43- 

53, 2010 

[2] F.J.Vermolen. et al., Biomechanics and modeling in 

mechanobiology, to appear, 2011 





Wound Models in Monolayer Cell Cultures, 

Quantitative Analysis of Cell Kinematics 

Amit Gefen * , Orna Shaharabany-Yosef, Gil Topman 

* Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Israel, gefen@eng.tau.ac.il 

Introduction 

Cell migration is a critical process in wound 

closure, including closure of pressure ulcers (PU). 

Wound healing assays are simple but effective 

means for studying cell migration in vitro, and 

such assays were found to represent the 

kinematics of in vivo migration to a reasonable 

extent. In wound healing assays, cells migrate 

from a populated area into a denuded area, 

created e.g. by local crush, scratch or ablation of 

the cells, and hence the "wound" is covered. One 

of the commonly used measures for the 

performances of the migrating cells is the area of 

the "wound" over time, and in particular how fast 

can that area be covered by cells post infliction of 

the damage. However, current methods that are 

available for measuring the area-time behavior of 

the "wound" are typically subjective and 

inaccurate, or costly, or cumbersome to apply. 

Here we present a new method, based on timelapse 

digital optical microscopy and image 

processing, for quantifying the kinematics of cell 

colonies migrating from populated areas into a 

denuded area, in the context of modeling cell 

migration in PU healing. In particular, we 

employed our new method for determining the 

migration kinematics of different cell types which 

can be potentially involved in PU healing 

(fibroblasts, preadipocytes and myoblasts) as well 

as for characterizing effects of ischemic factors 

associated with PUs (low glucose, low 

temperature and acidosis) on the migration. 

Methods 

NIH 3T3 fibroblasts, 3T3-L1 preadipocytes and 

C2C12 myoblasts were thawed from liquid 

nitrogen storage and cultured in standard media 

that are specific to each cell type. When cultures 

were near confluency, a micro-indentor (size 

0.46×0.38mm) was used to inflict localized 

crushing damage to the cultures. Time-lapse 

images of the cultures were then acquired every 

2 hours, using an Eclipse TS100 microscope 

(Nikon) and DS-Fi1 digital camera with a 

resolution of 2560×1920 pixels (3 pixels per 

micron). During image acquisition, cultures were 

kept at 37ºC using a temperature control system, 

and HEPES was supplemented to the media in 

order to control the pH level. The time-dependent 

micrographs were post-processed by a MATLAB 

46 

code, based on texture homogeneity measures. 

Specifically, denuded areas in the digital 

micrographs were characterized by a 

substantially lower standard deviation (SD) of 

pixel intensities, as opposed to cell-populated 

areas where the SD of pixel intensities was high. 

The SD distributions were mapped over the 

micrographs per each time point, using two 

window sizes for each cell type: the first being a 

window with a course resolution and the second 

with a fine resolution. An intersection of these SD 

distribution maps obtained when using the two 

window sizes resulted in an adequate 

measurement of the time-dependent area of the 

denuded region. The experimental area vs. time 

data were finally fitted to Richards nonsymmetrical 

sigmoid functions for calculating 

migration rates from the coefficients of these fits. 

Results 

Cells covered the damage area after ~24 hours, 

however there were cell-type-dependent 

differences in rates of coverage. Specifically, 

fibroblasts and the fibroblast-like preadipocytes 

(3T3-L1) were faster than the myoblasts in 

covering the damage area under control culture 

conditions (37ºC, glucose=4.5g/ml, pH=7.4). The 

migration rate of the NIH3T3 fibroblast cells was 

reduced by ~50% at an acidic environment 

(pH=6.7) but the other cell types were not 

significantly affected by the acidosis. 

Discussion 

Developing a reliable and reproducible wound 

healing model in vitro is essential for studies of 

the etiology of PU as well as for testing the 

performances of any medication or food 

supplement aimed at improving cell motility for 

wound healing. The present method meets these 

needs and is easy to implement in a cell lab. 


A reliable, reproducible wound model system is 

essential for testing medications and food 

supplements claimed to improve healing of PU. 

Conflict of Interest: None 

References 

Topman, G., Shaharabany-Yosef, O., Gefen, A. A method 

for quantitative analysis of the kinematics of fibroblast 

migration in a monolayer wound model. Proceedings of the 

ASME 2011 Summer Bioengineering Conference, 

Farmington, PA, USA, June 22-25, 2011. 





Using MR elastography to map changes in muscle and other tissues due to mechanical 

loading and disease 

Lynne E. Bilston 1* 

1* Neuroscience Research Australia, Australia, L.Bilston@NeuRA.edu.au 

Introduction 

Magnetic Resonance Elastography (MRE) is an 

emerging noninvasive MR imaging technique that can 

measure the mechanical properties of soft tissues in 

human subjects in vivo. MRE is well-established in 

clinical studies of liver tissues, and is being explored to 

quantify changes in many tissues ranging from brain to 

skeletal muscle. Studies have measured mechanical 

changes in muscle tissues after exercise, and the 

effects of disease and treatment. Most recently, the 

ability to map changes in tissue mechanics during 

compression have been conducted. The potential 

utility of MRE for both basic and clinical studies of 

pressure ulcers will be outlined. 

Methods 

The fundamental principle of MRE is that the 

mechanical properties of a tissue affect how 

mechanical vibrations travel through that tissue. 

Waves travel faster in stiffer tissues, and are 

attenuated more rapidly in more viscous (or energyabsorbing) 

materials. By applying an external vibration 

to a tissue, and tracking the vibration within the tissue 

with the MRI scanner (synchronized to the vibration), 

we can estimate both the elastic and viscous 

mechanical parameters for that tissue. 

Fig. 1. Simulated wave propagation from a vibration source 

on the left. Note the stiffer region with different wave 

propagation in the centre. (image from R. Sinkus, INSERM) 

47 

Results/Discussion 

From the MRI data, mathematical inversion of the 

wave images allows elasticity and viscosity maps for 

the tissue to be obtained. Elasticity increases with 

applied compressive load, after eccentric exercise in 

skeletal muscles, and in the presence of some disease 

conditions. 


MR elastography may provide a useful tool for basic 

research into the biomechanics of pressure ulcer 

development, and may also be able to noninvasively 

map tissue changes in patients. 


This talk was partially supported by the 

TRANSCRIPTAR networking grant from the Leeds 

Fund for International Research Collaboration (FIRC) 

(Sponsors: Worldwide Universities Network and the 

University of Leeds) 


None to declare 


Thursday, 1 st September 2011, 9.00 

Room A4 

KCI Symposium

KCI Symposium 

A new chapter in pressure ulcer prevention and treatment; the Skin IQ 

microclimate manager 

Co-Chairs: Joyce Black and Michael Clark, 

Presenters Michael Clark, Joyce Black, Nils Lahmann, Eddy Koopman, Jacques Neyens 

09.00-09.10: 

Michael Clark 

An introduction to skin-microclimate and how it influences skin integrity 

09.10-09.30 

Joyce Black 

Negative airflow technology for microclimate management; pre-clinical data 

09.30 – 09.50 

Nils Lahmann 

Skin IQ Microclimate Manager, results of a pilot study on 43 hospital patients with 

moisture issues in Germany 

09.50-10.05: 

Eddy Koopman: 

Skin IQ microclimate management in pressure ulcer prevention and treatment 

10.05 – 10.20 

Jacques Neyens: 

Beyond pressure ulcers; the beneficial effects of moisture control in 


10.20 – 10.30 

Interactive discussion and Q and A 

Closure 10.15 

50


An introduction to skin-microclimate and how it influences skin integrity 

Michael Clark 

In the 1970’s the need to maintain a favorable microclimate between the skin and soft tissues in contact 

with patient support surfaces was seen as a prime requirement for successful pressure ulcer prevention. 

However, this element of pressure ulcer prevention was later overlooked as the drive towards support 

surface use in load management became the prime focus of preventive interventions. 

Excessive skin moisture and high relative humidity both weaken skin and increase the coefficient of friction 

of skin, increasing the likelihood of damage from pressure, shear and friction. Raised skin temperature may 

be related to pressure ulceration as this increases the metabolic demands of the local tissues, raising the 

tissue’s requirement for oxygen and susceptibility to the ischemic effects of pressure and shear This session 

will summarize the importance of microclimate management in pressure ulcer prevention and introduce the 

new microclimate manager overlay and so provide a foundation for subsequent seminar presentations that 

cover the new overlay, the available (pre-)clinical evidence and it’s clinical use in greater depth 

51


Negative airflow technology for microclimate management; pre-clinical data 

Joyce Black 

Moisture accumulation on the skin and increase in skin temperature, in conjunction with mechanical forces, 

can lead to tissue breakdown and potential ulcer formation. Controlling microclimate is an important and 

often overlooked area of pressure ulcer prevention. The Skin IQ MCM is a multilayer (vapor-permeable 

liquid-impermeable layers with a foam spacer in between) powered coverlet that uses a fan blower to 

draw air flow (Negative Airflow Technology) through the spacer. This way it helps reduce warm air and 

moisture contact with the patient’s skin. A clinical assessment of the product showed that the use of active 

negative airflow technology with the Skin IQ microclimate manager reduced local moisture levels and 

skin temperature when compared to controls. Additional in vitro experiments were conducted to assess the 

ability of the microclimate manger to affect bacterial growth and control odor. Data showed that both bacterial 

growth and odor were significantly reduced with the coverlet. 

52


Skin IQ Microclimate Manager, results of a pilot study on 43 hospital patients with 

moisture issues in Germany 

Nils Lahmann 

In order to test acceptance and usage of a newly developed cover system to manage the skin microclimate 

in acute care services, the Skin IQ Microclimate Manager (MCM) was provided to a number of healthcare 

centres in Germany. Centres were asked to take part in the evaluation by treating applicable patients with 

the Skin IQ MCM and subsequently filling out one case report form for each patient being treated with 

the device. Case report forms collected information on patient background, presence of pressure ulcers, 

development of pressure ulcers during use and patient and care giver experience with the device. Units 

involved were intensive therapy units, neurology wards, palliative care wards, radiation therapy units, burns 

units and oncology wards. Data from seven individual medical centres were collected for this evaluation. 

The session will focus on two research questions: What were the characteristics of the patients being treated 

with the Skin IQ MCM system, and what was the perception of the nurses regarding patient comfort and 

ease of use of the Skin IQ MCM. 

53


Skin IQ microclimate management in pressure ulcer prevention and treatment 

Eddy Koopman 

The Skin IQ microclimate manager is intended to help prevent the skin against the effects of external 

forces such as friction, shear and pressure. A reduction in skin moisture levels and temperature is intended 

to help reduce the oxygen and nutrient demands and reduce the coefficient of friction. This session will 

show the results of microclimate management using the Skin IQ MCM in patients that suffered from skin 

complications as a result of moisture in our hospital. Clinical outcome, patient and care giver experiences will 

be presented. 

54


Beyond pressure ulcers; the beneficial effects of moisture control in 


Jacques Neyens 

Moisture and temperature control for bedridden patients does help prevent skin damage that may result from 

external forces such as pressure and friction. In addition managing the skin microclimate will improve patient 

comfort in cases where patient’s suffer from increased sweating and/or a high skin temperature. In our 

nursing home we were offered the opportunity to test a newly developed mattress-cover that was designed 

to help reduce moisture levels and skin temperature, but that can also reduce friction and shear. A number 

of patients that were at high risk for moisture and temperature issues were treated with the skin microclimate 

manager. In this presentation our clinical experience with the new product in the treatment of patients with 

Huntington disease will be presented. 

55

Thursday, 1 st September, 12.30 

Room A4 

Hill-Rom workshop


Hill Rom Workshop: 

Developments in Microclimate Management 

Dr. Roland de Roche, MD 

Charlie Lachenbruch, PhD, Hill-Rom 

The initial part of this two-part workshop will focus on new developments in microclimate management 

(MCM), what microclimate management surfaces are intended to do, and how surface performance is 

assessed. In part two, Dr. de Roche will discuss appropriate uses of MCM surfaces in specific clinical 

situations. 

Part 1 

Microclimate management products are estimated to account for approximately 1/6 of hospital beds in the 

US. 1 This is primarily due to the increasing appreciation of the effects of the skin’s microclimate in pressure 

ulcer development and healing. Microclimate management consists of maintaining the temperature and 

humidity of the skin / support surface interface in optimal ranges. Increased temperature has been shown 

to increase the metabolic rate of the tissue 2 and increase the risk of ischemic breakdown for a given load. 3 

When the skin is warmed beyond its perspiration threshold, local sweating is also stimulated and the 

accumulation of moisture reduces the skin’s tensile strength and increases friction with adjacent materials. 

Excessively cool temperatures cause patients to be uncomfortable and may cause vasoconstriction, 

negating any metabolic benefit. 

Products manage the microclimate through their ability to combat the accumulation of heat and humidity at 

the skin surface. Methods of reliably assessing performance are currently being validated by the NPUAP’s 

Support Surface Standard’s Initiative. 4 The intent of this presentation will be to discuss the issues that must 

be considered in determining appropriate ranges of MCM product performance. 

Part II 

Excess moisture has been identified as a common risk for pressure ulcer development in Braden, Norton, 

and Waterlow pressure ulcer risk scores. For specific patient types, moisture management is critical 

to achieve successful clinical outcomes. The discussion will address specific patient characteristics 

and situations that require adequate moisture management, and will speak to the clinical application of 

Microclimate Management surfaces. 

References 

1. Lachenbruch C, VanGilder C, Janoff K. High Pressure Ulcer Risk Patients and Specialty Surface 

Utilization: Data from the 2010 International Pressure Ulcer Prevalence Survey.Poster presentation at 

Symposium on Advanced Wound Care (SAWC) Dallas, TX April 14-17, 2011. 

2. Ruch RC, Patton HD, eds. Physiology and Biophysics, 19th ed. Philadelphia, Pa.: WB 

Saunders;1965:1030–1049. 

3. Kokate JY, Leland KJ, Held AM, et al. Temperature-modulated pressure ulcers: a porcine model. Arch 

Phys Med Rehabil. 1995:76:666–673. 

4. Support Surface Standards Committee (S3I). Minutes of NPUAP’s S3I committee meeting in Las Vegas, 

NV, February 2011. 

58


12.30 – 13.30 Free papers 1 


Diane Langemo, USA 

Pressure Ulcers in a Post Disaster Setting: Benefits of Advanced 

Wound Care Techniques 

Jeff McNutt, Haiti 

Epidemiology, diagnosis and management of infected chronic wounds 

Armand Rondas, The Netherlands 

Characterization of patients with pressure ulcers of the neurological 

clinical: a path to prevention 

EEC Moura, Brazil 

59





Diane Langemo, PhD, RN, FAAN 1* , Joyce Black, PhD, RN, CPSN, CWCN, FAAN 2 

1* University of North Dakota College of Nursing, Grand Forks, ND, USA, dianelangemo@aol.com 

2 University of Nebraska Medical Center, Omaha, Nebraska, USA 

Introduction 

Pressure ulcers occur all too frequently throughout the 

world, as do fungating wounds, particularly among 

palliative care individuals, and are painful, expensive 

to treat, and diminish quality of life. Individuals in 

palliative care are at increased risk for pressure ulcer 

development related to their frail, deconditioned state. 

Sufficient informed clinical consensus exists in the 

literature to support the management of a pressure 

ulcer in individuals in palliative care, inspite of the 

ethically understandable absence of randomized 

controlled trials comparing various management 

approaches. [1] “Within palliative care, it is never going 

to be possible to eradicate pressure [ulcers] because 

of the multiple risk factors experienced by the 

patients.” [2] Palliative care individuals are also at risk 

for development of a fungating wound, and these 

types of wounds are difficult, at best, to manage. 

Methods 

This presentation will focus on up-to-date pressure 

ulcer and fungating wound prevention and treatment 

strategies in individuals in palliative care. The 2009 

NPUAP-EPUAP Pressure Ulcer Prevention and 

Treatment Guidelines [3] as well as the most up-todate 

literature will provide a framework for the 

presentation related to pressure ulcers. [4] The most 

current up-to-date literature related to treatment of 

fungating wounds will frame this section. Patient 

scenarios will be addressed and analyzed. 

Results 

Specific guideline recommendations for prevention 

and treatment of pressure ulcers in palliative care 

individuals will be provided for attendees. Specific care 

recommendations, based on current literature and 

practice, will be presented for fungating wound care in 

palliative care individuals. 

60 

Discussion 

Prevention and treatment of pressure ulcers and 

fungating wounds in palliative care individuals includes 

patient and risk assessment; management of 

pressure, shear and friction; positioning and 

repositioning; nutrition and hydration; care of the skin; 

care of the pressure ulcer and fungating ulcer; pain 

assessment and management; and assessment of 

resources for the palliative care individual. All will be 

discussed along with patient care scenarios. 


The number of palliative care individuals with pressure 

ulcers and/or fungating wounds is growing yearly. 

Ensuring quality care individualized to these 

individuals is of utmost importance. 


We appreciate the work of the NPUAP-EPUAP 

Guideline Development Group work on the 2009 

Pressure Ulcer Prevention and Treatment Guidelines. 


There is no conflict of interest for either author that is 

relevant to this presentation. 

References 

[1] Langemo DK, Black J. Adv Skin Wound Care. 

2010;23(2):59-72. 

[2] Walding M, Andrews C., Professional Nurse. 11(1): 

33-38, 1995 

[3] National Pressure Ulcer Advisory Panel and 

European Pressure Ulcer Advisory Panel. Prevention 

and treatment of pressure ulcers. 2009 

[4] Langemo DK., et al. Adv Skin Wound Care. 19(3): 

148-154 

[5] Langemo D, Brown. Skin Fails Too: Acute, Chronic 

& End Stage Skin Failure, Adv Skin Wound Care. 

2006;1994):206-211. 

[6] SCALE Panel (includes D Langemo). SCALE: Skin 

Changes at Life’s End. WOUNDS, 21(12):329-336. 

[7] Langemo DK (2011). Palliative Wound Care, In: 

Wound Care Essentials: Practice Principles, 3 rd Ed. 

Baranoski S, Ayello EA (Eds). Philadelphia: Lippincott, 

Williams & Wilkins. 





Pressure Ulcers in a Post Disaster Setting: Benefits of Advanced Wound Care Techniques 

McNutt, J, Miller, J, Cherry, J, Eyssallenne, A 

Hospital Bernard Mevs Project Medishare, Haiti, jbm911@hotmail.com 

Introduction 

On January 12, 2010 Haiti was rocked by a 7.0 

magnitude earthquake just outside the capital city of 

Port au Prince. Though the earthquake only lasted 35 

seconds, approx 316,000 people died, 300,000 were 

injured and 1,000,000 made homeless. This was 

devastating to a country already mired in poverty, and 

lack of advanced medical care. Many injuries required 

patients to be non-mobile before definitive care could 

be provided, while others were left with spinal cord 

injuries [SCI], conditions that occurred secondary to 

trauma even before the earthquake. Many of these 

people were left lying on the dirt floors of their tents or 

lying on hard cots in field hospitals with no pressure 

relief capabilities. Multiple pressure ulcers of all 

stages were created. Our presentation will discuss the 

need for advanced wound care techniques, especially 

following a disaster of this sort, types of techniques 

used and examples of patients treated. 

Methods 

Here we present 2 case studies of patients (E and C) 

treated at Hospital Bernard Mevs Project Medishare in 

Port au Prince, Haiti. Both had spinal cord injuries and 

sustained their wounds following periods of prolonged 

immobility and inadequate care which included lack of 

medical support, lack of pressure relieving surfaces 

and poor nutritional intake. 

At the time of admission to our service E (a 24 y/o 

quadriplegic since March 2010) had a Grade 4 sacral 

ulcer with comorbidities of systemic infection, severe 

malnutrition and severe depression. She sustained her 

wounds from sleeping on hard flooring. 

C is a 40 year old paraplegic (since 2004) who 

presented with multiple wounds (up to grade IV) on his 

sacrum and lower limbs. He lost his home in the 

earthquake and had moved to a tent where he slept on 

the ground and had no pressure relieving surfaces. He 

had comorbidities of severe anemia (Hg 4.4g/dL), 

systemic infection and severe malnutrition on 

admission to our hospital. 

Both patients were treated with a combination of 

surgery, silver dressings, KCI V.A.C. ® negative 

pressure therapy, physical therapy, appropriate 

pressure relief and nutritional supplementation during 

their stay. 

Results 

Wound measurements 

Patient Date Wound Size 

E sacrum Oct 2010 13.5 x 6.6 x 3.5cm with 

undermining 

Apr 2011 Healed 

C sacrum Oct 2010 

13.4 x10.3 x11.0cm 

Apr 2011 

Healed with STSG 

61 

C (R Troch) 

C (L Troch) 

Oct 2010 

Apr 2011 

Oct 2010 

April 2011 

6.5 x 6.2 x 1.4cm 

2x2cm 

5.7 x 5.1 x >0.1cm 

Healed 

Discussion 

Pressure ulcer prevention in SCI patients is a 

challenge. Poor nutrition and inadequate pressure 

relief surfaces, compounded with decreased personnel 

to provide care to patients in need contribute to 

formation of wounds. Our case studies illustrate the 

need for advanced wound care in a post disaster 

setting and show that provision of such services can 

offer the opportunity for complete healing of severe 

wounds. Due to the lack of pressure relief surfaces, it 

is also extremely important to increase education level 

in mobility and therapy techniques to prevent further 

pressure ulcers. 

It is well known that good nutrition is necessary for 

wound healing. Patients in “first world countries” with 

wounds frequently require special nutritional 

interventions. This is even more important in “third 

world” countries when even prior to a national disaster 

there is widespread starvation and malnutrition. 

Deficiencies in protein and essential vitamins weaken 

collagen synthesis, cellular cohesion, and leave soft 

tissue more susceptible to breakdown and infection 

due to immunosupression. [1] 

Use of KCI’s V.A.C. ® Negative pressure wound 

system, silver dressings, pressure relieving 

techniques, physical therapy and improved nutritional 

support have either closed, or greatly improved the 

status of the wounds of the presented patients. 

Educating local staff and patients in turning schedules, 

mobility, and proper nutrition will continue to help heal 

current ulcers, and hopefully prevent new pressure 

ulcers from forming. 


We demonstrate herein that advanced wound care 

techniques, proper nutrition, education and superior 

support surfaces will improve success in wound 

healing in resource poor settings. 


We appreciate the help of the staff and administration 

of Hospital Bernard Mevs, and Project Medishare, and 

numerous volunteers from all over the world. 

References 

[1] Bryant R., Acute and Chronic Wounds. (Mosby- 

Year Book Inc. 1992) p.115 





Characterization of patients with pressure ulcers of the neurological clinical: a path to 

prevention 

Introduction 

Moura, E.C.C. 1* , Vasconcelos, I.C.M 2 , Caliri, M.H.L 3 , Silva, G.R.F 4 

1* Federal University of Piauí, Brazil elainecrism@bol.com.br 

2 Federal University of Piauí, Brazil 

3 University of São Paulo, São Paulo, Brazil 

4 Federal University of Piauí, Brazil 

Pressure Ulcers (PU) are a common problem of 

nursing practice. However, the complexity of risk 

factors and accurate assessment of them, numerous 

complications associated with these wounds, including 

the risk of death, among other problems as the 

demand of time and cost of hospitalization, all this 

make of the prevention and treatment of the PU a 

challenge for health professionals. In this context, 

evidence-based practice is indicated for a systematic 

care of quality. The objective of this study is raise the 

profile of neurological patients with pressure ulcers. 

Metodos 

This is a documentary study, descriptive and 

retrospective realized on the medical records of 

neurology clinical, in the period from 2008 to 2009, in a 

General Teaching Hospital in Teresina, Piauí, Brazil. 

After approval by the ethics committee and research 

institutions, the medical records were reviewed and 

among the 1175 records identified in that period, 46 

met the inclusion criteria: presence of UP registration. 

Results 

Table 1: Principal data on demographic characteristics 

of patients with PU. Teresina (PI), Brazil, 2010. 

Variáveis n % 

Sex 

Male 32 69,57 

Female 14 30,43 

Age 

< 20 2 4,35 

20-30 14 30,40 

31-40 7 15,22 

41-50 5 10,87 

51-60 7 15,22 

61-70 7 15,22 

71-86 4 8,70 

Marital Status 

Married 24 52,17 

Single 20 43,48 

Windower 2 4,35 

Total 46 100 

62 

Table 2: Principal data for the characterization of 

patients with UP.Teresina (PI), Brazil, 2010. 

Variáveis N % 

Referred from another hospital 

Yes 33 71,74 

No 13 28,26 

Presence of PU 

Hospitalization 30 65,22 

Admission 16 34,78 

Diagnosis 

Spinal cord injury 16 34,78 

Brain tumor 7 15,22 

Stroke 6 13,04 

Cerebral aneurysm 6 13,04 

Traumatic brain injury 6 13,04 

Hydrocephalus 3 6,52 

Syringomyelia and siringobulbia 1 2,17 

Guillain-Barre Syndrome 1 2,17 

Total 46 100 

Discussion 

There was a predominance of PU occurrence in young 

patients with principal diagnosis the spinal cord injury. 

This is because young patients with severe 

neurological deficit are susceptible, although 70% of 

PU occur in patients older than 65 years [1]. It is 

noteworthy the fact that 34.78% of patients being were 

admitted with PU and no records of the preventive 

actions to PU or application of risk assessment scales. 

It is known that early identification and treatment of PU 

allow a significant reduction in costs, and prevent its 

progress and accelerate the healing process [2].. 


The knowledge of the profile of the patients with UP 

suggests that the results can be improved, it is 

important to implement more effective intervention, 

with the intention of alerting healthcare professionals 

about the importance of prevention strategies and 

interventions based on evidence since of the 

admission aiming at the safety to the neurological 

patient. 

References 

[1] Bluestein,D; Javaheri, A. Am Fam Physician., 

78(10):1186-94,2008. 

[2] Brem, H; Lyder, C. Am J Surg., 188:9-17,2004. 





Epidemiology, Diagnosis and Management of Infected Chronic Wounds 

A.A.L.M. Rondas 1 , J.G.M.A. Schols 2 , RJ.G. Halfens 3 , E.E. Stobberingh 4 

1 De Zorggroep, Venlo, The Netherlands. Email: a.rondas@maastrichtuniversity.nl, 2 FHML-department 

General Practice, Maastricht University, The Netherlands. 3 Department of Health Care and Nursing 

Science, School for Public Health and Primary Care, Maastricht University, The Netherlands. 4 Academic 

Medical Centre, Maastricht, The Netherlands. 

Introduction 

Chronic wounds affect more than 1% of the U.K. 

population and cost society at least ₤1 billion per year 

[1], so the costs, both financial and emotional are high. 

At this moment there are no data on the number and 

costs of chronic wounds in the Netherlands. 

Although an accurate history may help to determine the 

initial etiology of a chronic wound, chronicity of dermal 

wound healing is often related to secondary factors such 

as infection or vascular insufficiency [2]. Chronic 

wounds contain a bacterial load that is different from the 

load found in acute, potentially contaminated, surgical 

and traumatic wounds [3]. In chronic wounds the signs 

of local infection and even systemic infection can be 

subtle or misleading. Therefore, already in1969, Robson 

proposed bacterial quantification as a potential 

technique to diagnose infection [4]. This strategy, 

however, has evolved into the excessive and 

indiscriminative tendency to culture chronic wounds, 

under the false hope that this will identify underlying 

infection. Wound cultures mostly will be positive and this 

finding subsequently has led to further promoting this 

false belief [5]. Moreover, this has invariably fostered 

the use of systemic broad-spectrum antibiotics with the 

associated risk of antibiotic resistance. The PhD study 

that will be presented, examines the number of 

(infected) chronic wounds in the Netherlands. Following 

the review of the literature on obtaining a culture 

specimen of a chronic wound, a more targeted and 

efficient method for wound culturing will be presented. 

Finally, the PhD study aims to validate the clinical 

symptoms of infected chronic wounds as published in 

the international guidelines of EWMA and WUWHS [6, 

7]. 

Methods 

Following the methodology of the Dutch National 

Prevalence Measurement of Care problems (LPZ) [8], 

the prevalence of (infected) chronic wounds will be 

assessed via a specifically developed module on 

(infected) chronic wounds which recently has been 

pilot tested. A systematic review has been conducted 

on the method to obtain in a validated way a culture 

specimen of an infected chronic wound. An empirical 

study will be performed to assess the clinical 

symptoms of an infected chronic wound [7]. 

Additionally, the symptoms mentioned in the current 

international standards [6,7] will be validated by taking 

a swab and a biopsy of the wound at the same time. 

63 

Results 

The following preliminary results will be presented: 

1. The prevalence of (infected) chronic wounds as 

assessed in the pilot study together with data on the 

feasibility of the newly developed LPZ module. 

2. The results of the systematic review on obtaining 

culture specimens of an infected chronic wound. 

3. The design of the planned empirical study on 

validating the symptoms mentioned in the current 

international standards. 

Discussion 

The total research project will further reveal the clinical 

relevance of infected chronic wounds and related to 

this the importance of an adequate strategy to manage 

them. Clear clinical and relevant microbiological 

confirmation of the presence of infection of a chronic 

wound is crucial for targeting an effective and efficient 

intervention, and to prevent the current practice of 

often unnecessary prescription of antibiotics. 


When the clinical diagnosis of infection of chronic 

wounds is made more accurately, it is conceivable that 

the actual arbitrary practice of prescribing antibiotics 

will reduce, and that the problem of antibiotic 

resistance may decrease. 


None. 

References 

[1] Thomas DW, Harding KG. Wound healing. British Journal of 

Surgery 89:1203-1205, 2002. 

[2] Mostow EN. Diagnosis and classification of chronic wounds. 

Clinics in Dermatology 12:3-9,1994. 

[3] Bowler PG. The 10 5 bacterial growth guideline: reassessing its 

clinical relevance in wound healing. Ostomy & Wound Management 

49:44-53, 2003. 

[4] Robson MC, Heggers JP. Bacterial quantification of open 

wounds. Military Medicine 134:19-24,1969. 

[5] Bowler PG, Duerden B, Armstrong D. Wound microbiology and 

associated approaches to wound management. Clinical 

Microbiology Reviews 14:244-68, 2001. 

[6] European Wound Management Association. Position Document: 

Identifying criteria for wound infection London: Medical education 

Partnership Ltd., 2005. 

[7] WUWHS: Infection. Principles of Best Practice Wound infection 

in clinical practice. An international consensus. London: MEP Ltd., 

2008. 

[8] Halfens RJG, Meijers JMM, Du Moulin MFMT, van Nie NC, 

Neyens JCL,Schols JMGA. Rapportage resultaten Landelijke 

Prevalentiemeting Zorgproblemen. Maastricht: Datawyse/ 

Universitaire Pers Maastricht, 2010. 


Thursday, 1st 

September, 14.30 

Parallel Sessions 

65




Pressure Ulcer Assessment 

Marco Romanelli, Valentina Dini, Isabella Banchini, Alice Canale, Sabrina Barbanera. 

Introduction 

Department of Dermatology, University of Pisa, Italy, m.romanelli@med.unipi.it 

Assessment of cutaneous wounds in 

order to detect the progression of a 

disease is a routine part of medical 

practice. Although measurement 

technology has evolved continuously 

over the years in all fields of 

medicine, its direct application to 

cutaneous disorders has increased 

only in recent years (1). In fact, only 

over the past decade has significant 

research been undertaken to further 

develop techniques for specifically 

examining the skin. Advances in both 

the technology of imaging and 

computer systems have greatly 

supported this process and brought it 

closer to the clinical area. The authors 

present a new wound measurement and 

documentation system. 

Methods 

We collected wound planimetry in 30 patients 

affected by pressure ulcers. To estimate the 

repeatability and the reproducibility of wound 

assessment, 2 female students participated 

in this study. The intra- and inter-rater 

reliability of measurement were observed 

using intraclass correlation coefficient (ICC) 

and Bland-Altman test. 

Results 

No statistically significant differences were 

found between scans evaluated by 2 

investigators about wound area and depth. 

The ICC values were excellent either for 

intra- or inter-rater reproducibility with a very 

low relative error value. The intra- and interrater 

measurement were demonstrated to be 

reliable as indicated by high ICC values (> 

0.80). The mean ± SD time for a full scan 

67 

acquisition on the wound area and depth was 

2.2 ±1.2 minutes. 

Discussion 

The scanner was found to be accurate and 

reliable, easy to learn and use, portable and 

compact. The results presented suggest that 

this device may be a viable choice in the 

management of different types of chronic 

wounds. 


Wound measurement is essential in 

assessing the progress of wound healing. 

The most commonly used tools include 

wound tracing, width and length 

measurements, and digital photography. 

This innovative device combines a digital 

camera and structured lighting in the form of 

2 laser beams to automatically correct for 

image scale and skin curvature, allowing 

rapid and accurate measurements of the 

wound surface area and depth. 


We appreciate the help of Mrs. Graziana 

Battaglia 


References 

[1] Schultz G, Mozingo D, Romanelli M, 

Claxton K. Wound healing and TIME: new 

concepts and scientific applications. Wound 

Rep Regen 2005; 13 (4): S1-S11. 





Retrospective analysis of patients with ulcers of (arterio-)venous, traumatic or decubitus origin 

treated with autologous skin substitute 

C.M.A. Reijnders 1 , L. Vink 1,2 , C.S. Blok 1 , R.J. Scheper 1,2 , C. van Montfrans 1 , E.M. de Boer 1,2 , S. Gibbs 1*,2 

1* VUmc, Netherlands, s.gibbs@vumc.nl; 2 A-Skin BV, Netherlands, 

Introduction 

We have developed an autologous full thickness living 

skin substitute consisting of reconstructed epidermis 

on fibroblast populated human dermis (SS) (Fig. 1). 

The SS is constructed from very small (3 mm 

diameter) punch biopsies of healthy skin taken from 

the patient during routine visits to the out patient clinic. 

The time taken to culture the SS is 3 weeks. The aim 

of this retrospective study was to evaluate the safety, 

efficiency and applicability of the SS together with the 

transferability of the protocol between different centres 

for treating chronic, hard to heal ulcers in an out 

patient as well as a hospitalized setting. The 

recurrence rate one year after complete healing was 

also assessed. Ulcers of (arterio-)venous (venous with 

in some cases an arterial component), post-traumatic 

or decubitus origin were treated in multiple studies 

between 2004 and 2009 in 7 Dutch centres. 

Methods 

Retrospectively a series of 5 studies (i) pilot, ii) 

insurance initiated, iii) nursing home, iv) individual 

case studies and v) an interim multicentre trial) were 

analysed. Ulcers of varying location, size and aetiology 

(e.g. (arterio-)venous insufficiency, post-traumatic, 

decubitus) were included. Sixty six ulcers (54 patients; 

ulcer size: 0.75-150 cm 2 ; duration: 0.25- 32 years) with 

a minimum follow-up time of 24 weeks after SS 

application were assessed. Wound-bed preparation 

consisted of vacuum-assisted-closure-therapy (5 days, 

hospitalized) or application of acellular dermis (5-7 

days, ambulatory). Patients received one application of 

SS followed by weekly evaluation and wound 

treatment. Time to heal, adverse events and 

recurrence rate one year after complete healing were 

recorded. 

Fig. 1: Full thickness autologous skin substitute 

68 

Results 

Complete ulcer healing occurred in 41 of 66 ulcers (62 

%). Ulcer size was significantly reduced at week 12 

compared to week 0 and week 24 compared to week 

12. At 12 weeks, ulcer size was significantly reduced 

in the hospitalized group compared to the out patient 

group. However after 24 weeks this difference 

between hospitalized versus out patient treatment was 

no longer observed. Ulcer recurrence was assessed 1 

year after time to complete closure. From the 41 

closed ulcers, 37 were available for follow-up, of which 

thirty (81%) were still closed. Only one minor adverse 

event was recorded (mild erythema of unknown cause 

around the area of the skin substitute which was 

successfully treated with systemic anti-histamine. 

Discussion 

This retrospective analysis shows that SS provides a 

safe and successful treatment for particularly hard to 

heal chronic ulcers of various origin. The protocol was 

transferable to 7 Dutch centres. The SS could be 

applied in an out patient setting making it more cost 

effective and less time consuming than hospitalized 

treatment. 


Treatment for closure of hard to heal chronic skin 

wounds 


We appreciate the help of all specialists, wound-care 

nurses and technicians involved in this study. 

Participating centres were: Phlebologic Centre 

Oosterwal, Nursing home Naarderheem, Groene Hart 

Hospital, Nursing home Ter Gooi, Red Cross Hospital 

Beverwijk, Waterland Hospital 


R.J. Scheper, E.M. de Boer and S. Gibbs are cofounders 

of the university spin off company A-Skin 

References 

[1] Gibbs S, et al. Br J Dermatol 155: 267-74, 2006 

[2] Spiekstra SW et al., Wound Repair Regen 

15(5):708-17, 2007. 

[3] Vriens AP et al., Cell Transplant 17(10-11):1199- 

209, 2008. 


Thursday, 1 st September, 14.30 

Room A4 

Stryker Symposium


STRYKER SYMPOSIUM 

Is it a Pressure Ulcer? SCALE & SOPE: Consensus and Cases 

Keynote/Host: Thomas P. Stewart, PhD 

Facilitator: Cynthia Sylvia, MSc MA RN CWOCN 

Speakers 

Diane L. Krasner PhD RN MAPWCA FAAN, Co-Chair 

R. Gary Sibbald MD FRCPC (Med, Derm) MEd MAPWCA, Co-Chair 

This program will present an overview of the two recent consensus panel initiatives; Skin Changes At 

Life’s End (SCALE) and Shifting the Original Paradigm Expert Panel (SOPE). Dr Stewart will welcome 

the participants with a greeting and his vision of the initiatives as they contribute to the evidence and the 

work that has come before. As introduction, a brief history of the evolution of the process implementing the 

modified Delphi method will be offered by Ms Sylvia. Dr Krasner and Dr Sibbald will each comment on both 

of the initiatives, based upon their experience as co-chairs of the Panels. The program will then proceed 

with a series of case presentations by the co-chairs illustrating SCALE and SOPE. The aim is to relate the 

work of the Panels to clinical practice and bring the evidence back to the bedside while facilitating a forum for 

participation by the attendees of the session. The session will conclude with closing remarks by Dr. Stewart. 

70


14.30 – 15.30 Free papers 2 Programme 

A 3-in-1 perineal care washcloth impregnated with dimethicone 3% 

vs. water and pH neutral soap to prevent and treat incontinenceassociated 

dermatitis: a randomized controlled clinical trial 

Dimitri Beeckman, UK 

Moisture Related Skin Excoriation: a retrospective review of 

assessment and management across 5 Glasgow hospitals 

Janice Bianchi, UK 

Skin the Greatest Organ. Back to the Essentials Using 

Millennium Technology 


71




A 3-in-1 perineal care washcloth impregnated with dimethicone 3% vs. water and pH 

neutral soap to prevent and treat incontinence-associated dermatitis: a randomized 

controlled clinical trial 

Dimitri BEECKMAN 1*, 2, 3 , Tom DEFLOOR † 2 , Lisette SCHOONHOVEN 4 , Katrien VANDERWEE 2 

1* King’s College London, United Kingdom, dimitri.beeckman@kcl.ac.uk, 2 Ghent University, Belgium, 

3 Artevelde University College, Belgium, 4 Radboud University Medical Center, The Netherlands 

Introduction 

Incontinence- associated dermatitis (IAD) is an 

inflammation of the skin in the genital, buttock or upper 

leg areas that occurs when urine and/or feces comes 

into contact with the skin [1]. The past decade has 

seen a huge growth in publications focusing on the 

clinical observation of IAD and the differentiation 

between IAD and pressure ulcers. Differentiation is 

particularly important since prevention and treatment 

are different. The clinical observation of IAD ranges 

from erythema (with or without loss of skin integrity) to 

cutaneous infections (such as candidiasis) [2]. IAD is 

often associated with redness, rash, or vesiculation [2]. 

The lesions are superficial, but are likely to become 

slightly deeper if an infection occurs [2]. 

An increasing amount of evidence draws attention to 

the importance of a consistent, defined skin care 

regimen to prevent and treat IAD. Although studies on 

the effectiveness of different regimens show extensive 

variation in their components, all of them include (1) 

gentle perineal cleansing, (2) the application of a 

moisturizer, and (3) the application of a skin 

protectant. 

Multiple studies showed that a single-step intervention 

has the potential to maximize time efficiency and to 

encourage adherence to the skin care regimen. These 

single-step products include disposable washcloths 

that incorporate cleansers, moisturizers, and skin 

protectants into a single product. 

The aim of this study was to compare the 

effectiveness of a 3-in-1 perineal care washcloth 

versus the standard-of-care (water and pH neutral 

soap) to prevent and treat IAD. 

Methods 

A randomized controlled clinical trial was designed. 

The setting included a random sample of 11 nursing 

home wards (6 experimental; 5 control) in a 

convenience sample of 4 nursing homes Belgium. The 

sample included nursing home residents at risk for 

and/or affected by IAD (defined as permanently 

incontinent for urine, feces, urine/feces, and/or having 

discoloration of the perineal skin (not caused by 

pressure/shear), and/or having an edematous skin in 

the genital area. Participants in the experimental group 

were treated according to a standardized protocol, 

including the use of a 3-in-1 perineal care washcloth 

impregnated with dimethicone 3%. Participants in the 

72 

control group received perineal skin care with water 

and pH neutral soap. The study period was 120 days. 

Data were collected between February and May 2010. 

IAD prevalence and severity were assessed using the 

IAD Skin Condition Assessment Tool. The surface 

(cm 2 ), redness, and depth of the perineal lesion were 

assessed daily by the nurses. This tool generates a 

cumulative severity score (Maximum score = 10) 

based on area of skin affected, degree of redness, and 

depth of erosion. 

Results 

In total, 464 nursing home residents were assessed 

and 32.9% (n=141) met the criteria for inclusion (exp. 

= 73, contr. = 68). Baseline IAD prevalence was 

comparable in both groups (exp.: 22.3% vs. contr.: 

22.8%, p=0.76). Baseline IAD severity was 6.9/10 in 

the experimental and 7.3/10 in the control group. A 

significant intervention effect on IAD prevalence was 

found (exp.: 8.1% vs. contr.: 27.1%, F= 3.1, p= 

0.003). A non- significant effect on IAD severity could 

be determined (exp.: 3.8/10 vs. contr.: 6.9/10, F= 0.8, 

p=0.06). (See figure 1) 

Figure 1. Evolution IAD prevalence and severity over time. 

Experimental 

Control 

Time 1 = day 1, 2= day 21, 3= day 42, 4= day 63, 5= day 91, 6= day 

119 


A defined standardized skin care regimen, including 

the use of a soft pre- moistened washcloth (3% 

dimethicone) resulted in a significantly reduced 

prevalence. The introduction of a 1- step skin care 

product needs to receive full attention. 


None 

References 

[1] Nix D. et al. Ostomy Wound Manag. 50: 59-62, 

2004 

[2] Gray M. et al. Am J Clin Dermatol. 11:201-10, 2010 





EPUAP Annual Conference 2011 Oporto Portugal 

Moisture Related Skin Excoriation: a retrospective review of assessment and management 

across 5 Glasgow hospitals 

Bianchi J 1* , Johnstone A 2 

1* Independent Medical Education Specialist, Scotland, Janice.bianchi@gmail.com 

2 NHS Greater Glasgow and Clyde, Scotland 

Introduction 

Skin excoriation is an extremely debititating and often 

very painful condition. It can also lead to the 

development of moisture lesions and/or pressure 

ulcers. In recognition of this, a skin excoriation 

grading tool was developed by members of the 

National Association of Tissue Viability Nurses 

Scotland in conjunction with Quality Improvement 

Scotland. The tool was introduced across NHS 

Greater Glasgow and Clyde (NHS GGC) between 

January and June 2009. This was followed by the 

introduction of clinical guidelines and a protocol on the 

use of for Faecal Management Systems (FMS) 

recognising that faecal incontinence can cause 

extreme irritation and skin injury to the perianal area 

due to bacteria and digestive enzymes within faecal 

matter (Johnstone 2005). In order to determine 

whether the excoriation tool and FMS guidelines were 

being implemented, a retrospective review of case 

notes was carried out across 5 NHS GGC hospitals. 

The main aim of the study was to answer the 

questions: 

1 Was there evidence that the excoriation tool was 

being used? 

2 Was a consistent approach in the management of 

patients with excoriation including the use of FMS? 

Methods 

One year after implementation, a retrospective review 

of the case notes of patients who had been referred to 

tissue viability services with skin excoriation was 

carried out. For the purposes of this study, data were 

collected on demographics, length of stay, treatment 

options and concordance with guidelines/excoriation 

tool. 

Results 

A total of 35 sets of case notes were reviewed. Of 

these 25 patients fitted the criteria for the study, the 

remaining 10 patients had chronic wounds but no 

evidence of skin excoriation. 

Table 1 details demographic details, it is noteworthy 

that that many patients had a prolonged length of stay, 

this was due to deteriorating medical condition in many 

but skin damage could not be excluded as a 

contributory factor. 

Table 1: Summary of demographic data and length of stay 

Age Sex LOS 

Range 39-89 

Mean 63.4 

F 16(64%) 

M 9 (36%) 

10-180 days 

Mean 40.8 days 

73 

Table 2 details the many different products being used 

to treat excoriation, some of which are outwith the 

recommendations of the excoriation tool. 

Table 2: Treatments recommended in excoriation tool vs 

treatments used 

Recommended: barrier cream, barrier film 

Used: Cavilon (cream, lollipop, spray); flamazine; canesten HC; 

hydrogel; aqueous cream; clotrimazole; fucidin, zinc and caster oil; 

doublebase; purilon; conotrane; 50:50 white soft paraffin in liquid 

paraffin; E45 

The excoriation tool uses a 1-3 grading system, there 

was no evidence of this system being used. The 

preferred option was the use of various adjectives 

such as: red; excoriated; erythema; raw; fragile; 

tender. 

All 25 patients were either admitted with or developed 

acute faecal incontinence prior to the onset of 

excoriation. NHS GGC Guidelines suggest FMS 

should be considered when this occurs. Casenote 

review indicated FMS were considered in 9 (36%) 

patients and used in 5 (20%). 

Discussion 

From the evidence presented here, there is little 

evidence that the excoriation tool had been used to 

inform decision making. 

Additionally the clinical guidelines on FMS do not 

appear to have been fully implemented with only a 

small percentage of patients assessed for the device. 


The onset of acute diarrhoea can cause skin injury 

within a short period of time. It is therefore essential 

that systems are put in place to minimize tissue 

damage. This study indicates that despite the fact that 

guidance was available, uptake was poor, therefore 

we need to develop better methods of disseminating 

information. A treatment pathway with consideration 

for circulation may be the next step. 


We appreciate the help of NHS GGC medical records 


This study was supported by an unrestricted 

educational grant by ConvaTec 

References 

[1] Johnstone A Wounds UK. 1;3:110-114, 2005 





Skin the Greatest Organ. Back to the Essentials Using Millennium Technology. 

Tracy Nowicki 1, Kerri Roosen 2, Paul Fulbrook 3 

1, 2 The Prince Charles Hospital, Australia, Tracy_Nowicki@health.qld.gov.au 

3 The Prince Charles Hospital, Australia PhD, MSc, PGDipEduc, BSc (Hons), Nursing Director, Research 

and Practice Development 

Introduction 

Pressure injury prevention is a priority due to the 

pain and discomfort for patients and the added 

expense of additional resources and increased 

length of stay in hospitals (1). In our hospital, 

despite ongoing pressure injury management 

including risk assessment, a base mattress 

replacement program, and acquisition of a variety 

of pressure relieving devices, pressure injury 

prevalence increased from 7.55% in 2006 to 

13.73% in 2008. Of the 75 pressure injuries 

identified, 43 (57%) were stage one. To address 

the increased prevalence we implemented a 

pressure injury prevention project, with the aims 

of improving practice to reflect evidence based 

guidelines and standardising continence, skin 

care, and nutrition management. 

This clinical update is based upon the findings of 

a recent clinical audit in our hospital. To 

determine evidence based practice, we took a cue 

from the latest pressure injury forums and 

investigated further evidence to guide our 

practice. The purpose of this update is use a 

pragmatic approach to outline current best 

practice with respect to continence, skin care and 

nutrition management, and to highlight some of 

the issues regarding customary practices. 

Results 

After implementing the actions described above, 

our pressure injury prevalence has decreased from 

13.78% in 2008 to 5.15% in 2010, which 

represents a 62% reduction. Of these pressure 

injuries, 53% were stage one. 

Discussion 

To prevent pressure injuries our experience 

indicates the importance of focusing on three key 

74 

areas of practice: continence, skin hygiene, and 

nutrition. These are a synergistic trio, and many 

patients require considered management in all 

three areas. In addition to targeting specific 

aspects of nursing care in these areas, it is also 

crucial that there is organisational buy-in for 

strategic initiatives. Some of the ways that we 

achieved this are outlined below: 

• Support from managerial level by presenting 

evidence and education to senior nurses and 

directors. 

• Nurse unit managers completed individual 

ward action plans outlining their individual 

commitments to reducing pressure injuries. 

• Providing support and education to staff to 

choose and use continence products 

effectively. 

• Support from allied health colleagues in 

prevention of pressure injuries. 

• Standardizing skin care and continence 

products 

• Removing continence mats from mattresses 

References 

(1) Duncan, K.D. 2007. Preventing pressure 

ulcers: the goal is zero. Joint Commission 

Journal on Quality and Patient Safety. 

33(10):605-610. 


Thursday, 1 st September 16.00 

Auditorium 

75


From the neonate to the young person – the development of 

the skin 

Dr Ana Garrido, Portugal 

77




Prevention of Pressure Ulcers in Pediatric Care 

Guido Ciprandi 1* , Enrico Castelli 2 , Michaela Carletti 3 and Massimo Rivosecchi 1 

1 Wound Care Pediatric Surgical Center, Dpt of Surgery and Transplantation, Bambino Gesu’ Children’s 

Hospital, Palidoro and Rome, Italy, guidociprandi@gmail.com 

2 Unit of NeuroRehabilitation, Bambino Gesu’ Children’s Hospital, Palidoro and Rome, Italy 

3 Unit of Microbiology, Bambino Gesu’ Children’s Hospital, Palidoro and Rome, Italy 

Introduction 

Prevention of Pressure Ulcers (PUs) in children begins 

from the maintenance of the skin integrity: accepting 

that the skin is the largest organ of the body this 

statement requires an heavy work and a complete 

understanding of the wound healing process, which is 

a complex regulated physiologic response to traumatic 

skin injury. Skin integrity, clinical examination, 

analysis of the risk, educational strategies, and a 

natural comprehension of the different PUs stages are 

the main tessera of the important wound care puzzle 

called “Prevention”. Pediatric is an heterogeneous age 

most prone to be affected by PUs because of the 

fragility of the skin, the thickness of the complex 

epidermis-dermis (less than 2.1 mm) and high-risk for 

skin breakdown (SB) patients: prematures, newborn. 

Methods 

During the last 6yrs, 363 children affected by Pressure 

Ulcers (Pus) were treated at Bambino Gesu’ Children’s 

Hospital for a total of 602 lesions. At the same time a 

Prevention’s Program had been instituted. Considering 

the differences from adults, children admitted to NICU, 

PICU, and NeuroRehabilitation Units have to be 

managed by an aggressive prevention. All kind of 

undue friction or pression at the level of occiput, ear 

and heels, which symbolizes in children the main 

affected sites by PUs (60%), must be avoided. The 

“head to toe” skin assessment, mobility, incontinence, 

nutrition, pain and an immediate counselling of the 

parents represent the 1 st step of our prevention 

protocol. The 2 nd step is the classement of the 

admitted patiens. We considered 6 top-risk class of 

children: 1. disabled, 2. still-motionless, 3. mentalimpaired, 

4. incontinent, 5. spinal and 6. syndromic 

patients. The third step is to pay more attention to the 

oedema development. Whatever is the cause, the prearteriolar 

space is increased, the distance between the 

capillary boundles and diffusion of the Oxygen to the 

tissues is reduced. The fourth step is the accurate 

surveillance of devices and a rotational protocol is 

advocated. 

Results 

Considering the 4 steps of the protocol, we analysed 

the difference between the 1 st period (2005-2007) vs 

78 

the 2 nd period (2008-2010) (Table 1). The Student 

unpaired t-test was used and is pointed at p


INTRODUCTION 



Validation and implementation of the Braden Q Scale 

Miguéns Cristina 1* , Ferreira Pedro 2 

1* Community Health Centre Figueira da Foz, Portugal, cristina.miguens67@gmail.com 

2 CEISUC,Portugal 

Many are the pressure ulcer risk assessment tools 

available for adult patients, valid and reliable. 

For paediatric population there are just a few 

tools, and in Portugal none is valid. 

To remedy this, we translate and validate the 

Braden Q scale for Portuguese paediatric 

population. 

OBJECTIVES: The purpose of this study was to: 

( 1) establish the predictive validity of Braden Q 

Scale for the Portuguese paediatric population;(2) 

determine the critical cut-off point for classifying 

children risk; (3)evaluate the prevalence and 

incidence rates during the all study 

METHODS: Multisite prospected cohort 

descriptive study. Sample of 263 children 

inpatient for at least 24 hours without pre-existing 

pressure ulcers or congenital heart disease, were 

enrolled from 4 wards ( Intensive Care Unit, 

Medicine, Surgery, Orthopaedics / 

Neurosurgery).The Braden Q score and Skin 

Assessment were independently rated and data 

collectors were blind to the other measures. 

Children were observed at each 48 hours, until 

discharge. 

Four prevalence studies were taking during the all 

study: 1 study, before start the application of the 

Braden Q and Skin Assessment. 

RESULTS: 

15 children developed pressure ulcers during the 

study (incidence rate = 5,7%). 

Most pressure ulcers (60%) developed at the third 

observation. 

The cut-off point of 22 for the paediatric 

Portuguese population, the sensitivity was 0,89 

and the specificity was 0,64. 

Interrater reliability between the coordinator 

group and local researchers was evaluated twice 

79 

during the study and the agreement is quite good 

for all subscales > 0,72 , except to subscale 

Moisture. 

The prevalence study demonstrates a decreased in 

the number of pressure ulcers, particularly 

following the use of the Braden Q scale and the 

Skin Assessment instrument. 

Actually , there are several Portuguese hospitals, 

paediatrics and no paediatrics, using the Braden Q 

scale, for the paediatric population. 



Student paper Competitions 

Room A4 


Pressure ulcer prevalence in critically ill patients: Nursing care, 

Hospital facilities, and the prevalence of pressure ulcers in Jordanian 

Intensive Care Units 

Rana Al Awamleh, UK 


Elizabeth McGinnis, UK 

Relationship Between “Tilt in Space” Wheelchair Function and Risk of 

Pressure Ulcer Development 

Christian Olesen, Denmark 

Room B4 



Amanda Jonsson, Sweden 

With or without a risk assessment scale? An evaluation of the Impact 

of the Braden Scale on allocation of preventive interventions to 

traumatological patients 

Sylvia Mallison, Germany 

80




Pressure ulcers prevalence in critically ill patients: Nursing care, Hospital facilities, and the 

prevalence of pressure ulcers in Jordanian Intensive Care Units. 

Introduction 

Rana Al-Awamleh 1* , Sanaa Al-Awamleh 2 , Marwan Al-Abadi 3 

1* University of Sheffield, School of Nursing and Midwifery, United Kingdom, 

corresponding author. E-mail address: nrp07ra@sheffield.ac.uk 

2 Jordanian Royal Medical Services, Jordan, 3 Jordanian Royal Medical Services, Jordan 

Pressure ulcers remain a serious problem in intensive 

care units in Jordan. There is very limited literature 

about this topic and the relationship between pressure 

ulcer development, the quality of care and the 

availability of hospital facilities.Therefore, this study 

aimed to investigate the pressure ulcers prevalence in 

government and private Jordanian hospitals, assess 

the nurses’ knowledge regarding pressure ulcers 

prevention measures, and evaluate the availability of 

the hospitals facilities and polices towards PUs care. 

Methods 

A descriptive cross-sectional comparison design and a 

prospective cross-sectional comparison design were 

used. First, an assessment of pressure ulcer 

prevalence through (EPUAP) prevalence survey was 

carried out. A total of 80 critically ill patients with 

pressure ulcers were included. PU prevalence data 

was analyzed by frequency distribution to determine 

the PU prevalence, and then the inferential statistics 

were used: Mann-Whitney U test, independent group ttest, 

and Chi-Square test. Second the nurses’ 

knowledge, interventions, and the availability of the 

hospitals facilities were assessed by using two survey 

questionnaires; the knowledge survey questionnaire, 

and interventions and hospital facilities questionnaire. 

A total of 115 registered nurses in the ICU in the six 

hospitals took part in the survey. Data analysis was 

carried out through different tests; knowledge 

questionnaire by descriptive statistics and Chi-Square 

test to compare the nurses’ knowledge perception 

between the two sectors. While, nursing interventions 

and hospital facilities survey through frequency 

distribution, Mann-Whitney U test, and Chi-Square 

test. 

Results 

Overall PU prevalence was 13%. 

Table 1: PU prevalence in both government and private 

hospitals. 

Institution PU Prevalence 

Government 14% 

Private 11% 

There is a lack in the knowledge dissemination 

particularly about non-useful measures, while useful 

preventive measures are more familiar among nurses. 

81 

Private hospitals were better than government 

hospitals in the availability and applicability of the most 

PUs prevention measures, PUs care policies, and staff 

education. 

Discussion 

PUs prevalence in Jordan was low comparing with 

many European counties for example; Germany 

(21.1%) [1], Australia (28.2%) [2], Italy (27%) [3], these 

results may be due to the differences in the 

demographic data and health care systems between 

Jordan and European countries. The prevalence in this 

study is close to the results were found previously in 

Jordan (12%) [4]. the nurses’ knowledge in Jordanian 

hospitals regarding the usefulness of pressure ulcers 

preventive measures are not up-to-date, which was 

similar to the nurses’ knowledge in Dutch hospitals [5]. 


This study considered as an original study because 

only one published work was found about this topic in 

Jordan, It is difficult to generalise western studies and 

apply their results in attempt to solve this problem in 

Jordan. The findings will guide policy makers, 

employers, nurses into promoting and enhancing the 

pressure ulcer care. 


We appreciate the help of everyone who facilitate the 

process of this research, especially Prof Roger 

Watson, Dr Mark Limb, and Prof Ruud Halfens. 


There are no conflicts of interest 

References 

[1] Lahmann N. et al., J. Ostomy/Wound 

Management.52: 20-33, 2006. 

[2] Gardner A. et al., J. Wound Practice and Research. 

17:134-145, 2009. 

[3] Capon A. et al., J. Advanced Nursing. 58: 263-272, 

2007. 

[4] Tubaishat A. et al., J. Tissue Viability. 20: 14-19, 

2011. 

[5] Halfens R. et al., J. International Journal of Nursing 

Studies. 32: 16-26, 1995. 






Elizabeth McGinnis 

Leeds Teaching Hospitals NHS Trust, England. Elizabeth.mcginnis@leedsth.nhs.uk 

Introduction 

Pressure ulcers result in suffering and morbidity to 

patients and are costly to the healthcare provider. 

Heels are a common location for pressure ulcers 

(PUs) [1]. Heel PUs are considered separate entities 

to other body sites as the physiology of the heel is very 

different: the epidermis is thicker, the dermis has no 

sebaceous glands and contains fatty pockets within 

the fascia; they are more prone to arterial disease, 

neuropathy and oedema. Interventions for healing all 

PUs include offloading the pressure, wound treatments 

and correcting intrinsic factors e.g. nutritional deficits. 

A systematic review of the evidence for effectiveness 

of support surfaces for offloading the pressure did not 

show efficacy of any specific type of support surface 

[2]. No studies have been identified which provide 

sufficient evidence for other healing interventions. This 

study aims to identify prognostic factors for healing 

heel PUs and offer insights that will inform future 

intervention studies. 

Methods 

A prospective cohort study was performed. Patients 

with heel PUs ≥ Category 2 were recruited from an 

acute hospital, in specific inpatients areas where heel 

ulcers were known to occur. Patients were followed up 

weekly while in hospital then monthly following 

discharge until healing or 18 months. Data was 

collected on factors thought to be prognostic for 

healing and included demographics, intrinsic factors, 

patient and ulcer characteristics, treatments both 

systemic and ulcer specific. Analysis was based on 

time to healing of each ulcer, this was performed using 

Cox proportional hazards (PH) models [3] with robust 

standard errors (SE) to allow for clustering. 

Results 

140 patients with 183 PUs were recruited. 77 (42%) 

ulcers healed, 88 (48%) did not heal as the patients 

died, 5 (3%) were on limbs which were amputated, 11 

(6%) had not healed after 18 months and 2 (1%) were 

lost to follow-up. Univariate analysis using a Cox 

proportional hazards model identified 12 variables 

which reached significance at the p≤0.2 level. Eight 

variables were entered into a multivariate model of 

which two emerged that reached significance at the 

p≤0.1 level: severity of the ulcer and the presence of 

peripheral vascular disease. 

Discussion 

This study is the first known of its kind. 

82 

More than half of the ulcers did not progress to healing 

as a consequence of the death of the patient. 

Several factors emerged from the univariate model 

which affected the probability of healing but not all of 

these reached the p≥0.2 level of significance, these 

could have occurred by chance or were due to the 

small sample size. 

This cohort consisted of a specific patient population 

where heel PU were known to occur, results may not 

be generalisable to other hospital populations however 

as two thirds of the data collection occurred in the 

community it seems reasonable to apply cautionary 

generalisability to this care setting too. 

Data on recruitment rates, duration and outcomes from 

this study can be used inform future intervention 

studies. 


As severe pressure ulcers are likely to take longer to 

heal than superficial ulcers thus long term care plans 

should reflect their needs for ongoing ulcer 

management. The presence of PVD is also likely to 

delay healing; all heel pressure ulcer patients should 

have their peripheral arterial status established to 

inform ongoing ulcer management. 


This study was supported by a Charitable Trustees 

Fellowship from LTHT and a Smith & Nephew/ Multiple 

Sclerosis Society Studentship 

Academic supervisors: Prof EA Nelson, Prof JE Nixon, 

Dr D Greenwood 


None. 

References 

[1] Dealey C. The size of the pressure ulcer problem in 

a teaching hospital. Journal of Advanced Nursing 16: 

633-70, 1991 

[2] McGinnis E. Support surfaces for healing pressure 

ulcers: A Cochrane Systematic Review. Proceedings 

of the 12 th Annual European Pressure Ulcer Advisory 

Panel Meeting. Amsterdam, Holland. 2009 

[3] Cox DR. Regression models and life tables (with 

discussion). Journal of the Royal Statistical Society. 

Series B 34:187-220, 1972 





Relationship Between “Tilt in Space” Wheelchair Function and Risk of Pressure Ulcer 

Development 

Introduction 

Olesen, C.G. 1* , Siefert, A. 2 , de Zee, M 3 , Pankoke, S. 2 , Rasmussen, J. 1 

1* M-Tech, Aalborg University, Denmark, (cgo@m-tech.aau.dk) 

2 Wölfel Beratende Ingenieure GmbH + Co.KG, Würzburg, Germany 

3 Department of Health Science and Technology, Aalborg University, Denmark, 

It is well acknowledged that sustained mechanical 

loading of soft tissues causes pressure ulcers [1]. 

The wheelchair adjustments affect the tissue loading in 

the sense that the tissue stresses, and thereby the risk 

of ulceration, change when the seated posture is 

adapted [2]. This study focuses on a basic wheelchair 

adjustment called the “Tilt-in-Space” function, with 

which many wheelchairs are equipped. The tilt-inspace 

function enables the cushion and backrest to 

incline while the angle between the cushion and 

backrest is kept constant [3]. When the tilt-in-space 

function is used, the cushion and the backrest reaction 

forces change, which causes a change in tissue 

deformation under the buttocks. This study focuses on 

investigating how much the reaction forces between 

the body and the chair change when tilted in space; 

this information will then be used to estimate how the 

buttock tissue is deformed. 

Methods 

The Seated Human computational model from the 

AnyBody Modeling System was used to calculate 

reaction forces acting between the seat and the 

human for different postures. The model has been 

validated with respect to the calculated forces by 

experimental data. 

Figure 1 show the seated AnyBody model not tilted, and 

tilted 

The “Tilt-in-Space” function was modeled by fixing the 

cushion and backrest at a 90° angle relative to each 

other. The chair was then rotated backwards with 5° 

increments to a maximal inclination of 45° and the 

reaction forces for each increment were computed. 

The calculated reaction forces were then applied as 

boundary conditions to the human body model 

CASIMIR. In the interest of limiting computational time, 

the finite element model only comprises the buttocks. 

Finally the tissue deformation changes caused by the 

“Tilt-in-Space” function were evaluated. The FE-model 

83 

used was a commercially available model developed 

by Wölfel, Würzburg, Germany [4]. 

Figure 2 Human body model CASIMIR used for 

calculating tissue deformation 

Results 

Preliminary results show that the reaction forces 

between the seat and the buttocks change, and this 

leads to a change in buttocks tissue deformation. 

Discussion 

The preliminary results found in this study indicate that 

the “Tilt-in-Space” function found on many wheelchairs 

is not optimal, with respect to risk of developing 



This work is clinical relevant for wheelchair designers 

who aim to enhance wheelchair design with respect to 

prevention of pressure ulcers. 


This work was supported by the project Minimizing the 

risk of developing a pressure ulcer (ERDFN-09-0070), 

supported by Growth Fund North Denmark and 

European Regional Development Fund. 


There were no conflict of interests 

References 

[1] Romanelli M. et.al. Science and Practice of 

Pressure Ulcer Management, Springer, 2005 

[2] Bush TR. et.al. J.Biomech.Eng. 129: 1: 58-65, 

2007. 

[3] Michael SM et.al. Clin.Rehabil. 21: 12: 1063-1074, 

2007 

[4] Siefert A. et.al. Int.J.Ind.Ergonomics 38: 5-6: 410, 

2008. 






Amanda Jönsson 1* , Erica Engman 2 

1* Red Cross University College, Sweden, erica.engman@hotmail.com 

Introduction 

Although Pressure ulcer is common in high and middle 

income countries it is rarely researched in low income 

countries. Evidence based interventions of pressure 

ulcer prevention are developed but the gap between the 

evidence and the clinical practice is wide. The Aim of 

this study is to describe the nurses’ knowledge about 

pressure ulcer prevention at a provincial hospital in 

Ghana. 

Methods 

An empirical qualitative approached was used and 

semi-structured interviews were made with nurses at 

the Kwahu Governmental Hospital in Atibie, Ghana. 

The interviews were then analyzed using a content 

analysis and a deductive content analysis. In addition 

the material was compared against categories made 

out of the evidence based nursing interventions 

suggested by the North American Nurses Association 

(NANDA)[1]. 

Results 

Table 1: The themes and categories found 

Themes 

Categories 

PRESSURE ULCER 

PREVENTION 

Pressure 

Mobilization 

Friction and shear 

Moisture 

Cleaning 

Massage 

Patient education 

Caregiver education 

Risk patients 

Risk areas 

Documentation 

Nutrition 

NURSES 

KNOWLEDGE 

Knowledge 

achievement 

Opinion about 

achieved 

knowledge 

84 

Discussion 

The themes Pressure ulcer prevention and Nurses’ 

knowledge were found. Most of the evidence based 

interventions were mentioned by the participants. Thus 

the participants explained massage as a preventive 

intervention although the evidence advice against 

massage. The participants did not mention any 

interventions considering documentation and nutrition. 

Further the nurses explained that they achieved their 

knowledge in school by practical demonstrations and 

examinations. The nurses’ opinion was that their 

knowledge is enough to prevent pressure ulcers. 


Competent nurses are one of the most important 

resources to build up the hospital care in a country 

This study gives a view of the knowledge nurses in a 

low income country possess, but also a sense of what 

to improve for the nursing care on pressure ulcer 

prevention to be fully evidence based. 


We appreciate the help of Lotta Lundberg and Lars 

Strömberg att the Red Cross University College. We 

also thank Mrs. Osabutey at the Kwaho Midwifery 

Nurses’ School and Dr. Osabutey and all the staff at 

Kwaho Governmental Hospital for making this study 

possible. 


References 

[1] Author A. et al., J. Tissue Viability. 10:1-10, 2009 

[2] Author B. et al., J. Wound Care. 11:155-7, 2007 





With or without a risk assessment scale? An evaluation of the impact of the Braden Scale on 

allocation of preventive interventions to traumatological patients 

Sylvia Mallison 1 , Laura Kremer 1 , Anne Junghans 1 , Katrin Balzer 1 

1 Institute for Social Medicine, Universität zu Lübeck, Germany, katrin.balzer@uk-sh.de 

Introduction 

Traumatological patients are exposed to increased 

pressure ulcer (PU) risk but seem to be systematically 

under-supplied with preventive measures [1]. To date 

the evidence whether use of a pressure ulcer risk 

assessment scale (PURAS) improves PU preventive 

care in hospital patients is lacking [2]. Therefore, 

following research question was investigated: Does 

routine use of the Braden Scale (BS), one of the 

widespread PURASs in German hospitals, increase 

the number of traumatological patients at high PU risk 

receiving adequate preventive measures? 

Methods 

A quasi-experimental study was conducted in 2 

independent traumatological wards at one university 

hospital. In ward A, nurses regularly used the BS 

along to their clinical judgement over a period of 6 

months (intervention periods 1+2). In ward B, for 3 

months nurses appraised patients’ PU risk based on 

their clinical judgement alone (intervention period 1). 

They were asked to regularly document their 

assessment result by means of a four step global 

judgment scale. After this period, nurses in ward B 

also used the BS along to their clinical judgement 

(intervention period 2) (Fig. 1). 

Fig. 1: The trial setup. (*assessment of current state of 

preventive practice, **Training in use of Braden Scale before 

start of intervention phase 2, mo=months) 

Patients aged ≥18 years, not suffering from PU >grade 

1 and having an expected length of hospital stay ≥5 

days were eligible for consecutive inclusion. 

Data were collected by trained study assistants who 

regularly observed patients for presence of risk 

factors, preventive interventions and PU. Primary 

endpoint was presence of adequate preventive 

measures when patients were noted to be at high PU 

risk for the first time during follow-up as assessed by 

study assistants. Prevention was considered adequate 

85 

if patients at high risk received two pressure-relieving 

interventions at least, e.g., repositioning, pressureredistributing 

support surface, or offload of the heels. 

Results 

In total, 571 patients were included, with 377 being 

assessed at high PU risk (232 in intervention periods 1 

or 2). Univariate analysis revealed non-significant 

differences between study groups in the primary 

endpoint. However, these differences are inconsistent 

in direction and size of impact of BS (Tab. 1). 

Table 1: Univariate results for primary endpoint 

Patients with ≥2 

pressure-relieving 

measures (%) 

Ward A: periods 

27 (27 %) 

1+2 (BS) n=100) 

Ward B: period 1 

19 (25 %) 

(GJ) (n=76) 

Ward B: period 2 

8 (15 %) 

(BS) (n=55) 

BS=Braden Scale, GJ=Global Judgement 

Odds Ratio (95 CI) 

Inter-group Intra-group 

1,11 

(0,21-2,19) 

0,51 

(0,21-1,27) 

Discussion 

Use of the BS seems to have had no clear-cut effect 

on allocation of preventive measures to patients at 

high PU risk in this trial. Further analyses are required 

to control for the impact of baseline differences 

between study groups. Explorative analyses are 

planned to identify clinical characteristics of patients 

whose risk is likely to be overseen and to assess the 

impact of sub-adequate prevention on PU incidence. 


Results from awaiting trial analyses are expected to 

reveal critical issues for improving nurses’ PU risk 

assessment and preventive care in traumatological 

patients. 


This trial was funded by a grant of the foundation 

B. Braun Stiftung. The funding source had no role in 

design and conduct of the study. All authors declare 

that they have no conflict of interest. 

References 

[1] Baumgarten M. et al., Gerontologist. 50: 253-262, 

2010 

[2] Kottner J. et al., J Multidiscip Healthc 3:103-111, 

2010. 




TexiSense « Smart Sock » - Textile Pressure Sensor and 3D Realtime 

Finite Element Model of the Diabetic Foot for a Daily Prevention 

of Pressure Ulcers 

Marek Bucki, France 

Energy expenditure and balance in pressure ulcer patients: a 

systematic review and meta-analysis of observational studies 

Emanuele Cereda, Italy 

A Different Type of Expertise; patient and public involvement in 

pressure ulcer research 

Delia Muir, UK 

Pressure Ulcer healing with electrical stimulation: Achievements 

translated to clinical guidelines. 

Luther Kloth, USA 

86




The TexiSense « Smart Sock » - Textile Pressure Sensor and 3D Real-time Finite Element 

Model of the Diabetic Foot for a Daily Prevention of Pressure Ulcers 

Introduction 

M. Bucki 1*,3 , N. Vuillerme 2 , F. Cannard 3 , B. Diot 4 , G. Becquet 5 , Y. Payan 1 

1* TIMC-IMAG, Université Joseph Fourier, La Tronche, France, marek.bucki@imag.fr, 

2 AGIM FRE 3405 CNRS, Université Joseph Fourier, EPHE, La Tronche, France, 

3 TexiSense, www.texisense.com, Montceau-les-Mines, France, 

4 IDS, Montceau-les-Mines, France, 5 Centre de l’Arche, Saint Saturnin, France. 

The term « diabetic foot » refers to a set of foot 

pathologies essentially stemming from the neuropathy 

and arteriopathy of the lower limb associated with 

diabetes mellitus. Chronic ischemia weakens the 

healing potential and favours the development of 

wounds on a more vulnerable foot. Friction or repeated 

micro-traumas can lead to an ulceration (which in turn 

can end up in an amputation) that will remain 

unnoticed because of the somato-sensory deficiency. 

The current prevention techniques largely relying on 

visual inspection of the foot and enhancement of the 

foot/insole interface are not fully satisfying as the 

prevalence of plantar ulcers remains very high [1]. 

Methods 

A device for the prevention of plantar ulcers – called 

“Smart Sock” is described. It consists of (cf. Fig. 1): 

1. A sock made of a 100% textile pressure sensing 

fabric developed by the TexiSense company; 

2. A microcontroller running a biomechanical model of 

the soft tissues of the foot of the diabetic person; 

3. A vibrating watch (or a smartphone) used to warn 

the bearer if an overpressure pattern threatens the soft 

tissues integrity. 

Fig. 1: Overview of the “smart sock” device. 

Internal overpressures within the soft tissues, 

especially nearby bony prominences are likely to 

evolve into deep foot ulcerations. A linear Finite 

Element biomechanical model of the foot is used to 

compute estimates of internal pressures magnitudes 

based on the external pressures measured by the 

sock/sensor. The device sends a vibro-tactile alert in 

case of occasional overpressure or excessive stress 

dose accumulated during daytime activities. 

Thanks to the linear nature of the model its global 

deformation can be computed as a linear combination 

of a set of elementary deformations pre-computed offline 

and stored in the device memory [2]. 

87 

Results 

Internal stresses and stress doses are estimated in 

real-time as the pressure values reading and the Finite 

Element model update require less than 100 

milliseconds. Figures 2 and 3 show a colormap of the 

Von Mises equivalent internal stress on a sagittal slice 

within the 3D model of the foot. 

Fig. 2: Internal pressure patterns in forefoot stance. 

Fig. 3: Internal pressure patterns at heel contact. 

Discussion 

The TexiSense “Smart Sock” can be designed so that, 

when worn, pressure sensors fall onto sensitive 

anatomical areas such as the dorsal side of the toes or 

the posterior side of the heel, which makes it also 

possible to monitor regions located outside the sole of 

the foot. 


The continuous use of the device, compatible with 

daytime activities of the diabetic person, helps 

compensate for the lack of attention in the prevention 

of pressure ulcer formation. 


This project is supported by ANR Tecsan 2010 and the 

Techtera competitiveness pole. 

Conflict of Interest None. 

References 

[1] Boulton, A.J.M, et al. The global burden of diabetic 

foot disease. The Lancet, Vol. 366, pp. 1719-1724, 

2005. 

[2] Cotin S. et al. Real-time elastic deformations of soft 

tissues for surgery simulation. IEEE Trans. on Vis. and 

Comp. Graphics, 5(1), pp. 62-73, 1999. 





Energy expenditure and balance in pressure ulcer patients: a systematic review 

and meta-analysis of observational studies 

Emanuele Cereda 1* , Catherine Klersy 2 , Mariangela Rondanelli, 3 Riccardo Caccialanza 1 

1* Servizio di Dietetica e Nutrizione Clinica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, 

e.cereda@smatteo.pv.it 

2 Servizio di Biometria ed Epidemiologia Clinica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy 

3 Ambulatorio di Dietologia, Dipartimento di Scienze Sanitarie Applicate e Psicocomportamentali, Sezione 

di Nutrizione, Azienda di Servizi alla Persona di Pavia, Università degli Studi di Pavia, Pavia, Italy 

Introduction 

Nutritional treatment is reported to contribute to wound 

healing [1,2] and current guidelines recommend 

prescribing an energy intake of 30-35 Kcal/kg/day. 

However, such advice is based on expert consensus, 

rather than rigorous methodological approach. 

Moreover, the effectiveness of interventions requires 

an accurate estimation of individual energy needs 

which in turn rely on accurate methods of assessment. 

The primary aims of this systematic review and metaanalysis 

were to evaluate 1) the resting energy 

expenditure (REE) of pressure ulcer (PU) patients 

compared to matched controls and 2) the potential 

estimation bias of REE predictive equations and 3) to 

estimate the recommendable daily requirements in 

PUs. The energy balance of PU patients (daily energy 

requirements vs calorie intake) was also considered. 

Methods 

All-language original full-text research articles, 

published between 1 January 1950 and 31 July 2010 

were searched through electronic databases. Relevant 

studies were also identified by citations reviewing. 

Only studies providing data on measured REE were 

initially included. Data extracted were: measured REE, 

predicted REE and daily calorie intake. 

Fig. 1: Flow diagram of systematic review of literature. 

88 

Results 

Five studies were included in the meta-analysis. PU 

patients (n=92) presented higher measured REE than 

controls (n=101) and predicted REE (by Harris- 

Benedict formula in all the studies). In PU patients 

(n=78) energy intake was also significantly lower than 

total daily requirements that it were computed being 

29.9±2.8 kcal/kg/day (median, 30.6 [25th-75th 

percentile, 26.1-32.5]). 

Discussion 

PU patients are characterized by increased REE. In 

the estimation of REE by Harris-Benedict formula a 

correction factor (x 1.1) should be considered. A 

calorie intake of 30 Kcal/kg/day seems appropriate to 

cover daily requirements. The monitoring of energy 

intake in such patients is recommended also toward 

the potential necessity to plan guideline-based 

nutritional interventions. 


As suggested by current international guidelines a 

calorie intake of 30 Kcal/kg/day seems appropriate to 

cover the daily requirements of PU patients. Given the 

positive effect of nutritional support on the healing 

process, the monitoring of energy intake and the timely 

planning of appropriate guideline-based nutritional 

interventions to cover energy needs is advisable. 


We wish to thank Professor Patrick Ritz (Toulouse 

University Hospital, France) for kindly providing us all 

the original data necessary to complete the study. 

Funding: The study was supported by the Fondazione 

IRCCS Policlinico San Matteo and by an Investigator 

Grant from Nutricia (to EC). 


None to be reported 

References 

[1] Cereda. et al., J. Am. Geriatr. Soc. 57:1395-402, 

2009 

[2] National Pressure Ulcer Advisory Panel (NPUAP) 

and European Pressure Ulcer Advisory Panel 

(EPUAP). Prevention and treatment of pressure 

ulcers: clinical practice guideline. Washington, DC: 

National Pressure Ulcer Advisory Panel; 2009 





A Different Type of Expertise; patient and public involvement in pressure ulcer research 

Introduction 

Recent healthcare reforms in the UK have pushed for 

a more patient centred National Health Service (NHS), 

where pateints play a central role in their own care and 

have more choice about the services they use. 

Patients and carers are increasingly being recognised 

as experts by experience as they live with conditions 

on a day to day basis. This cultural change is being 

reflected in healthcare research. Patient and Public 

Involvement (PPI) in research is widespread in the UK 

and researchers are now required to demonstrate 

active PPI at all stages in the research process. 

INVOLVE, the Department of Health funded PPI 

advisorary body, describe 3 levels of involvement, 

Consultation: Seeking people’s views and ideas and 

using these to inform decision making. 

Collaboration: Active, ongoing partnership in which 

patients and the public are involved in the research 

process. 

User control: People who use services are in charge 

of the research. 

Many funding bodies now require researchers to 

demonstrate a minimum level of PPI as early as the 

grant application stage. 

PPI is a growing field and involvement in pressure 

ulcer research is perhaps less developed in 

comparission to other areas. This is partly due to the 

lack of existing patient groups or charities with a 

pressure ulcer focus. Also the complex needs and comorbidities 

which much of the pressure ulcer 

population experience makes recruiting and supporting 

people challenging. 

Methods 

To combat this, the Leeds Clinical Trials Research 

Unit (CTRU) have brought together patients, carers 

and family members with personal experience of the 

prevention or treatment of pressure ulcers to form a 

network. This is known as the UK Pressure Ulcer 

Research Service User Network (PURSUN). 

We have taken a flexible, asset based approach to 

involvement which allows network members to take on 

varying roles depending on their skills, needs and the 

level of commitment they feel able to give. 

Network members are prepared and supported by a 

dedicated PPI officer. Preparation includes a series of 

Delia Muir 1* , Jane Nixon 2 

1* University of Leeds, UK, d.p.muir@leeds.ac.uk 

2 University of Leeds, UK 

89 

workshops based on the Patient Learning Journey 

Model [1]. 

The structure and terms of reference for the network 

have been developed collaboratively with network 

members. 

Results 

Members of PURSUN are now actively involved in 

pressure ulcer research at CTRU and beyond. So far 

their activities have included: 

• Contributing to the development of a new clinical 

trial, including one member being a co-applicant. 

• Sitting on the Pressure Ulcer Programme of 

Research (PURPOSE) steering committee and 

sub groups. 

• Contributing to the development of a Pressure 

Ulcer Minimum Data Set (PUMDS) and Risk 

Assessment Framework (PURAF) 

• Helping to develop a patient focused website 

Discussion 

Members of PURSUN have been able to use their 

personal experiences of living with pressure ulcers and 

accessing healthcare to inform research. This is 

something which researchers have found very usuful. 

By working in partnership with academics and 

clinicians network members bring a different and 

valuable perspective to the research process. This can 

help to ensure that research is grounded in real world 

experineces and is relevenat to the people it is 

ultimately aiming to benefit. 


PPI in pressure ulcer research can help to ensure that 

research is relevant to the public and has an impact in 

the clinical environment. 


We would like to acknowledge all members of the 

PURSUN network and the PURPOSE project team. 


None 

References 

[1] Morris P, Dalton E, McGoverin A and Symons J. 

Preparing for patient-centred practice: developing the 

patient voice in health professional learning, In: 

Bradbury H, Frost N, Kilminster S, Zukas M. Beyond 

Reflective Practice, Routledge, Oxford, 2009. 





Pressure Ulcer Healing with Electrical Stimulation: Achievements Translated to Clinical 

Guidelines 

Luther C. Kloth 

Department of Physical Therapy, Marquette University, United States, (luther.kloth@marquette.edu) 

Introduction 

Humans and other mammals have natural 

endogenous electric field signals that guide cells to 

migrate directionally to heal epithelial wounds. 

Physiological electric fields have been shown to 

override other guideance cues that direct epithelial cell 

migration at the wound edge [1, 2]. Pharmacologic in 

vivo manipulation of ion transport has been shown to 

regulate the endogenous wound electric fields and 

effects wound healing [3]. During the past 30 years 20 

RCTs (9 on pressure ulcers) have provided strong 

evidence that supports exogenous electric field 

stimulation (EEFS) as a wound healing intervention. A 

meta-analysis has validated the research findings of 

the 9 RCTs with the strongest evidence [4,5,6] 

supporting pressure ulcer (PU) healing [Table 1]. Best 

practice clinical guidelines including that of EPUAP / 

NPUAP have strongly recommended EEFS as a PU 

treatment. Using EEFS to enhance healing of PUs and 

other chronic wounds requires that one understand the 

types of electrical currents, waveforms and devices 

that have been reported to enhance wound healing. 

Methods 

Proof of the existence of endogenous electric fields 

and their influence on wound healing based on 

evidence will be presented. In addition, evidence from 

clinical trials and best practice guidelines showing that 

EEFS enhances PU healing will be presented (Fig. 1). 

Identification and description of appropriate electrical 

currents, waveforms, devices and treatment protocol 

will also be explained [7]. 

Fig. 1: Exogenous electric field stimulation setup. 

90 

Results 

Table 1 

Discussion 

Human skin has an inherent bioelectrical system that 

significantly contributes to wound healing. Augmenting 

this system with exogenous electric field stimulation 

may explain why several RCTs have confirmed that 

this intervention plus standard wound care (SWC) 

hastens the rate of healing faster than SWC alone. 

Although different combinations of electric field 

parameters (pulse frequency, duration and amplitude) 

have been used nevertheless, since the electrical 

charge quantity in these studies fell between 250 and 

500 µC, this dosage delivered to the wound tissues 

produced positive wound healing outcomes. 


EEFS for healing pressure ulcers is supported by 

strong evidence from RCTs 


Thank you to Dr. Min Zhao for permission to use 

several of his illustrations in my presentation. 

Conflict of Interest - None 

References 

[1] McCaig CD, et al. Physiol Rev. 85, 943-78, 2005. 

[2] Zhao M, et al. Nature. 442, 457-60, 2006. 

[3] Song B, et al. Proc Natl Acad Sci USA 99:13577- 

582, 2002. 

[4] Feedar J, et al. Phys Ther 7: 639-49, 1991. 

[5] Gentzkow G, et al. WOUNDS 3: 158-70, 1991. 

[6] Wood J, et al. Arch Dermatol 129: 999-09, 1993. 

[7] Kloth LC, Zhao M. Endogenous and exogenous 

electric fields for wound healing. In: McCulloch JM, 

Kloth LC Wound Healing: Evidence Based 

Management , 4 th ed. F.A. Davis Co., Philadelphia, 

2010. 





Yohan Payan, France 


Ami Hommel, Sweden 

Preventable hospital-acquired pressure ulcer prevalence in Western 

Australian Public Hospitals: Serial data 2007 – 2009 

Jenny Prentice, Australia (replacing Mulligan) 

Pressure Ulcer Prevalence Reductions Seen from the International 

Pressure Ulcer Prevalence Survey 

Charlie Lachenbruch, USA 

91





Olivier Chenu 1,2 , Yohan Payan 1 ,Petra Hlavackova 1,3,4 , Marek Bucki 5 ,Bruno Diot 2 , 

Francis Cannard 5 , Jacques Demongeot 1,3 , Nicolas Vuillerme 1,3,4 

1* TIMC-IMAG UMR CNRS 5525 Grenoble Joseph Fourier University, France, olivier.chenu@imag.fr 

2 IDS, France, 3 AGIM FRE 3405 CNRS-Grenoble Joseph Fourier University-EPHE, France, 

4 Clinical Investigation Centre devoted to Technological Innovation, Raymond Poincaré University 

Hospital (AP-HP) Garches, France, 5 TexiSense, France 

Introduction 

Currently available techniques and/or protocols 

designed to prevent pressure sore formation in 

persons with spinal cord injury and wheelchair users, 

mainly based on the improvement of the skin/support 

interface and on a postural and behavioural education 

are not efficient. Indeed, the prevalence and incidence 

of pressure sore still remains very high, so that 

development and validation of an efficient solution to 

prevent pressure sore is strongly needed. 

Methods 

In this study, we adopted a user-centered approach 

which involves the end-users as real actors in the 

design decision making process to design, develop 

and assess an embedded biofeedback system for 

pressure sore prevention. The results of two 

complementary studies we conducted are presented: 

1. a participative conception study aimed at 

determining paraplegic persons’ needs, values, 

requirements and preferences; 

2. a usability study aimed at assessing the degree 

of effectiveness, efficiency and satisfaction with which 

they can use the embedded pressure sore prevention 

system. 

Results 

Results of the study using participative design 

methodology lead us to design and prototype the 

following embedded device for pressure sore 

prevention (VIGI-SORE) (Fig. 1) which consists in: 

1. putting a pressure mapping system onto the chair 

seat area that allows continuous and real-time 

acquisition of the pressure applied on the seat/skin 

interface; 

2. detecting/identifying excessive buttock pressure 

concentration (localization, intensity, duration); 

3. estimating the user’s posture modification that 

would reduce this overpressure concentration through 

mathematical modelling and the data-processing 

simulation of the relationship between buttock 

pressure distributions and seated postures; 

4. if necessary, sending this information to the user 

who could be (i) alerted via wrist vibratory stimulation 

provided by an in-house watch and (ii) informed of the 

localization of the excessive seated buttock pressure 

via a visual display (e.g., Smartphone). 

92 

Fig. 1: Principle of functioning of VIGI-SORE system [1]. 

Results of the usability study showed that paraplegic 

persons were able to use feedback information 

provided by wrist vibratory stimulation and visual 

display to make appropriate postural changes that 

reduce buttock overpressures in seated posture, with 

ease, effectiveness, efficiency and satisfaction. 

Discussion 

This study demonstrates the feasibility and the 

usability of the VIGISORE system for pressure sore 

prevention in paraplegic persons. Based on these 

encouraging results, this system is planned to be 

clinically assessed in real-life condition during a long 

period of time with the use of a fully wireless 

customizable and washable mat made of a textile able 

to measure and estimate in real time the internal 

sacral/buttock pressures [2]. 


Thanks to a user-centered approach, VIGI-SORE 

could offer the possibility to provide a reliable and 

usable solution to pressure sore formation in persons 

with spinal cord injury and wheelchair users. 


We appreciate the help of the IDS company (France), 

Grenoble Alpes Valorisation et Innovation 

Technologique, Pôle d’Allongement de la Vie Charles 

Foix, Carnot Institute LSI, Garches Foundation and 

AXA Research Fund. 


None. 

References 

[1] Vuillerme N. et al.., WO2010/057926. 

[2] Bucki et al., Proceedings of the 14th Annual 

European Pressure Ulcer Meeting, 2011 






Ami Hommel 1* , Carina Bååth 2 , Ewa Idvall 3 , Lena Gunningberg 4 

1* Lund University & Skåne University Hospital, Sweden, Ami.Hommel@med.lu.se 

2 Karlstad University & County Council of Värmland, Sweden 3 Malmö University & Skåne University Hospital, Sweden 

4 Uppsala University & Uppsala University Hopital, Sweden 

Introduction 

Two hospitals in Sweden conducted in 2002 the first 

pressure ulcer prevalence study, using the 

methodology developed by the European Pressure 

Ulcer Advisory Panel (1). The methodology has spread 

to many hospitals and nursing homes and shows 

prevalence that vary between 19-27% when pressure 

ulcer category 1 is included (2,3). But there has also 

been quality improvement work using different 

methodologies, which make it difficult to compare 

outcomes. In Sweden there are about 100 quality 

registries and public comparison is available between 

the 21 county councils and regions. These quality 

registries have focused on medical diagnosis and few 

include nursing sensitive quality measures. The 

Swedish Associations of Local Authorities and 

Regions (SALAR) launched a patient safety initiative in 

2007. One out of six areas that were prioritized was 


The aim of this study was to describe pressure ulcer 

prevalence and prevention in hospitals and nursing 

homes on a national level. 

Methods 

The study used a cross sectional design and all 

Swedish hospitals (n=84) and nursing homes (2100) 

were invited to participate. The hospitals and nursing 

homes decided if and how many wards they were able 

to include. All patients 18 year and above were 

applicable to the study. The study was conducted 

during one specific day in March 2011 

An expert group was formed by the SALAR. This 

group developed the data collection protocol and 

instructions for the site coordinators. 

Educational sessions (n=10) were conducted in 

different parts of Sweden, including possibility to 

participate on-line. The PUCLAS educational program 

was recommended for all data collectors. 

Instructions, protocols, information letter to the patients 

were available on the SALAR web site. The 

methodology followed the EPUAP recommendations 

(1). In addition, information to identify hospital acquired 

pressure ulcers were gathered from the patient 

records (4) 

93 

Results 

Totally 37 113 patients were included in the study, 

17353 from hospitals and 18 865 from nursing homes. 

All 7 university hospital participated. 

The results will be published online in May 2011, and 

then prepared for this report. 

Discussion 

The Swedish government and the SALAR have an 

agreement to improve patient safety during year 2011 

to 2014. The agreement includes all heath care funded 

by the county councils and has a performance-based 

remuneration model to the county councils. When 

more than 50% of a hospital’s wards participated this 

generated money to the county council. Totally 100 

million Swedish crowns were allocated. This might 

have been a reason why so many hospitals 

participated in the study. However, many municipals 

participated as well without any extra money. 


This study highlights the importance of nursing 

sensitive outcomes in quality improvement work on a 

national level. 


We appreciate the support of the Swedish 

Associations of Local Authorities and Regions. 


None 

References 

[1] Vanderwee K, Clark M, Dealey C, Gunningberg L, 

Defloor T. Pressure ulcer prevalence in Europe: a pilot 

study. J Eval Clin Pract, 2007;13(2):227-35. 

[2] Gunningberg L, Brudin L, Idvall E. Nurse Managers’ 

prerequisite for nursing development: a survey on 

pressure ulcers and contextual factors in hospital 

organizations. J Nurs Manag 2010:18:757-766. 

[3] Wann-Hansson C, Hagell P, Willman A. Risk 

factors and prevention among patients with hospitalacquired 

and pre-existing pressure ulcers in an acute 

care hospital. J Clin Nurs 2008;17:1718-27. 

[4] Aydin C, et al. Creating and analyzing a statewide 

nursing quality measurement database. J Nurs 

scholarsh 2004;36:371-378. 





Preventable hospital-acquired pressure ulcer prevalence in Western Australian Public 

Hospitals: Serial data 2007 - 2009 

Susannah Mulligan 1* , Jenny Prentice 2 , Keryln Carville 3 , Nick Santamaria 4 

1* WoundsWest, Australia, Susannah.Mulligan@health.wa.gov.au 

2 WoundsWest, Australia, 3 Silver Chain Nursing Association & Curtin University of Technology, Australia, 

4 University of Melbourne & Royal Melbourne Hospital, Australia 

Introduction 

This paper will describe methods used by 

WoundsWest to determine the epidemiology of 

preventable hospital-acquired pressure ulcers among 

patients admitted to public health facilities within 

Western Australia. 

Methods 

Annually between 2007 and 2009 all consenting inpatients 

of public hospitals and residential facilities 

attached to public hospitals in Western Australia 

underwent skin inspections to determine if they had a 

wound. Wounds were categorised into 6 groups: 

acute wounds, pressure ulcers, skin tears, burns, 

malignant and other wounds. Wounds not 

documented within 24 hours of admission were 

considered hospital-acquired. Teams of surveyors 

were educated and tested for competency in 

recognising and classifying wounds and conducting 

prevalence surveys to ensure consistency in audit and 

data collection methods. 

Results 

Approximately 8,900 patients were examined during 

the 3 annual prevalence surveys. Results identified a 

preventable hospital-acquired pressure ulcer 

prevalence of 8% in 2007 and 9% in 2008 compared 

to 6% prevalence in 2009. The data are highly 

comparable given the methodological rigour applied. 

Further results will be reported in terms of pressure 

ulcer prevention, compliance with work practices, and 

contextual data related to organisational wound 

management protocols, and equity and access to 

resources. 

94 

Discussion 

Between 2008 and 2009, WW demonstrated a 33% 

reduction in hospital-acquired pressure ulcers. This 

has saved WA Health a minimum of $3.8M due to a 

projection of 4,448 bed days saved over a 12-month 

period. Recommendations for continuing to lower 

preventable hospital-acquired pressure ulcers will be 

discussed. 

Data will also be compared to other Australian public 

hospital data. 


Preventing hospital-acquired pressure ulcers improves 

patient outcomes, reduces length of stay and 

associated costs allowing scarce resources to be 

redirected to staff and patient education, clinical care 

and preventative strategies. 


WoundsWest acknowledges the generous effort and 

commitment of staff and patients who contributed to 

the successful outcomes of WoundsWest’s 3 annual d 

Western Australian State-wide Wound Prevalence 

Surveys conducted between 2007 and 2009. 


Nil 



Introduction 



Pressure Ulcer Prevalence Reductions Seen from the 

International Pressure Ulcer Prevalence Survey 

Catherine VanGilder, MBA, BS, MT, CCRA, Charlie Lachenbruch, PhD, Stephanie Amlung, PhD, 

Patrick Harrison BA, Stephanie Meyer, AS 

1* Hill-Rom Clinical Research and Engineering Departments, Batesville, IN, USA 

catherine.vangilder@hill-rom.com 

There has been a generalized focus in pressure ulcer 

prevention efforts across national healthcare systems. 

Guidelines for these efforts have been put in place following 

reports of poor healthcare quality in 1999 by the Institute of 

Medicine, which stated that thousands of Americans either 

died from errors in care, or suffered non-fatal injuries.[1] This 

was followed by a 2001 report Crossing the Quality Chasm 

which noted that “there was an absence of real progress in 

addressing quality and cost concerns and in the 

improvement of clinical care processes“.[2] In contrast with 

these general findings, data from the International Pressure 

Ulcer Prevalence Survey, which surveys almost 100,000 

patients each year, there has been a significant annual 

reduction in pressure ulcers in the US for the last 4 years, 

and in Canada over the last 2 years. This report will provide 

a summary of overall prevalence (OP) and facility acquired 

pressure ulcer prevalence (FAP) data from 2003-2010 from 

the US and 2008-2010 data from Canada. 

Methods: As part of quality improvement efforts, 

participating facilities perform prevalence surveys in their 

facilities during a pre-determined 24 hour period within a preselected 

2 to 3 day window. While the goal of the survey is 

to assess all admitted patients in a facility, 100% patient 

inclusion is not mandated for participation. Sites sign up on 

the sponsor’s website and receive study materials consisting 

of data collection forms, educational materials and general 

instructions. Facilities then receive a detailed report 

demonstrating individual progress and aggregate data are 

summarized for trends. 

Results: There has been a significant decrease in annual 

overall prevalence in the US each year from 2004-2006 and 

2008-2010 (p

Friday 

2nd September 

ABSTRACTS 

97

Friday September 2nd 



Biomechanics of the Heel 

Amit Gefen 1* , Ran Sopher 1 , Elizabeth McGinnis 2 , Jane Nixon 3 

1* Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Israel, gefen@eng.tau.ac.il 

2 Leeds Teaching Hospitals NHS Trust, and 3 Clinical Trials Research Unit, University of Leeds, United Kingdom 

Introduction 

Heel ulcers (HU) are the second most common 

type of pressure ulcers (PU). In this talk, the 

biomechanical factors associated with HU 

development will be reviewed through use of 

analytical and computational biomechanical 

modeling of the heel-support interaction. 

Methods 

First, an analytical approach to the heel-support 

problem will be described, based on the Hertz 

contact theory, using which the heel bone 

(calcaneus) is represented by a rigid spherical 

surface and the overlying fat and skin tissues are 

represented by an elastic layer with finite 

thickness [1]. The Hertz-based analytical 

modeling approach can be used for studying the 

effects of anatomical factors such as the weight 

of the foot, curvature of the calcaneus or 

thickness of the soft tissue layer at the posterior 

heel on the magnitudes of soft tissue mechanical 

loading that occur when the posterior heel is 

supported [1]. Likewise, the analytical modeling 

can be used to explore the effects of soft tissue 

stiffness changes that are associated with 

diabetes or with edema of the feet [1]. Second, an 

anatomically-realistic three-dimensional (3D) 

finite element (FE) model of the posterior heel, 

developed for studying the risk for HU in 

bedridden patients, will be presented [2]. We 

specifically simulated a heel that is resting on 

supports with different stiffness properties, at 

upright and inclined foot postures. Our objective 

when developing the anatomically-realistic 3D FE 

model was to examine the effects of foot posture 

and stiffness of the support on mechanical strains 

and stresses within the fat pad of the resting heel 

[2]. 

Results 

We found that internal mechanical loading in the 

posterior soft tissues of the heel is considerably 

affected by the internal anatomy, i.e. by the 

sharpness of the calcaneus and thickness of the 

soft tissue layer. The mechanical properties of the 

soft tissue layer were also influential, which is 

relevant to pathologies such as diabetes and 

edema. The modeling pointed at edema of the 

99 

feet, in particular, as a potentially important risk 

factor for HU, as the edema stiffens the soft 

tissues substantially. Lastly, the 3D FE modeling 

indicated that strains and stresses in the soft 

tissues of the posterior heel are considerably 

reduced when the foot is positioned so that its 

lateral aspect is at 90° with respect to the horizon 

compared to an abducted (60°) foot posture. 

Discussion 

The analytical modeling studies reviewed herein 

indicate that theoretically, some foot anatomies 

are more vulnerable to HU than others, 

particularly anatomies characterized by sharp 

bony surface of the calcaneus and thin overlying 

soft tissues [1]. Diabetes and edema were both 

shown to be important factors influencing the 

internal loading in the posterior soft tissues of the 

heel, and edema of the feet was shown to have a 

particularly strong detrimental effect on the 

internal heel loading [1]. The 3D FE modeling 

further demonstrated that an inclined foot posture 

puts a bedridden patient at a higher risk for HU 

with respect to an upright foot posture, which may 

be explained by the anatomy of the heel that 

faces a lower curvature and better cushioned 

region against the support when the foot is 

upright [2]. 


Heel ulcers are a common, but a poorly studied 

type of PU. Biomechanical modeling can 

contribute not only by providing better 

understanding of the etiology of these PUs but 

also in identifying risk factors that are specific to 

this type of injury. 


None 

References 

[1] Gefen A. The biomechanics of heel ulcers. J Tissue 

Viability. 2010, 19(4):124-31. 

[2] Sopher R, Nixon J, McGinnis E, Gefen A. The 

influence of foot posture, support stiffness, heel pad 

loading and tissue mechanical properties on 

biomechanical factors associated with a risk of heel 

ulceration. J Mech Behav Biomed Mater. 2011, 

4(4):572-82. 



100 

Proceedings of the EPUAP 2011 Annual Conference 

Porto, Portugal 

Pressure ulcer prevention: Different lying positions and their effects on tissue blood flow 

and skin temperature in elderly patients while lying on a pressure reducing mattress. 

Ulrika Källman 1* , Sara Bergstrand 2 , Anna-Christina Ek 3 Maria Engström 4 Margareta Lindgren 5 

1* - 5 Department of Medical and Health Sciences, Linköping University, Linköping, Sweden 

ulrika.kallman@vgregion.se 

1* Department of Dermatology, Södra Älvsborgs Hospital (SÄS), Borås, Sweden 

Introduction 

In order to relieve pressure on bony prominence and 

reduce risk of pressure ulcers, turning and 

repositioning immobile patients is a standard nursing 

practice. In the present study we have compared 

different lying positions and their effects on tissue 

blood flow and skin temperature, in elderly patients. 

Methods 

Twenty elderly patients, an equal number of women 

and men, 65 years of age or older were included 

consecutively in the study. Blood flow and skin 

temperature was measured over the sacral, gluteus 

and trochanteric-areas in six different lying positions; 

tilt position 30º, supine position 0º, supine position 30º, 

semi-fowler position 30-30º, lateral position 30º and 

lateral position 90º (fig 1). 

The measurements was carried out in a separate, 

quiet room at the hospital. A pressure reducing 

mattress (Optimal 5zon, Care of Sweden), covered 

with a hospital sheet, was used. The measurements 

started with the patient placed in a 90 degree lateral 

position on his/her left side. After 15 minutes, the 

patient’s body temperature and blood pressure was 

noted. The measurements begun with the tissue 

unloaded to gather baseline data and the patients was 

their own reference. Thereafter the measurement 

procedure begun with the patient lying five minutes in 

each position and with five minutes resting on his/her 

right side between each position. 

All measurements in the study were carried out noninvasively. 

Blood flow was measured at two depths 

(approx. 2 mm and of ≥ 10 mm respectively) using a 

two channel photo-plethysmography (PPG). The 

temperature was measured with a single sensor 

integrated in a measurement probe. 

Results 

Mean age of participants was 83.9 ± 7.5 years. The 

mean relative change of superficial blood flow at 

trochanter in the lateral position 30 degree was 

significantly lower than all other positions. The deep 

tissue blood flow was less affected than superficial 

blood flow in all positions. The mean skin temperature 

increased during the procedure. The statistical 

elaboration shows large individual differences. 

Fig. 1: The six lying positions evaluated in the study. 

Discussion 

In this pilot study we have obtained some knowledge 

about the way different lying positions effect tissue 

blood flow in elderly patients. However, the 

measurement lasted for only five minutes in each 

position and the skin temperature condition was not 

equivalent in all positions. How these different lying 

positions affect the blood flow, in relation to pressure 

and temperature, over time will be studied in the next 

step. 


These results will give us knowledge about appropriate 

lying positions and turning intervals. 


The research is funded by Swedish Research Council, 

Research and development council of the county 

Södra Älvsborg, Department of Dermatology SÄS 

Borås, SwedBank Sjuhärad Borås. We appreciate the 

help of Care of Sweden AB, Sweden. 


There is no conflict of interest. All results will be 

published irrespective of company. 

References 

[1] Bergstrand S. et al., Skin Res Technol. 15:139-47, 

2009 





Repositioning: the clinical perspective 

Alves, Paulo 1 , Neves-Amado, João 1 , Vales, Lúcia 2 

1 Health Sciences Institute – Oporto – Catholic University of Portugal 

2 Adult Emergency Department - Hospital S. João, EPE - Oporto 

Pressure ulcers are a major and global health 

problem, conducts to major burdens in healthcare 

systems all over the world, affecting millions of 

patients and inevitably high costs. 

Is well acknowledged that pressure sores are primarily 

caused by sustained mechanical loading of the soft 

tissues of the body, and most evidence focuses the 

relationship between external pressures applied to a 

patient’s skin and tissues not adapted to these 

pressures, as well as the effects of the same on the 

local microcirculation[1]. More than 100 risk factors are 

described in the literature; Age, Reduced mobility and 

reduced sensation are three of the most important 

elements in the breakdown of tissue and the 

development of pressure sores. The nutritional status 

of an individual plays a significant role in tissue 

perfusion and skin integrity and conditions that 

decrease tissue oxygenation or reduce oxygenated 

blood to the tissue, such as peripheral vascular 

disease, cardiac disorders, hypo tension, 

arteriosclerotic disease [2,3]. 

Early identification of people in risk and timely adopted 

preventive strategies are cost effective measures and 

avoid adverse health consequences of UP. Knowledge 

of both the aetiology and risk factors associated with 

pressure ulcer development are the key to successful 

prevention strategies. Prevention should be the main 

target in the management of this serious problem. The 

costs of treating a patient who develops a pressure 

ulcer far outweigh the costs of prevention. 

The interventions strategies more focused in the 

literature are repositioning and the support surfaces. 

NPUAP & EPUAP[4] defines repositioning as the 

action that “involves the change in position in the lying 

and seated individual, with the purpose of relieving or 

redistributing pressure and enhancing comfort, 

undertaken at regular intervals”. The most effective 

measures decrease the level and/or the duration of the 

pressure and shearing force [1]. 

Repositioning involves not only the act “per si”, but a 

lot of other factors as, the patient characteristic’s, the 

numbers of patients in relation to the number of 

professionals, the frequency of repositioning, the 

correct posture during positioning, the different support 

surfaces available to use and the knowledge to use it 

correctly. 

In clinical daily practice, the only focus that nurses 

have is not only prevention of pressure ulcers, so they 

have to use their time as a scarce item, so they have 

to use it appropriately. 

The frequency of changing position determines 

whether this intervention measure is effective, 

pjalves@porto.ucp.pt 

101 

conventionally the recommendation to repositioning is 

every 2 hours [5], 3 hours [6] or 4 hours [7]. 

It’s important to refer that the repositioning frequency 

should be influenced by the individual and the support 

surface in use [1,4,8]. 

In order to make it more feasible, repositioning should 

be combined with pressure-reducing support surfaces, 

distributing the area of pressure, and also reduce the 

distortion of internal tissues by a limited extent [9]. 

The process of repositioning requires knowledge of 

certain principles to ensure, correct posture in the 

different positions in lying and seated positions, use of 

correct technic to health professionals without 

incidents and with energy needed, to assure the 

effectiveness of the intervention. 

Suggestions will be made to be considered, such as 

frequency, different positions, restriction to certain 

positions, quantity and type of spontaneous 

movements, reposition schemes techniques in 

conjunction with others. 

It is worth considering a multiple approach, and 

establishing precise measures of repositioning the 

patients. These interventions should be adjusted 

according to individual patient needs and available 

resources in services, not according to habits and 

institutional routines. 

Repositioning is most effective measure to prevent 

pressure ulcers if we take on consideration all this 

aspects. 

The repositioning, seems to be easy, but is not always 

easy to adapt evidence to clinical practice, this is our 

biggest challenge, to ensure the quality of care. 

References 

[1] Romanelli, M., Clark, M., Cherry, D., Defloor, T., & co-editors. (2006). 

Science and Practice of Pressure Ulcer Management. London: Springer 

[2] Critical appraisal: notes and checklists. Edinburg: Scottish Intercollegiatte 

Guidelines Network; available on the 12 of June, 2011 

from:http//www.sign.ac.uk/methodology/checklists.html 

[3] Sackett, D.L. Rules of evidence and clinical recommendations on the use 

of antithrombolic agentes. Chest. 1989:95 (suppl) 

[4] NPUAP & EPUAP (2009). Prevention and treatment of pressure ulcers: 

clinical practice guideline. Washington DC: National Pressure Ulcer Advisory 

Panel. 

[5] Panel for the prediction and prevention of pressure ulcers in adults(1992). 

Pressure ulcers in adults: prediction and prevention. Clinical practice guideline 

number 3. Rockville: Agency for health care policy and research, Public 

Health Service, US Departement of Health and Human Services, AHCPR 

Publication nº 92-0047 

[6] Bakker H (1992). Herziening Consensus Decubitus [revision of pressure 

ulcer consensus]. Ultrecht: CBO 

[7] TomDefloor, Dirk De Bacquer, Maria H.F. Grypdoncka (2005). The effect of 

various combinations of turning and pressure reducing devices on the 

incidence of pressure ulcers. International Journal of Nursing Studies 42 37– 

46 

[8] Moore, Z., & Price, P. (2004). Nurses’ attitudes, behaviours and perceived 

barriers towards pressure ulcer prevention. Journal of Clinical Nursing , 942– 

951. 

[9] Linder-Ganz & Gefen. Journal of Biomechanical Engineering ASME 2009 





The effectiveness of repositioning in preventing pressure ulcers 

Introduction 

International prevalence figures indicate that attention 

to pressure ulcer prevention remains necessary. 

Effective preventive measures reduce the magnitude 

and/or limit the time of pressure and shearing forces. 

Regular repositioning prevents pressure ulcers by 

reducing the duration of pressure and shearing forces. 

It involves a change in position in the lying or seated 

individual, with the purpose of relieving or 

redistributing pressure and enhancing comfort, 

undertaken at regular intervals. [1] Repositioning is 

commonly recognized and recommended as an 

important and effective preventive measure. [1,2] 

Aim 

The aim of this presentation is to give an overview of 

the current evidence about the effectiveness of 

repositioning. Special attention will be paid to the work 

of Tom Defloor as he significantly contributed to the todate 

knowledge in this area. 

Findings 

Firstly, postures are discussed. A number of laboratory 

studies examined the influence of different postures in 

sitting and in lying position on pressure. Based on the 

results of these studies, sitting upright in an armchair 

with the feet on the ground or sitting back in an 

armchair with the lower legs on a rest seem to be most 

pressure redistributing positions. The 30 degree semi- 

Fowler position and the 30 degree lateral position are 

recommended in lying position. Also a recent 

randomised controlled trial showed a reduction in the 

pressure ulcer incidence using the 30 degree tilt in 

combination with the 3-hourly repositioning compared 

with the standard care. [3] 

So far, two randomised clinical trials have been carried 

out into the necessary turning frequencies to prevent 

pressure ulcers. [3-5] Two of these studies indicate 

that the needed repositioning frequency depends on 

the support surface used [4-5]. 

Katrien Vanderwee 

Ghent University, Belgium, katrien.vanderwee@ugent.be 

102 

Fig. 1: Tom Defloor 

Discussion 

Generally, research on repositioning is scarce. Only a 

limited number of clinical trials examined the 

effectiveness of repositioning frequency. This should 

be further investigated. Future studies should examine 

repositioning in combination with the various pressure 

redistribution support surfaces commonly used in 

current clinical practice. 

References 

[1] European Pressure Ulcer Advisory Panel & 

National Pressure Ulcer Advisory Panel, Prevention 

and Treatment of Pressure Ulcers: Quick Reference 

Guide. National Pressure Ulcer Advisory Panel, 

Washington DC, 2009. 

[2] Romanelli M. et al., Science and Practice of 

Pressure Ulcer Management. Springer-Verlag, 

London, 2006. 

[3] Moore Z. et al. J. Clin. Nurs. Epub ahead of print, 

2011. 

[4] Defloor T. et al. Int. J. Nurs. Stud. 42: 37-46. 

[5] Vanderwee K. et al. J.Adv. Nurs. 57: 59-68. 



Room A4 

9.00-10.15 Free Papers 5 

Development and Effectiveness of a Pediatric Pressure Ulcer 

Prevention Bundle 


Factors Influencing the Development of Pressure Ulcers in Neonatal 

and Pediatric Patients 


Effective pressure ulcer care in a specialized spinal cord injury 

rehabilitation department 

Ora Pilo, Israel 

The incidence rate of occipital pressure ulcers in adults at 5 intensive 

care units 

Nancy Van Genechten, Belgium 

103


Introduction 



Development and Effectiveness of a Pediatric Pressure Ulcer Prevention Bundle 

Ann Marie Nie 1* , Pat Schaffer 1 , Marty Visscher 1 , Diana Bailey 1 , Pattie Bondurant 1 

1* Cincinnati Children’s Hospital Medical Center, USA, marty.visscher@cchmc.org 

Reduction in pressure ulcers (PUs) is an important 

international patient safety issue reinforcing the need 

for evidence-based strategies for prevention, 

intervention and compliance. The literature on PUs in 

pediatric patients is sparse due, in part, to the 

relatively limited information on neonatal/pediatric skin 

integrity and response to stressors (e.g., pressure, 

moisture) [1]. The initial PU prevalence at Cincinnati 

Children’s Hospital Medical Center (CCHMC) in 

January of 2007 was over 10%, higher rate than the 

4% reported in national pediatric survey [2]. An 

interdisciplinary team was charged to develop a 

comprehensive strategy to significantly reduce and 

prevent PUs. 

Methods 

Quality improvement science methods, i.e., aim 

statements, key drivers, multiple tests of change and 

PDSA (plan-do-study-act) cycles, were applied over 18 

months in four critical care units: NICU, PICU, 

Transitional Care (Trach) and Rehabilitation. During 

this work, the factors, patient characteristics and 

demographics that impacted PU development were 

identified via biweekly head to toe skin assessments of 

all patients in the four units from September 2007 

through October of 2009. The hospital CWOCN 

validated that the wound was a pressure ulcer, staged 

the ulcer and determined the cause. The incidence 

overall, by stage and cause was evaluated over time 

with regression methods. Frequency data within the 

population of patients with PUs was assessed using ztests 

(p < 0.05). 

Results 

The Pediatric Pressure Ulcer Prevention Bundle (Fig. 

1) was developed and then implemented house wide. 

Fig. 1: Pediatric Pressure Ulcer Prevention Bundle 

104 

Patients at moderate to high risk were repositioned 

every 2 hours and patients at low risk every 4 hours. 

Pressure reduction surfaces were used for beds and 

chairs. Moisture management strategies included 

removal at required intervals. Among the 3779 

patients, the overall occurrence rate (total PUs) 

trended downward. The reduction in stage I PUs was 

significant (p < 0.05)(Fig 2). 

Fig 2. Stage I pressure ulcers with prevention bundle 

Discussion 

The quality improvement process facilitated the task 

and reduced the time for testing thereby allowing the 

team to identify both effective and ineffective 

strategies. The intense focus has increased in the 

awareness of PUs and their consequences. Ongoing 

efforts are in place to reinforce education and insure 

that assessments are completed. The frequency of 

stage III and IV PUs remains low in the institution. 

However, while the number of device related stage II 

PUs was somewhat reduced, they continue to be 

problematic and the focus of ongoing efforts. 


A PU prevention bundle can be successfully 

implemented in the pediatric population. Ongoing 

monitoring is required to maintenance of the lower 

frequency. Prevention of device related PUs, 

particularly Stage II PUs, remains a challenge. 

Specific device attributes and interventions to lessen 

moisture of occlusion will be necessary to further 

reduce these ulcers. 


We appreciate the help of Teresa Taylor, Christine 

Myers, Mary Stange and Mary Jo Giaccone. 


References 

[1] Nikolovski J. et al., JID. 128:1728-36, 2008 

[2] Mclane K et al., J. Wound Ostomy Continence 

Nurs. 131:168-78, 2004 





Factors Influencing the Development of Pressure Ulcers in Neonatal and Pediatric Patients 

Introduction 

Ann Marie Nie 1* , Marty Visscher 1 , Pat Schaffer 1 , Pattie Bondurant 1 , Teresa Taylor 1 

1* Cincinnati Children’s Hospital Medical Center, USA, marty.visscher@cchmc.org 

Pressure ulcer incidence rates of 5 – 42% have been 

reported for critical patients, with significantly 

increased mortality (4x) and costs [1]. Pediatric 

patients are at risk for pressure ulcers (OUs) due to 

their medical condition and associated factors 

including compromised blood perfusion, decreased 

mobility, poor nutrition, limited and/or heightened 

neurological responsiveness, fluid retention, excess 

moisture, and the presence of devices [2]. The 

objective was to determine the patient factors 

associated with and the causes of PUs among high 

risk pediatric and neonatal patients. 

Methods 

A descriptive retrospective chart review was 

conducted of biweekly skin assessments of all patients 

in four units: NICU, PICU, Rehabilitation and 

Transitional (Trach) over a two year period from 2007 

to 2009. PU stage, location and cause were 

documented by clinical staff and validated by the 

hospital CWOCN. Patient characteristics were age, 

hospital unit, medical diagnosis, and status at 

discharge. Frequency data within the population of 

patients with PUs was compared for various factors 

using z-tests (p < 0.05). 

Results 

The PU occurrence rate was 7.3% from 276 PUs in 

3779 patients. The mean age was 34.4 wks for the 

NICU and 6.4 years for the other units. For the 276 

PUs, the frequencies by stage were: 26% stage I, 53% 

stage II, 11% stage III, 0% stage IV, 7.6% unstageable 

and 1.4% deep tissue injury. A total of 23.6% of the 

pressure ulcers were accounted for by patients who 

expired. The cause by stage is shown in Table I. 

Table 1. PU Stage by cause 

Stage No. 

No. 

Device 

% 

Device 

No. 

Pressure 

% 

Pressure 

I 73 47 64.4 26 25.6 

II 144 95 66.0 49 34.0 

III 30 25 83.3 5 16.7 

IV 0 0 0 0 0 

Unstageable 21 5 23.8 16 76.2 

DTI 4 1 25 3 75 

Unknown 4 --- --- 

Of the device related PUs, those caused by bipap or 

cpap masks were the most frequent at 22.5% (of 

device related) followed by 13.3% due to tracheostomy 

devices. A comparison of the neonatal and pediatric 

ICUs is shown in Table 2. 

105 

Table 2. Pressure ulcers for two ICUs 

NICU 

Stage No % No P % P No D % D 

I 6 10.7 1 16.7 5 83.3 

II 32 57.1 5 15.6 27 84.4 

III 4 7.1 0 0 4 100 

IV 0 0 0 0 0 0 

Unstageable 12 21.4 10 83.3 2 16.7 

DTI 2 3.6 1 50 1 50 

Total = 56 Pressure = 17 (30.4%) Device = 39 (69.6%) 

PICU 

Stage No % No P % P No D % D 

I 55 36.2 20 36.4 34 61.8 

II 79 52.0 35 44.3 44 55.7 

III 10 6.6 3 30 7 70 

IV 0 0 0 0 0 0 

Unstageable 5 3.3 4 80 1 20 

DTI 2 1.3 2 100 0 0 

Unknown 1 0.6 

Total = 152 Pressure = 64 (42.1%) Device = 86 (56.2%) 

The units did not differ in the percent of PUs due to 

pressure and devices. The NICU had a lower percent 

stage I ulcers (z = 3.4, p < 0.001). For stage II ulcers, 

the percent due to devices is higher for the NICU (z = 

2.6, p = 0.008). The NICU had a higher percent of 

unstageable PUs than the PICU (z = 3.9, p < 0.001). 

In both units, patients with device related pressure 

ulcers were significantly younger than those with 

pressure related PUs. 

Discussion 

The age effects could reflect differences in skin 

properties for the NICU population since they tended 

to be more premature. In the PICU, the age effects 

could reflect the fit of the devices, particularly since 

masks were the most common cause. 


Device related PUs, particularly stage II PUs, account 

for a significant number in the neonatal and pediatric 

population. This may reflect the occlusive nature of 

devices in that they cause transepidermal moisture to 

accumulate. Increased moisture may contribute to the 

frictional component of the injury. 


We appreciate the assistance of Diana Bailey, Mary 

Stange, Mary Jo Giaccone, and Christine Myers. 


References 

[1] Keller B. et al., Intensive Care Med 28:1379-88, 

2008 

[2] Schindler C. et al., Am J Crit Care. 16:568-74, 2007 





Effective pressure ulcer care in a specialized spinal cord injury rehabilitation department 

0ra Pilo, Rifat Azam, Renata Bartal Mirman, Tami Polliack, Amiram Catz 

Loewenstein Hospital Rehabilitation Center, Israel, orap@clalit.org.il 

Introduction 

Loewenstein Hospital is a referral center for the 

rehabilitation of patients with various disabilities, 

including those with spinal cord injury (SCI). Patients 

are referred by general hospitals or arrive from the 

community. Pressure ulcers are among the common 

life-threatening complications among SCI patients (1), 

and their treatment requires a unique and specific 

approach (2). 

A case report of an SCI patient admitted to our center 

with a pressure sore is presented. A 26 year old single 

male, with C4A tetraplegia following a work accident, 

contracted "swine flu" one year after discharge from 

rehabilitation, while living at home with his parents and 

a personal assistant. After being in a critical condition, 

and following mechanical ventilation in a general 

hospital he developed a 20x20 cm deep sacral 

pressure ulcer that was completely covered by eschar 

tissue. After clinical stabilization, he was admitted to 

the Loewenstein Hospital Spinal Department for rerehabilitation. 

Methods 

The patient was laid on a dynamic mattress, and a 

multidisciplinary team was assigned to him. Nursing 

and medical staff investigated, documented, and 

treated the pressure sore. The evaluation included 

respiratory, urinary, nutritional, and skin assessments, 

as well as various laboratory tests, X-ray 

examinations, a bone scan, and a consultation with a 

plastic surgeon. The pressure ulcer care included 

chemical, bed-side surgical and autolytic debridement, 

and various dressings. 

Results 

The wound healed within 140 days, and the patient 

was gradually allowed to sit on a viscoelastic pillow. 

Respiratory volume increased from 1000 to 2000 cc, 

hemoglobin increased from 9.8 to 12.5 g/dL, CRP 

decreased from 22.6 to 1.0 mg/dL, and albumin 

increased from 3.8 to 4.3 gr/dL, without any hospital 

complications. The patient's family and his personal 

assistant were given instructions for further treatment, 

and he was discharged to his home. 

Discussion 

The present report is a reminder of the ability of 

professional, meticulous, conservative nursing and 

medical care to contribute to SCI patients’ longevity 

and quality of life. In the case described here this was 

achieved by excellent wound healing, reducing 

morbidity and avoiding operative complications. At the 

106 

same time, additional medical and functional 

rehabilitation objectives were attained. 


SCI patients are a unique group that requires a unique 

therapeutic approach, mainly because of sensation 

and movement problems. Thorough assessment and 

care, following guidelines, in a specialized SCI 

rehabilitation setup is effective in the cure of pressure 

ulcers, and can accomplish additional patient goals, 

minimizing healthcare costs. 


There is no conflict of interest. 

References 

[1] Thomason SS. et al., JSCM. 30:117-126, 2007. 

[2] Guihan M. et al., SCI Nurse. 21:136-142, 2004. 





The incidence rate of occipital pressure ulcers in adults at 5 intensive care units 

Nancy Van Genechten 1* , Mark Willekens 1 , Erik Franck 1 Annabelle Van den Mooter 1 

1* Karel de Grote University College, Belgium, nancy.vangenechten@kdg.be 

Introduction 

Pressure ulcers are a common problem in bedridden 

patients. In 2008 a nationwide prevalence study was 

undertaken in 84 Belgian hospitals. The study showed 

an average prevalence of 12,1% [1]. Occipital 

pressure ulcers (OPU) are less common but entail 

specific risks. At the occipital region there is very little 

subcutaneous tissue. Therefore, these pressure ulcers 

can progress rapidly to more severe categories [2]. 

Occasionally, these severe sores can even evolve into 

alopecia [3]. In clinical practice, OPU are mostly 

observed in the intensive care units (ICU) [4]. On ICU, 

hospitalization is often accompanied by a long period 

of immobility and patients are at high risk for pressure 

ulcers. Research regarding the incidence of OPU with 

adults is lacking. The aim of the present study was to 

examine the incidence rate of OPU in adults admitted 

to the ICU. 

Methods 

The incidence measurement was carried out at the 

intensive care unit of 5 hospitals in the Antwerp region 

(Belgium). There were 2 measurement periods of 5 

weeks: from November 15, 2010 till December 17, 

2010 and from February 14, 2011 till March 18, 2011. 

The study population comprised of patients admitted to 

the ICU without an existing OPU or any other lesion at 

the occiput. Patients younger than 18 years old or with 

a contraindication to turn the head were excluded. At 

admission and during the stay at ICU, data on patient 

features and influencing variables were collected. The 

study protocol was approved by the Ethics committee 

of the University Hospital of Antwerp. 

The occiput was observed daily by staff nurses using a 

standardized registration form. The pressure ulcers 

were classified according to the EPUAP classification. 

Results 

A total of 1047 patients participated. 455 patients were 

included during the first measurement period, 443 

patients were included during the second 

measurement period. Of the patients who were 

excluded, 17,4 % had an existing OPU at the time of 

admission. During the registration period, 32 patients 

developed an OPU resulting in an incidence of 3,6 % 

across all categories. The incidence rate did not differ 

between the 2 measurement periods. Table 1 

represents the distribution of patients with OPU by the 

EPUAP classification. 

107 

Table 1: Distribution of patients with OPU 

by EPUAP classification (N=32) 

Category N 

1 27 

2 

3 

3 

1 

4 

1 

Discussion 

The results in the present study demonstrate that OPU 

are an underestimated problem in patients admitted to 

the ICU. Further research in the excluded patients with 

OPU is necessary to know the history of the lesion. 

Category 1 OPU are difficult to detect. 

Furthermore, there is a lack of knowledge among 

nurses and there are difficulties in the observation 

method regarding OPU. It is essential that specific 

prevention material for these sores should be 

developed. 


With these results it is possible to adjust the existing 

protocols for the prevention of pressure ulcers. 


We would like to thank the nursing staff of the 

intensive care units of the participating hospitals for 

their help in collecting the data. 


None 

References 

[1] Defloor et al., 2008 

[2] EPUAP, 2010 

[3] Gershan et al., Arch Dis child. 68: 591-3, 1993 

[4] Kottner et al., Int J Nurs Stud. 47: 1330-40, 2010 





Debridement revisited 

Trudie Young 

Aneurin Bevan Health Board, Wales, reachtrudieyoung@gmail.com 

Introduction 

Debridement is an accepted part of wound 

bed preparation (1). Within the UK there are 

many different methods of debridement 

utilised in clinical practice, each having its 

advantages and limitations (2). However no 

national guidance exists to assist clinicians, 

this has resulted in variations in wound 

debridement (3). Debridement is undertaken 

by a variety of clinicians including podiatrists, 

nurses and surgeons. The chosen method of 

debridement method may relate to the skill 

level of the clinician along with access to 

equipment rather than the clinical need of the 

client. 

Methods 

A multi professional group of clinicians which 

included podiatrists, nurses, and surgeons 

contributed to a consensus meeting to review the 

subject of debridement and stimulate a national 

debate upon the topic (3). 

Results 

A s a result of the consensus meeting a 

document was published (3). The document 

reiterated the purpose of debridement along with 

a review of the current methods of debridement 

used in the UK. The document provided structure 

for clinical decision making via a suggested 

debridement pathway. 

Discussion 

Debridement is an establish part of wound care 

which can lead to faster healing, a reduced risk of 

infection and an improvement in quality of life. It 

is questionable as to whether clients receive 

debridement at the appropriate time utilising the 

most efficient and effective method. This may be 

due to a reliance on autolytic debridement due to 

a lack of knowledge and skill on the part of the 

clinicians. The key pre debridement questions for 

the clinician are what do they hope to achieve 

and how quickly do they need to achieve their 

objective. For certain clients a delay in the 

108 

debridement process may put them at risk of 

generalised infection and its subsequent 

consequences. In order for the client to receive 

the most timely and appropriate method of 

debridement referral to a specialist colleague or 

the acquisition of new skills may be necessary. 


New debridement techniques have been 

developed however their uptake in clinical 

practice in the UK is limited to specialist areas. 

Clinicians should be ensuring the client receives 

timely debridement via the most appropriate 

method. 


We appreciate the help of .Activa Healthcare. 


References 

[1] European Wound Management Association 

(EWMA). Position 

Document: Wound Bed Preparation in Practice. 

London: MEP Ltd, 2004. 

(2) Ousey K, McIntosh C (2010) Understanding 

wound bed preparation and wound debridement 

British Journal of Community Nursing, Vol. 15, 

Iss. 3 Suppl, pp S22 - S28 

(3) Gray D, Acton C, Chadwick P, Fumarola S, 

Leaper D, Morris C, Stang D, Vowden K R, 

Vowden P, Young T (2011) Consensus guidance 

for the use of debridement techniques in the UK. 

Wounds UK 7 (1) 77-84 





Biofilm and Debridement 

Christina Lindholm 

1* Karolinska University Hospital, Sweden, email@corresponding.author 

c.lindholm@telia.com 

Abstract 

During the past decade, biofilm in chronic wounds has 

attracted increased interest.Traditionally, bacteria 

isolated and treated in wounds are planctonic. Bacteria 

in biofilm are incapsulated in a slime-like structure 

consisting of extracellular polymers. Biofilm-bacteria 

are not detected with traditional laboratory 

methodology. Bacteria in biofilm are virulent against 

antibiotics. It is believed that biofilm might cause 

delayed wound healing in pressure ulcers. Eradication 

of bacteria in biofilm might partly be achieved by some 

topical antiseptics, particularly those containing 

surfactants. Mechanical debridement seems however 

to be the most important action to minimize biofilm. 

The previous paradigm to protect the wound from 

mechanical damage seems to have to be re-evaluated 

and shifted. However, biofilm is re-created within 10- 

12 hours also after mechanical debridement, so a 

combination of mechanical debridement and 

antiseptics might be the optimal solution in wounds 

recalcitrant to healing. 

Biofilm and debridement methods will be described 

according to present research and clinical experience. 

One new debridement methodology will be presented. 

. 

109 





Larval Therapy 

G. Cazander, MD, PhD 1* , M.W.J. Schreurs, PhD 2 , C.M.J.E. Vandenbroucke-Grauls, MD, PhD 3 , 

G.N. Jukema, MD, PhD 4 

1* Bronovo Hospital The Hague, The Netherlands, gwendolyn_cazander@hotmail.com 

2 Erasmus MC Rotterdam, The Netherlands, 3 VU University Medical Center Amsterdam, The Netherlands, 

4 Zürich University Hospital, Switzerland 

Introduction 

Maggot therapy is successfully used for the treatment 

of wound infections. The underlying mechanisms of 

action of maggot therapy are unknown, but could 

provide information for a novel treatment modality 

against infection, which is important in these times of 

increasing antibiotic resistance. Therefore, in this 

research the effect of living maggots on planktonic 

cells was investigated. Furthermore, the influence of 

maggot excretions/secretions (ES) on planktonic cells, 

on bacterial biofilms and on complement activation 

was tested. 

Methods 

Sterile tubes were filled with living maggots in a 

bacterial suspension and every two hours samples 

were cultured and compared with controls. A 

turbidimetric assay was performed to test the 

susceptibility of six bacterial species to ES. Bacterial 

biofilms were formed in vitro on polyethylene, stainless 

steel and titanium and ES were added to test their 

influence. The effect of ES on complement activation 

was investigated in healthy donor sera and in pre- and 

postoperatively gained sera from trauma patients. 

Different immunoassays, that are also clinically used 

to determine complement deficiencies in patients, 

were performed in absence or presence of maggot ES. 

Results 

The results show that living maggots as well as their 

ES stimulate the bacterial growth of S. aureus, E. 

faecalis, CNS, S. pyogenes and K. oxytoca (all pvalues≤0.0002). 

The strongest biofilms in vitro were 

formed by S. aureus, S. epidermidis and P. 

aeruginosa. ES were added to these biofilms and 

reduced these on all biomaterials. The maximal biofilm 

inhibition by ES was seen on polyethylene: 82% for P. 

aeruginosa (p


Mechanical and ultrasonic debridement 

Prof David Gray, Scotland 

111


11.00 – 12.00 Free Papers 6 



Body weight and pressure ulcer occurrence 

Jan Kottner, Germany 


Cees Oomens, Netherlands 

Wound bed preparation with an enzyme alginogel in the treatment of 



112





Evan Call MS RSM (NRM) 1* , Justin Pedersen 2 , Brian Bill 3 Craig Oberg PhD 4 Martin Ferguson-Pell 5 

1* Weber State University, Ogden Utah, USA, ecall@weber.edu 

2 University of Utah, USA, 3 Weber State University, USA, 4 Weber State University, USA, 5 University of 

Alberta, Canada 

Introduction 

Wound dressings are known to significantly alter the 

microclimate at the surface of both compromised and 

uncompromised skin. Understanding and being able 

to create the proper environment for healing and for 

prevention of ulceration begins with measurement of 

the characteristics of the dressings and the influence 

of the materials of construction and the architecture of 

their structure. These form the inputs in the dynamic 

environment observed under the dressing over the 

time that the dressing is applied to the skin. A new 

test has been developed following the principle 

identified by Ferguson-Pell et al (2009), with 

modifications to allow a complete accounting of the 

moisture applied in the test system. This new test 

system allows the accurate determination of dynamic 

moisture vapor transmission, which changes over time 

as the moisture management bed of a dressing 

becomes saturated with wound exudate or other fluids. 

Methods 

A modified version of the HWVT rig as described by 

Ferguson-Pell [1] was constructed and used to 

measure the moisture absorbed in the wound bed of 

various wound dressings. All testing is performed in a 

temperature and humidity controlled laboratory [2]. A 

moisture (sweat) reservoir is charged with dH2O at the 

beginning of the test. The dressing is weighted prior to 

the test and applied to the test rig. The dressing is 

clamped in the rig to prevent moisture loss via any 

route other than transmission through the dressing. 

See Figure 1. The outer canister is charged with a 

weighed mass of desiccant. The system is then 

attached to a circulating water bath set at 37°C and 

1.5 liters per minute flow. Calibrated temperature and 

humidity sensors are positioned both under the 

dressing, and at the dressings outer surface. 

Additionally the ambient environment is measured 

through out the test. The test is run for 3 to 24 hours 

and the temperature and humidity is logged 2 times 

per minutes through out the test. At the end of the test 

the desiccant is weighted to determine the moisture 

that has been transmitted through the dressing, the 

dressing is weighed to determine the total moisture 

absorption, and the reservoir is weighed to determine 

the moisture that has not moved through the test rig. 

See Figure 1. This provides a full accounting of the 

moisture movement throughout the test. 

113 

Fig.1: Dressing clamped in assembled test rig. 

Results 

Fig. 2: Moisture Retention over 24 Hours. 

Discussion 

This system allows for the first time a test system that 

documents a full accounting of the moisture present in 

the test system and allows the characterization of the 

wound bed’s affinity for moisture. See Figure 2. 


Identifying the optimal environment for wound 

prevention and healing requires an understanding of 

the performance of the dressings used. This system 

provides that opportunity. 


We appreciate partial funding of this project by 

Molnlycke 

Conflict of Interest None. 

References 

[1] Ferguson-Pell M, et al. J of Reha Res and Dev. 

2009;46:945-956 

[2] IS0 554 Standard Environments for Testing and 

Calibration Laboratories. 





Body weight and pressure ulcer occurence 

Jan Kottner 1* , Amit Gefen 2 , Nils Lahmann 3 

1* Berlin, Germany, jan.kottner@email.de 

2 Department of Biomedical Engineering, Tel Aviv University, Israel, 

3 Department of Nursing Science, Charité-Universitätsmedizin Berlin, Germany 

Introduction 

Prolonged mechanical loads lead to compression, 

tension, shear and finally to breakdown of the skin 

and/or underlying tissues. In clinical practice these 

pathological loads are primarily related to immobility. 

Also the habitus characterized by the body mass index 

(BMI) and the features of different anatomic locations 

prone to pressure ulcer (PU) development seems to 

play a role in tissue breakdown. The overall aim was to 

explore the relationships between BMI, pressure ulcer 

type (superficial category 2 vs. deep categories 3/4) 

and anatomic locations (trunk vs. heels). 

Methods 

A secondary data analysis of 10 German-wide 

multicentre pressure ulcer prevalence studies was 

conducted. According to a standardized study protocol 

teams of two trained nurses collected data about 

demographics, PU risk, and conducted a head to toe 

skin assessment to indentify and classify PUs. 

For this secondary data analysis, patients 

being 17 years and older were included. The sample 

was categorized into 12 BMI groups according to the 

WHO [1] and the proportions of patients having at 

least one PU were calculated per BMI group. The 

analysis focused on four groups: (1) patients with at 

least one PU category 2 at the trunk (sacrum, 

trochanter, ischial tuberosity, scapula), (2) patients 

with at least one PU category 3/4 at the trunk, (3) 

patients with at least one PU category 2 at the heels, 

(4) patients with at least one PU category 3/4 at the 

heels. All four analyses were run for all patients and 

for at pressure ulcer risk patients only. 

Results 

In total, 50446 hospital patients were analysed. Mean 

age was 68 (IQR 55 to 78) years. 55.4% were female. 

Table 1: Overall proportions of pressure ulcers in % and 

99% CIs 

Category (anatomic location) All patients At risk 

2 (trunk) 2.0 (1.8 to 2.2) 6.5 (6.0 to 7.1) 

3/4 (trunk) 0.9 (0.8 to 1.0) 3.1 (2.7 to 3.5) 

2 (heels) 0.6 (0.5 to 0.7) 1.9 (1.6 to 2.3) 

3/4 (heels) 0.6 (0.5 to 0.7) 2.0 (1.7 to 2.4) 

Thin patients had significantly more superficial and 

deep PUs at the trunk (Fig. 1). Although there also 

seemed to be a relationship between BMI and heel 

PUs (Fig. 2), this was not statistically significant. The 

same pattern was observed in the at risk group 

(figures not shown). 

114 

Figure 1: Association between BMI groups and proportions 

(including 99% CIs) of category 3/4 pressure ulcers at the 

trunk (trochanter, ischial tuberosity, trochanter, shoulder) 

Figure 2: Association between BMI groups and proportions 

(including 99% CIs) of category 3/4 pressure ulcers at the 

heels 

Discussion 

Most of all PUs were superficial category 2 PUs. Thin 

hospital patients are at high risk for the development of 

deep category 3/4 PUs at the trunk. There seems to 

be no association between BMI and heel PU 

occurrence. Obesity in general seems to be unrelated 

to PU development. 


To prevent PUs at the sacrum, trochanter, ischial 

tuberosity, and scapula aggressive preventive 

measures should be given to underweight patients. 

The BMI is not a risk factor for heel PUs. 


None. 

References 

[1] World Health Organization. BMI classification. 

http://apps.who.int/bmi/index.jsp?introPage=intro_3.ht 

ml 






Cees Oomens 1 , Sandra Loerakker 1 , Klaas Nicolay 1 , Dan Bader 1,2 

1* Eindhoven University of Technology, The Netherlands, c.w.j.oomens@tue.nl 

2 University of Southampton, United Kingdom 

Introduction 

Prolonged mechanical loading of soft tissues overlying 

bony prominences, as experienced by bed-bound and 

wheelchair-bound individuals, can lead to damage in 

the form of pressure ulcers (PU). One type of PU is 

initiated in muscle tissues and progresses outward 

towards the skin layers. The treatment of this 

condition, termed Deep Tissue Injury (DTI), is 

necessarily complex and leads to a variable prognosis. 

The aetiology of DTI involves a number of factors, 

each triggered by mechanical loading, involving cell 

and tissue deformation, ischaemia, ischaemiareperfusion 

injury and impaired interstitial and 

lymphatic flows. The present work examines the 

relative contributions of these factors, by applying 

different mechanical loading regimens to a wellestablished 

animal model [1]. 

Methods 

A series of experiments was conducted, each of which 

involved indentation of the tibialis anterior muscle of 

the left hind limb of Brown Norway rats. The integrity of 

this muscle was monitored during both loading and 

unloading periods with T2 weighted Magnetic 

Resonance Imaging (MRI) and muscle perfusion as 

assessed by dynamic contrast-enhanced MRI. In 

addition, dedicated Finite Element Models were 

developed to estimate the local mechanical conditions 

within the muscle. Experiments involved both 

continuous and intermittent tissue deformation for 10 

minutes and 2 hours (short term loading), and 

continuous deformation for 4 hours (long term 

loading), followed by an unloading period of 2 hours. 

Results 

Damage due to loading periods up to 2 h occurred 

only in high-strain areas, and deformation correlated 

with the amount of muscle damage. Moreover, a 

threshold for damage was found that only depends on 

deformation. The exposure time influenced the amount 

of damage, and temporary load reliefs (as used in 

clinical practice) did not affect the development of 

muscle damage (fig. 1). Thus, within a 2 h loading 

period, deformation is the primary trigger for muscle 

damage. 

After 4 hours of ischaemia clear signs of tissue 

swelling became visible. Reperfusion after 4 h 

ischaemia caused a decrease in swelling in some 

areas. In other regions, reperfusion was absent, 

associated with a further increase in T2. 

115 

Fig. 1. There exists a mechanical threshold for muscle 

damage. a) Above this threshold, 2 h causes more damage 

than 10 min loading. b) Temporary load reliefs during a 2 h 

loading period did not affect the results.(adapted from [2]) 

Fig. 2 Perfusion (contrast enhancement) and swelling (T2) 

during 4 h ischaemia followed by 2 h reperfusion. 

Discussion 

These findings suggest that the relative importance of 

the initiating factors for the aetiology of DTI are 

temporally-dependent, with deformation dominating at 

shorter loading periods. 

The results must be considered in the light of a 

prevention strategy for DTI and highlight the need to 

minimise internal tissue strains in those individuals in 

which prolonged loading is inevitable. 

References 

[1] Ceelen KK et al. (2008) Compression-induced 

damage and internal tissue strains are related. J. 

Biomechanics, 41, 3399-3404 

[2] Loerakker S et al. (2010 Temporal effects of 

mechanical loading on deformation induced damage in 

skeletal muscle tissue, Ann. Biomed. Eng., 38(8), 

2577-2587 





Wound bed preparation with an enzyme alginogel in the treatment of pressure ulcer 

category 4 

Kris Bernaerts 1 , Adinda Toppets 1 , Ingrid Keyaerts 2 , Marina Reynaerts 2 

1 CNS wound care, University Hospitals Leuven, Belgium, kris.bernaerts@uzleuven.be 

2 Support team wound care, University Hospitals Leuven, Belgium 

Introduction 

Wound bed preparation is an essential part of the 

treatment of pressure ulcers. Wound bed preparation 

focuses on debridement, bacterial balance, 

management of wound exudates and the overall 

health status of the patient 1 . The goal of wound bed 

preparation is to stimulate granulation tissue, to 

prepare the wound for surgical closure 2 or to complete 

closure of the wound. 

Enzyme alginogels address each of the four 

components that underpin wound bed preparation 

described in the T.I.M.E. framework. Flaminal ® Hydro 

and Flaminal ® Forte keep the wound moist, they carry 

out continuous debridement of the wound, they protect 

the wound edges and they restore the bacterial 

balance 3,4 . These items are important in the treatment 

of a sacral pressure ulcer. 

Case 1: an obese women, 72 years old with diabetes 

type II, arterial hypertension and chronic kidney 

insufficiency. 

Reason for admission was pneumonia, respiratory 

distress and multiple organ failure. She developed a 

sacral pressure ulcer category 4 due to bad overall 

condition. 

Case 2: a morbide obese man of 150kg, 44 years old 

with diabetes type II, hyperlipidemia, COPD and 

asthma. He developed a sacral pressure ulcer 

category 4 due to bad overall condition and limited 

mobilisation. 

Methods 

After surgical debridement we prepared the wound 

bed using negative pressure wound therapy. For 

different reasons (infection, bleeding) this therapy was 

stopped and we apllied an enzyme alginogel. 

The wound evaluation was monitored by pictures and 

by measuring wound surface reduction. 

Results 

Both wounds were clean and almost without debris 

within a week. The enzyme alginogel created the ideal 

condition for the development of granulation tissue. 

Exudate was managed by the alginates in the enzyme 

alginogel. Because of the presence of antibacterial 

enzymes no clinical signs of infection occurred during 

application of the enzyme alginogel . 

Due the bad overall condition and limited mobilization 

of both patients, flap surgery was not possible. The 

current therapy was continued. 

116 

Within a short period of time the wound evolution was 

positive in both cases with a spectacular development 

of granulation tissue and epithelial cells. 


The application of an enzyme alginogel is a very good 

adjuvent treatment to negative pressure wound 

therapy in the preparation of the wound bed. This 

ensures woundhealing from the point of debridement 

to re-epithalisation and meets all components of the 

T.I.M.E. framework. 

References 

[1] Sibbald R. et al., Ostomy Wound Manage; 46:14- 

35, 2000 

[2] Schultz G. et al., Wound Repair Regen; 13 

(4suppl): 1S-11S, 2005 

[3] White R., Wounds UK; 2(3): 64-69, 2006 

[4] Falanga V., Wound Repair Regen; 8: 347-52, 2000 


Thursday, 1st September, 11.00 

Room A4 

Smith & Nephew Symposium 

117


September 2nd 2011: 11.00-12.30 

Smith & Nephew Symposium 

Room A4 

Chair: Kátia Furtado 

Presenters: Joan Enric Torra I Bou, Paulo Alves, Ester Malcato 

Reducing the human and economic cost of pressure ulcers 

Joan Enric Torra I Bou 

Reducing the human impact and the economic cost in prevention and treatment 

Paulo Alves 

Infection Control in pressure ulcers 

Ester Malcato 

Skin care and negative pressure wound therapy 

118


The implementation of innovation in clinical practice 

Dr Lisette Schoonhoven, The Netherlands 

119




Pressure ulcer prevention and treatment guideline implementation process 

Betsie G.I. van Gaal 1* , Lisette Schoonhoven 1 , Joke A.J. Mintjes-de Groot 2 Raymond T.C.M. 

Koopmans 1 , Theo van Achterberg 1 

Introduction 

1* Radboud University Nijmegen Medical Centre, The Netherlands, 

2 HAN University of Applied Sciences Han University, The Netherlands 

b.vangaal@iq.umcn.nl 

Implementing a guideline is a complex intervention. 

Implementing more than one guideline at the same 

time is even more complex. The SAFE or SORRY? 

study developed a programme for the implementation 

of multiple guidelines, simultaneously. Besides the 

pressure ulcer guideline, we implemented the 

guidelines to prevent urinary tract infections and falls. 

To test the effectiveness of the programme, we 

designed a cluster randomised trial, i.e. does it 

decrease the incidence of the three adverse events 

and increase the preventive care. 

The aim of the presentation is to focus on the 

development and implementation of the complex 

SAFE or SORRY? intervention and briefly show the 

results of the study with the lessons learnt. 

Methods 

The programme was developed with experts on each 

topic and in cooperation the participating wards in the 

first year of the study. It consisted of the 

recommendations of the guidelines, which were 

reduced into a manageable set of bundles. 

Additionally, we developed process and outcome 

indicators based on the existing guidelines. 

For the implementation of the programme a 

multifaceted implementation strategy was developed, 

including education, patient involvement and feedback 

through a computerised registration programme and 

was tailored to each individual intervention ward. 

A cluster randomised was conducted between 

September 2006 and November 2008 on ten wards in 

four hospitals and ten wards in six nursing homes. The 

wards were stratified for institute and type of ward and 

randomised to an intervention or usual care group. 

The primary outcome was the incidence of the three 

adverse events and the secondary outcome was the 

preventive care given to the patients at risk. The study 

has been registered with clinicaltrials.gov, number 

NCT00365430. 

Results 

During the follow-up, we observed 1576 patient weeks 

in 1081 hospital patients in the intervention group (5 

clusters) and 1782 patient weeks in 1120 patients in 

the usual care group (5 clusters). In nursing homes 

both groups had 196 patients and we observed in the 

intervention group (5 clusters) 2754 patient weeks and 

in the usual care group (5 clusters) 3045 patient 

weeks. 

120 

The results showed that patients in the intervention 

group developed 43% and 33% fewer adverse events 

compared to the usual care group in hospitals and 

nursing homes, respectively, but we did not find better 

preventive care given to patients at risk in the 

intervention groups, neither in hospitals nor in nursing 

homes. 

Discussion 

Given this positive result on the primary outcome, we 

also expected to find positive results on the secondary 

outcomes. Surprisingly, we did not find more 

preventive care in the intervention groups. We propose 

three possible explanations for these contradictory 

findings and a few implications for future research and 

practice. The first explanation lies in the use of 

evidence based guidelines, the second lies in the 

potential shortcomings of the implementation strategy 

used in this study and the last explanation concerns 

the validity of the data collected in our study. 

Evidence based guidelines are important for the 

quality of care in daily practice. More research is 

needed to investigate the effectiveness of the 

guidelines on patient outcomes and the process of 

care. 

For the programme, we developed outcome and 

process indicators based on the recommendations of 

the evidence based guidelines used. Using these 

indicators for monitoring or measuring quality 

improvement, they should be tested for their validity, 

reliability, as well as sensitivity to change. 

Collecting data on the preventive care given is not 

easy, because it is a continuous complex process and 

it is impossible to measure such care 24 hours a day 

and seven days a week. To obtain an accurate 

impression of the preventive care, we recommend 

collecting this kind of data by frequent 


This study showed that it is possible to implement 

multiple guidelines simultaneously, which is promising 

for organisations aiming at improving patient safety. 

The lessons learnt from this study are important for the 

implementation of guidelines..




Implementation of NPUAP/EPUAP pressure ulcer prevention guidelines 

on a national level in Sweden 

Lena Gunningberg 1* , Christina Lindholm 2 

1* Uppsala University and University Hospital, Sweden lena.gunningberg@pubcare.uu.se 

2 Karolinska University Hospital, Stockholm, Sweden 

Introduction 

In 2007, a national patient safety initiative was 

launched by the Swedish Associations of Local 

Authorities and Regions (SALAR) (1). It was inspired 

of the US Campaign “Protecting 5 million lives from 

harm”. In Sweden, the directors of the county councils 

decided to prioritize six areas, i.e. pressure ulcers, fall 

injuries, medication errors, urinary tract infections, 

central line infections and surgical site infections. 

Experts in these areas were asked to developed 

evidence-based guidelines that would be easy to 

understand and use. The time frame was very short, 

only a couple of months. 

Parallel with this work, the NPUAP/EPUAP guidelines 

for pressure ulcers were developed (2). Small working 

groups all over Europe were reading and appraising 

the evidence for pressure ulcer prevention. In the fall 

of 2009, these guidelines were published online, and 

thereafter the short version was translated to Swedish 

and spread during conferences and to tissue viability 

nurses. 

When the SALAR national guidelines were going to be 

revised in 2010, we had an excellent opportunity to 

integrate the NPUAP/EPUAP guidelines. 

The aim of this presentation is to describe how the 

NPUAP/EPUAP pressure ulcer prevention guidelines 

have been integrated in national guidelines and 

implemented in Swedish hospitals and nursing homes. 

Methods 

Three nurse researchers (including two EPUAP 

trustees) added evidence and recommendations from 

the NPAUP/EPUAP guidelines to the SALAR 

guidelines. These revised guidelines were published 

online and in a 17 pages broschure in March 2011. It 

is free of charge and after a month about 9500 

guidelines have been disseminated. 

121 

Results 

The guidelines consist of six recommendations: 

• Assess pressure ulcer risk 

• Assess skin status 

• Reduce pressure 

• Keep the skin dry and clean 

• Provide adequate nutrition 

• Inform the person and relatives 

• Inform the next care giver when the person is 

moving to another unit or institution 

First the strategies are described in simple and 

practical terms. Secondly, the evidence that support 

the strategies is presented. Finally, there are 

suggestions of small tests of change, using audit of 

patient records once a month, to get feedback on how 

well the guidelines are followed. 

Discussion 

Most health professionals now recognize the 

guidelines and have started to implement them in 

clinical practice, hospitals as well as nursing homes. 

Open comparison between county councils and pay 

for performance have increased the interest in 

evidence-based guidelines 

New patient safety law in January 2011 


Evidence-based guidelines are crucial in preventing 

pressure ulcer. However, the guidelines have to be 

easy to understand. 


The Swedish Associations of Local Authorities and 

Regions are acknowledged for leading this patient 

safety work. 


None 

References 

[1] www.skl.se/patientsakerhet 

[2] NPUAP/EPUAP. National Pressure Ulcer Advisory 

Panel and European Pressure Ulcer Advisory Panel. 

Prevention and treatment of pressure ulcers: clinical 

practice guideline. Washington DC: National Pressure 

Ulcer Advisory Panel, 2009 





Final version of PU-QOL: a patient-reported outcome measure of health-related quality of 

life for patients with pressure ulcers 

Claudia Gorecki 1* and Jane Nixon 1 , on behalf of the PUQOL project team 

1* CTRU, University of Leeds, Leeds, UK, C.Gorecki@leeds.ac.uk 

Introduction 

Assessment of health outcomes are increasingly 

included in clinical trials, with patient-reported outcome 

(PRO) data now an integral aspect of patient care, 

policy decision making and healthcare delivery. With 

International consensus for use of scientifically robust 

and responsive PRO measures in routine clinical 

practice and research, the careful stepwise 

construction of PRO instruments, based on current 

detailed guidelines is a must. Currently no PRO 

instruments are available to assess the impact of 

pressure ulcers (PUs) on health-related quality of life 

(HRQL) [1]. Previous presentations have presented 

the HRQL conceptual framework and PU-QOL 

instrument development methods. This presentation is 

the first of the content and measurement properties of 

the final version of the PU-QOL instrument. 

Methods 

We developed the PU-QOL to measure PU symptoms 

and HRQL in people with PUs on the basis of a 

conceptual framework of HRQL outcomes [2] 

developed from a systematic review [3], clinical 

expertise, and patient interviews. These three sources 

were used to generate an exhaustive item pool which 

was subsequently used to produce a draft PU-QOL. A 

multidisciplinary group of clinical and health outcome 

methodology experts evaluated the draft PU-QOL, 

which was then pretested using mixed methods. 

Psychometric evaluation was undertaken in two parts: 

1) Item reduction on the basis of PU-QOL data from 

227 patients with PUs and 2) formal psychometric 

evaluation using both classical and Rasch methods on 

the basis of PU-QOL data from 220 patients with PUs. 

Results 

The final PU-QOL consists of 10 validated scales to 

measure pain, exudate, odour, sleep, malaise, 

mobility/movement, activities of daily living, emotional 

well-being, self-consciousness and appearance and 

participation outcomes. The PU-QOL is intended as an 

administered instrument where patients rate the 

amount of “bother” attributed (e.g. “During the past 

week, how much have you been bothered by…?”) on a 

4-point response scale (e.g. 0=not at all– 3=a lot). We 

chose a recall period of the past- week on clinical 

grounds; as changes in PU severity and 

symptomology generally occur over days, a longer 

recall period would risk missing changes relevant to 

HRQL. 

122 

Discussion 

Rigorous methods, based on international standards, 

were used to develop and evaluate the PU-QOL 

instrument. PUs impact on physical, psychological and 

social functioning of people who develop them but 

these outcomes have not been included in previous 

PU research; research in the field has measured 

outcomes associated with healing rather than 

outcomes important to patients. Here, we provide a 

robust and psychometrically sound instrument for 

assessing outcomes important to patients such as PUspecific 

symptoms. This is the first outcome measure 

specific to PUs, reflecting the domains in a PU-specific 

conceptual framework of HRQL outcomes; content 

that differs from other chronic wounds [1], for use in 

research and clinical practice. 


HRQL assessment may: demonstrate prevention or 

treatment benefits not shown by traditional clinical or 

laboratory-defined outcomes; demonstrate important 

patient orientated differences between interventions to 

justify resource allocation; and inform decisions about 

patient care, policy decision making and healthcare 

delivery in the PU field. 


We appreciate the help of all research teams at 

participating centres around England and Scotland. 

Financial support was provided by the National 

Institute for Health Research (NIHR) under its 

Programme Grants for Applied Research funding 

scheme (RP-PG-0407-10056). The views and opinions 

expressed within this abstract are those of the authors 

and not necessarily those of the NHS, the NIHR or the 

Department of Health. 

Conflict of Interest – none to declare 

References 

[1] Gorecki et al., Wound Repair Reg. (under review) 

[2] Gorecki et al., Int J. Nurs Stud. 47:1525-347, 2010 

[3] Gorecki et al., J. Am Geriatr Soc. 57:1175-83, 2009 





Pressure ulcer pain prevalence in community populations: prevalence survey 

1* Nixon. J on behalf of the PURPOSE Pain Team. 

1* Clinical Trials Research Unit, University of Leeds, United Kingdom, j.e.nixon@leeds.ac.uk 

Introduction 

Pain is often a significant and disabling for those 

with pressure ulcers (PU) [1], but there are few 

PU pain prevalence studies. Establishing the 

extent and type of pain is important to guide 

clinical practice. There are essentially two types 

of pain: nociceptive pain resulting from the 

inflammatory response, and neuropathic pain 

occurring as a result of nerve damage or tissue 

ischaemia; both types of pain can occur during 

pressure ulcer development, but we don’t know if 

they occur equally or in combination. 

This study is one of 6 components of the NIHR 

funded Pressure UlceR Programme Of ReSEarch 

(PURPOSE). The aims were to: 

• determine the prevalence of PU pain in 

community patients with PUs 

• assess the type and severity of PU pain 

• explore the association between pain and PU 


Methods 

We undertook pain prevalence surveys in 2 

Primary Care Trusts in the UK, piggy-backing 

pain questions onto the routine annual PU 

prevalence audits. The Primary Care Trusts 

served a total population of approximately 

570,000 people across urban and rural areas in 

the NE of England, UK. 

In Trust 1 a prevalence survey form was 

completed for all patients on the district nursing 

caseloads and resident in nursing homes. In 

Trust 2 a form was completed only for patients on 

the District Nurse caseload with a PU (including 

home and nursing home residents). Individual 

patient data were recorded by the community 

nurse. Where a PU of any grade was reported, a 

member of the TVN team visited the patient and 

verified the PU audit data, then asked two 

questions relating to localised skin pain to 

establish PU pain prevalence. Where pain was 

indicated, consenting patients underwent a 

detailed pain and skin assessment using: 

1. numerical rating scale 

2. adapted Leeds Assessment of 

Neuropathic Symptoms and Signs 

(LANSS) Pain Scale 

3. Skin assessment using EPUAP 

classification. 

123 

Results 

287 patients across the 2 Primary Care Trusts 

were reported to have a PU (0.69:1000) and of 

these 176 were able to answer pain prevalence 

questions. Three quarters of people with a PU 

reported that they had pain (75.6%: 133/176), 

and 27.8% (37/133) of patients reporting PU pain 

consented to a detailed pain assessment. 

The characteristics of patients reporting PU 

related pain, the prevalence of inflammatory and 

neuropathic pain, and pain intensity by PU Grade 

will be presented. 

Discussion 

The scale and scope of PU pain in community 

patients, are clearly highlighted, indicating that 

pain is a common symptom experienced by 

patients. The results concur with the related PU 

prevalence reinforcing the need to develop 

clinical practice in an area which is a priority for 

patients and impacts upon their quality of life. 


PU pain for all Categories of PU is very common in 

both community and acute patient populations. Pain 

assessment should be embedded within skin 

assessment practice. 


None 


This conference paper presents independent research 

commissioned by the National Institute for Health 

Research (NIHR) under its Programme Grants for 

Applied Research funding scheme (RP-PG-0407- 

10056). The views expressed in this presentation are 

those of the authors and not necessarily those of the 

NHS, the NIHR or the Department of Health. We thank 

community staff, clinical research nurses and NHS 

collaborators at the participating Primary Care Trusts. 

References 

[1] Gorecki et al 2011 Pain reported pain: a mixed 

methods systematic review Journal Pain and Symptom 

Management (in press) 



Introduction 



Do organisations cause pressure ulcers? An exploratory review 

Lisa Pinkney 1* , Jane Nixon 2 , Justin Keen 1 

1* University of Leeds, Institute of Health Sciences, England, l.m.pinkney@leeds.ac.uk 

2 University of Leeds, Clinical Trials Research Unit, England, 

This paper discusses results from a literature review 

on pressure ulcers and organisational processes. 

Although there are two relevant literatures regarding 

pressure ulcer care and organisational influences, 

these are not linked to each other. Therefore it was not 

possible to do a traditional review in this area. There 

are two high quality research studies [1][2] and a large 

number of poor quality studies which suggest that 

organisational factors may be important. However, we 

need to draw more widely on literature about risk and 

error in organisations in general to understand why 

some patients develop severe pressure ulcers while 

others with a similar risk profile do not. 

Methods 

A literature review was carried out to explore literature 

on pressure ulcers and organisational environments. A 

number of literatures were reviewed separately and a 

method was devised for linking them together, which 

broadly follows a realist synthesis method [3]. The first 

stage of the review is set out in the diagram below (Fig 

1.) 

Fig 1 


and related terms 

Inclusion 

criteria 

Pressure ulcer: 

Primary 

research 

Audits 

Organisational 

factors 

associated 

with pressure 

ulcer outcome 

Safety 

management/risk/error/ 

quality of 

healthcare/adverse 

event 

Electronic search 

Citation search on systematic 

reviews 

No grey literature 

HMIC 8 

MEDLINE 155 

Psychinfo 11 

EMBASE 399 

CINAHL 171 

Assessed as 

potentially eligible 

and obtained in full 

for further scrutiny 

(n=) 

Primary research/audits 

to be included =57 

Organisation/ 

healthcare/or 

ganisational 

culture 

Exclusion criteria 

Opinion papers 

Editorials 

Mattress trials 

Equipment trials 

Patient level 

treatment 

intervention trials (eg 

mattresses, patient 

education 

programmes, healing 

of ulcers) 

Nurse education 

programmes/protocol 

implentation 

Pressure ulcers not 

primary outcome 

measure (unless 

process outcome 

related to PUs) 

The second stage involved widening the search to 

include a range of literatures on safety and health. The 

literature in the review was of varying quality; however 

it was still possible to draw out evidence and review it 

systematically using a realist approach. 

124 

Results 

Although the review offers insights into areas of 

pressure ulcer care and the effect of the organisational 

environment, there is little evidence of dynamic 

processes of care and development of pressure 

ulcers. There are no studies which focus on severe 

pressure ulcers. Patient safety research remains 

influenced by human factors, cognitive and social 

psychology [4]. Other safety research focuses on the 

socio-cultural, leaving little room to analyse safety from 

a small group perspective. 

Discussion 

This review shows that pressure ulcer literature and 

organisational safety literature remain almost 

completely unrelated, which suggests that more work 

needs to be done in these areas. There are few 

published methods which allow exploration of these 

unrelated areas. Little research attention has been 

given to examining failures of care using methods 

which allow for detailed focus on the ‘whole’ system 

including process and social influences. There is a 

need to explore links between environmental and 

individual patient safety issues and how these may 

affect pressure ulcer care. 


This study is part of the NIHR PURPOSE Programme 

Grant will inform a new risk assessment framework. 


Financial support was provided by the National 

Institute for Health Research (NIHR) under its 

Programme Grants for Applied Research funding 

scheme (RP-PG-0407-10056). The views and opinions 

expressed within this article are those of the authors 

and not necessarily those of the NHS, the NIHR or the 

Department of Health. 


None 

References 

[1] Berlowitz et al. (2003). Health Services Research 

38(1 Part 1): 65-83. 

[2] van Gaal et al. (2010). International Journal of 

Nursing Studies 47(9): 1117-1125. 

[3] Pawson (2006) Evidence Based Policy: A Realist 

Perspective. London, SAGE. 

[4] Reason (2000). BMJ 320(7237): 768-770. 





A Systematic Review of Pressure Ulcer Risk Factors 

Susanne Coleman 1* , Jane Nixon 2 , Claudia Gorecki 3 , Andrea Nelson 4 , on behalf of the PURE Project 

Team 

1* Clinical Trial Research Unit, University of Leeds, UK, medscole@leeds.ac.uk 

2 Clinical Trial Research Unit, University of Leeds, UK, 3 Clinical Trial Research Unit, University of Leeds, 

UK, 4 School of Healthcare, University of Leeds, UK. 

Introduction 

PUs are a worldwide problem affecting hospital and 

community patient populations. In practice, the 

emphasis is on identifying patients at risk and 

implementing appropriate interventions to prevent PU 

occurrence. It has been argued consistently that PU 

risk assessment scales need to be developed on the 

basis of multivariable analyses to identify factors which 

are independently associated with PU development. 

Methods 

A systematic review of primary PU research with 

methods based on those recommended by Cochrane 

(1) and CRD (2) was conducted. 

Inclusion Criteria: i) primary research, ii) adult study 

populations in any setting iii) outcome was the 

development of a new PU(s), iv) prospective cohort, 

retrospective record review or a controlled trial, v) 

length of follow-up at least 3 days, with exception of 

operating room studies for which no minimal was set 

and vi) outcome clearly defined as ≥ Grade/Stage 1 or 

equivalent, vii) multivariable analyses were undertaken 

to identify factors affecting PU outcome and viii) 

statistical methods included only independent data. 

Search: i) 14 electronic databases from inception to 

March 2010, ii) UK National Research websites, iii) 

hand search of grey literature, iv) contacted 13 experts 

and v) citation search of included studies. 

Each study was subject to robust quality assessment 

(3). Risk factors were categorized into themes and 

sub-themes. Evidence tables were generated 

summarizing both the quality and quantity of evidence 

for each sub-theme. These were summarized by 

narrative synthesis for both theme and sub-theme. 

Results 

5462 papers were retrieved of which 373 were 

potentially eligible. Of these 319 did not meet the 

quality criteria leaving 54 studies that were included in 

the systematic review, comprising 34 prospective 

cohort studies, 11 RCTs and 9 retrospective record 

reviews. 

A range of patient factors were reported as 

independently predictive of PU development, that is 

factors found to be significant in the presence of other 

confounding factors. The themes that emerged most 

consistently in multivariable analysis were: 

1. Mobility/ activity 

2. Skin condition 

125 

3. Perfusion (including diabetes) 

4. Haematological measures (including albumin) 

Other themes which emerged less consistently 

included moisture, body temperature, nutrition, age, 

sensory perception, mental status, race, gender, 

general health status and medication. 

Discussion 

This is an up date of the first systematic review of risk 

factors related to PU development. The methodology 

has been further developed to incorporate the quality 

of evidence for each risk factor. Results are consistent 

with pressure ulcer aetiology and conceptual 

frameworks confirming major themes of mobility and 

perfusion, whilst providing important new insights into 

the importance of skin condition and other risk factors 

associated with PU development. 


Having a clearer understanding of the risk factors 

associated with PU development will enable the 

development of an evidence based Pressure Ulcer 

Risk Assessment Framework (PURAF) for use in 

clinical practice. This is currently being undertaken as 

part of the PURPOSE programme of research (NIHR 

funded). 


This paper presents independent research 

commissioned by the National Institute for Health 

Research (NIHR) under its Programme Grants for 

Applied Research funding scheme (RP-PG-0407- 

10056). The views expressed in this paper are those 

of the author(s) and not necessarily those of the NHS, 

the NIHR or the Department of Health. 


None to report 

References 

[1] Higgins JPT, Green S (ed). Cochrane Handbook 

Version 5.0.2.September 2009. 

[2] Centre for Reviews and Dissemination. CRD 

University of York; 2009. 

[3] Hayden J, et al. Annals of Internal 

Medicine.144:427-437, 2006. 



Room B4 


Pressure ulcer care in Dutch and German nursing homes: a 

comparison of nurses’ knowledge and patient characteristics 

Ruud Halfens, The Netherlands 

Collaborative working of providers and commissioners, in the 

development and delivery of an integrated healthcare economy wide 

pressure ulcer pathway 

Jacqueline Warner, UK 

Implementation of the German Expert Standard Pressure Ulcer 

Prevention and Nosocomial Pressure Ulcers – A Multi-Level-Analysis 

Doris Wilborn, Germany 

The development and re-development of an electronic Pressure Ulcer 

Notification Tool (PUNT) for use within an NHS Acute Healthcare 

setting. 

Mark Collier, UK 

126




Pressure ulcer care in Dutch and German nursing homes: a comparison of nurses’ 

knowledge and patient characteristics 

Esther Meesterberends 1* , Ruud Halfens 2 , Christa Lohrmann 3 , Jos Schols 2 

1* Maastricht University, the Netherlands, e.meesterberends@maastrichtuniversity.nl 

2 Maastricht University, the Netherlands, 3 Medical University of Graz, Austria 

Introduction 

Results from annual national pressure ulcer 

prevalence surveys in the Netherlands and Germany 

reveal large differences in prevalence rates between 

both countries over the past ten years, especially in 

nursing homes [1,2]. Numerous studies have identified 

patient related factors, as well as nursing related 

interventions as risk factors for the development of 

pressure ulcers. Next to these more process oriented 

factors, structural factors such as staffing levels play 

also a role. This study was designed to investigate the 

incidence of pressure ulcers in nursing homes in the 

Netherlands and Germany and to identify patient 

related factors, nursing related factors and structural 

factors associated with pressure ulcer development. 

In this presentation preliminary results on patient and 

staff level will be presented. 

Methods 

A prospective multicenter study has been conducted in 

which a cohort of newly admitted nursing home 

residents in 10 Dutch and 11 German nursing homes 

were followed for a period of 12 weeks. Data were 

collected by research assistants using questionnaires 

on four different levels: resident, staff, ward, and 

nursing home. The resident questionnaires contained 

questions about demographic data, diseases, reason 

for nursing home admission, medication use, care 

dependency, mental status, existence of pressure 

ulcer(s), repositioning, mobilization, skin care and skin 

inspection, use of mattresses and cushions, nutrition 

and prevention of malnutrition, and incontinence care. 

The staff questionnaire consisted of three different 

parts (1) demographic characteristics; (2) knowledge 

about pressure ulcer prevention and (3) practice 

regarding pressure ulcer prevention. 

Results 

Results of the resident questionnaires showed 

significant variation between both countries for several 

resident characteristics like age, use of a wheelchair, 

care dependency, Braden scale score and urinary 

incontinence. In the German nursing homes more 

residents already had a pressure ulcer when they were 

admitted to the nursing home, while significantly more 

residents developed a pressure ulcer during the study 

in the Dutch nursing homes (Table 1). 

The results of the staff questionnaire showed that in 

both countries most respondents knew which 

measures are useful to prevent pressure ulcers, while 

non-useful preventive measures were less known. On 

127 

average only 2.5 (the Netherlands) and 3.2 (Germany) 

out of the 13 preventive measures were judged 

correctly as non-useful. The same pattern could be 

seen with regard to daily practice, since non-useful 

preventive measures were still commonly used 

according to the respondents. 

Table 1: Pressure ulcer development 

Residents with (a) pressure 

ulcer(s) at study start 

Residents who developed (a) 

pressure ulcer(s) during the study 

Discussion 

the 

Netherlands 

Germany 

5% 15.3% 

33.3% 14.3% 

This study shows that there is a significant difference 

in pressure ulcer incidence rates between Dutch and 

German nursing homes. Reasons for these findings 

are related to several determinants, like differences in 

patient characteristics and nursing performance. 

Nurses’ and nursing assistants’ knowledge about nonuseful 

preventive measures was poor. Outdated and 

ineffective pressure ulcer preventive measures were 

still in common use in Dutch and German nursing 

homes. 


Insight into the factors influencing pressure ulcer 

incidence is necessary in order to initialize a decrease 

in these rates and to optimize pressure ulcer care. The 

results show that nurses’ and nursing assistants’ 

knowledge and practice regarding pressure ulcer 

prevention could be changed, since they still use 

outdated preventive measures. 


The authors would like to thank all nursing home 

residents and staff who participated in the study. 


None to declare 

References 

[1] Tannen A. et al., Differences in prevalence of pressure ulcers 

between the Netherlands and Germany – associations between risk, 

prevention and occurrence of pressure ulcers in hospitals and 

nursing homes. J Clin Nurs. 17:1237-1244, 2008 

[2] Tannen A. et al., Explaining the national differences in pressure 

ulcer prevalence between the Netherlands and Germany – adjusted 

for personal risk factors and institutional quality indicators. J Eval 

Clin Pract. 15:85-90, 2009 





Collaborative working of providers and commissioners, in the development and delivery of an 

integrated healthcare economy wide pressure ulcer pathway. 

Jacqueline Warner 1* , Jane Harry 2 , Jo Greengrass 3 

1* Heatherwood and Wexham Park Hospital NHS Foundation Trust, jacqueline.warner@hwph-tr.nhs.uk 

2 Berkshire Healthcare Foundation Trust, UK 3 NHS Berkshire East PCT 

Introduction 

Pressure tissue damage is recognized as a major 

financial and care quality issue by Department of 

Health [4, 7]. Improved reporting and awareness of the 

cost of pressure damage during the last 2 years has 

led commissioners to move towards an integrated care 

pathway and policy. These initiatives are intended to 

reduce pressure ulcer incidence, length of hospital 

stay and need for health and social care and ultimately 

improve patient outcomes. The first step in developing 

a robust policy & pathway was to conduct a pressure 

ulcer point prevalence study which analyses total 

pressure ulcer numbers, financial implications and 

patient experience. 

Methods 

Both quantitative and qualitative data were collected. 

A one day point prevalence study was performed 

using a standardized data collection tool in November 

2010. 100% response rate was achieved. Patient 

experience data was collected over a six month period 

and is being analyzed and themed. 

The sample consisted of Acute Hospitals, District 

Nurses, Community Hospitals, Residential and 

Nursing Homes, Day Hospitals, Hospice, Mental 

Health Hospitals. Upon completion of the information 

the tool was returned to the Clinical Development Unit 

for analysis. 

The East Berkshire population was taken from the 

ONS predicted population based on the 2001 Census. 

Results 

Results are described in 3 parts; Overall prevalence, 

Financial Implication and Patient Experience. 

Overall prevalence- 

Total 

population 

sampled 

Inherited 

PTD 

PTD 

Developed 

in current 

Org 

Overall 

Prevalence 

3897 163 

(70%) 

66 (30%) 6% 

Table 1: Number of Patients with Pressure Tissue 

Damage (PTD) in Berkshire East 

Financial implication- The estimated central cost to 

the East Berkshire Health Economy based on the 

DOH Pressure ulcer productivity calculator [3] 

£1,990,000 

128 

Patient experience- Can you explain what the 3 

worst things were about having a pressure ulcer? 

“Longer time in hospital”, “Not being able to sit”, “Pain” 

Discussion 

In the absence of national comparative prevalence 

data this benchmark study demonstrates in real terms 

the cost of pressure ulcer damage not only for the 

patient but for the East Berkshire Health economy 

[1,2,3]. A detailed analysis, which supports table 1, 

defines the priorities in pressure ulcer reduction, 

underpinning the business case for service 

improvement, standardized practice and guidance 

[4,5,6,7,8]. The engagement between commissioning 

and provider arms has facilitated a cohesive patient 

centered, outcome driven approach to care [4,5,8] 


The results provide a platform for a reform of pressure 

ulcer prevention strategies uniting provider and 

commissioners in developing cost effective services 

and guidelines tailor made to the needs of the local 

population. 

Acknowledgments 

We appreciate the help of Arjo Huntleigh in the 

development of the audit tools used in this study 


References 

[1] Calianno C., Nurse Practitioner 32,7,10,13-15 

(2007) 

[2] Gorecki C et al., J. Am.Geriatr.Soc 57, (2009) 

[3] DH.,Pressure ulcer productivity calculator 

(2010) 

[4] DH., High Quality Care for all (2010) 

[5] DH., From good to great (2010) 

[6] EPUAP., Pressure ulcer Prevention (2009) 

[7] NICE.,Pressure Ulcer Risk assessment & 

Prvention (2001) 

[8] DH.,Equity and Excellence: Liberating the 

NHS (2011 





Implementation of the German Expert Standard Pressure Ulcer Prevention and Nosocomial 

Pressure Ulcers – A Multi-Level-Analysis 

Doris Wilborn 1* , Theo Dassen 1 , Ruud Halfens 2 Ulrike Grittner 3 

1* Charité Universitätsmedizin Berlin, Germany, Department of Nursing Science, doris.wilborn@charite.de 

2 Universiteit Masstricht, The Netherlands 3 , Charité Universitätsmedizin Berlin, Department of Biometry 

and Clinical Epidemiology 

Introduction 

The German Expert Standard Pressure Ulcer 

Prevention is a quality development instrument for 

nursing care and provides structural and process 

orientated interventions, additionally several 

measurable outcomes [1]. First research results about 

the relationship between the use of the instrument and 

patient outcomes showed no relationship [2]. 

According to the general recommendations of the 

Expert Standard, specific indicators namely providing 

staff education or using common patient 

documentation sheets by the different health 

professions, which describe the transformation of the 

Expert Standard, were developed. Aim of this study is 

to look at the level of implementation of the Expert 

Standard and to analyse the relationship between the 

implemented standard and the patient outcome 


Methods 

Data of 8299 patients and residents were collected in 

the German prevalence survey in 2009 in 14 hospitals 

and 76 nursing homes. For this study we used data 

from 4520 individuals at risk. To calculate the 

relationship between pressure ulcer prevalence and 

factors of implementation a multi-level-analysis was 

performed. Statistical significant individual 

characteristics of patients/residents, as positioning 

according schedule and skin inspection, ward and 

institutional characteristics as providing information 

leaflets, were included into the multi-level model. 

Nosocomial pressure ulcers grade two and higher 

were chosen as outcome indicator. 

Results 

The overall prevalence in nursing homes was 3.8% 

and in hospitals the prevalence was 7.9%. The 

descriptive analysis showed a pressure ulcer 

prevalence of 2.8% in nursing homes and a 

prevalence of 6.6% in hospitals with information 

leaflets for patients and relatives versus 5.1% in 

nursing homes and 10.1% in hospitals without 

providing information leaflets. The lower probability of 

pressure ulcers in nursing homes with information 

leaflets was confirmed by the multi-level-analysis (OR 

0.48 CI 0.30-0.76). On the individual level the 

descriptive results revealed a prevalence of 21.7% of 

129 

patients who were positioned versus 4.7% prevalence 

of patients who didn’t get positioning by a schedule. 

(OR 2.44 (CI 1.40-4.25) in hospitals for individual 

positioning schedules). That means that those 

individuals of risk have more often pressure ulcers 

even when getting individual scheduled positioning. 

There were no statistically significant differences in the 

pressure ulcer prevalence if institutions provide staff 

education or a certain positioning or a skin care 

framework. 

Discussion 

Only one factor on institutional level (information 

leaflets) showed a relationship between the level of 

implementation of the Expert Standard and the 

pressure ulcer prevalence. The results might indicate 

that structural factors are less important than 

assumed. The results on individual level indicate a 

higher degree of application of preventive measures if 

a pressure ulcer has occurred. 


Information flyers for patients/residents and their 

relatives should be used in hospitals and nursing 

homes. Educated and informed patients/residents and 

their relatives are probably more aware of the risk, the 

signs and symptoms of pressure ulcers so that they 

themselves are more active in pressure ulcer 

prevention. 


We appreciate the help of the data collecting nurses in 

the participating institutions. 


None 

References 

[1] Deutsches Netzwerk für Qualitätsentwicklung in der 

Pflege (DNQP) (Ed.). Expertenstandard 

Dekubitusprophylaxe in der Pflege. Entwicklung- 

Konsentierung-Implementierung. Osnabrück 2004. 

[2] Wilborn D et al. Journal of Clinical Nursing. 19:23- 

24; 3364-71, 2010 





The development and re-development of an electronic Pressure Ulcer Notification Tool 

(PUNT) for use within an NHS Acute Healthcare setting 

Mark Collier 1* , Chris Bailey 2 , David Black 3 

1* 

United Lincolnshire Hospitals NHS Trust (ULHT), c/o Pilgrim Hospital, Boston, Lincolnshire, UK 

2 3 

mark.collier@ulh.nhs.uk as above, as above. 

Introduction 

This paper/poster will illustrate both the development and the 

recent re-development of an online Pressure Ulcer 

Notification Tool (PUNT) to facilitate real-time recording of all 

in-patients with and all assessed pressure ulcers, within an 

acute healthcare setting. 

A basic online form was originally developed in 2004 but 

more recent guidance on pressure ulcer management has 

prompted the development of a more robust tool to record 

and report pressure ulcer activity. PUNT greatly reduces the 

overhead required to monitor and report upon pressure 

ulcers in line with the latest national and international 

guidance [1] [2] [3]. 

PUNT has led the way in the management of pressure 

ulcers throughout the NHS and fed into research information 

provided by the Royal College of Nursing. 

Methods 

PUNT improves the process of managing information about 

patients with pressure ulcers across all four hospital sites 

that make up the United Lincolnshire Hospitals NHS Trust 

(ULHT). 

PUNT was developed by the Tissue Viability and ICT 

departments. It is developed in industry standard 

technologies and meets all patient safety related DSCNs 

including the use of NHS / Microsoft Common User Interface 

(MSCUI) components. 

Following a patient’s skin assessment in the clinical setting 

(either on admission or ongoing) if any pressure damage is 

noted then the practitioner will record this information in the 

PUNT system, which is accessed via the Trust intranet. 

Only trained personnel can input into the system thanks to 

the use of an e-learning application that trains and tests the 

user and only permits system access when they have met 

the required competency level. 

PUNT data can be referenced between assessment dates, 

which should be no more than one week apart. The system 

highlights when subsequent assessments are overdue. User 

feedback confirmed that the system is easy to use and 

subsequent (weekly) ulcer reviews only require a quick 

record edit. 

The previous history of significant ulcers alert (all recorded 

as either category 3 or 4 damage) assists practitioners to 

identify potential ‘at risk’ anatomical areas on the time of this 

patients new admission/re-admission and therefore to plan 

care accordingly. 

The system includes reports such as a summary of current 

patients with pressure ulcers on each ward to assist with 

ward management processes. 

Additionally, appropriate ‘at risk’ scores, such as the 

Waterlow or Plymouth scores have been included in the tool 

and may be updated either weekly or as the patient’s clinical 

condition dictates. Finally a number of appropriate care 

interventions are also included to assist the practitioner in 

both planning immediate care and to facilitate audit of 

subsequent care. 

130 

Results 

This new process has improved skin assessment and the 

care of patient’s relevant needs. It has also helped to identify 

related conditions such as eczema thanks to the reporting 

and monitoring functionality it provides. 

Discussion 

There has been a national drive originating from the 

department of health to make sure all hospitals are reporting 

incidence and prevalence of pressure ulcers in a comparable 

way. 

Most Trusts collect this data in a paper format that is then 

collated retrospectively, which is labour intensive. PUNT 

enables the data to be updated straight after assessment so 

the latest information is always available to the relevant 

individuals within the organisation. This includes Risk 

Managers, Tissue Viability Nurses, Information Services and 

senior management. 

This product could be used by any hospital and other 

healthcare organisations have shown an interest at 

conferences such as “Avoiding Preventable Pressure Ulcers” 

organised by Healthcare Events 


This new process has already been demonstrated to have 

improved skin assessment and the care of patient’s relevant 

needs. Professional compliance with PUNT has risen from 

around 50% to over 90% since the launch of the 

redeveloped tool in April 2011. 

Other patient safety gains include (but are not limited to) the 

following:- 

• Improved patient quality of care. 

• Includes data about where patients were admitted from, 

which helps to inform primary care settings of potential 

problem areas. 

• Previous significant ulcers (category 3 and 4).are 

always highlighted when a patient record is retrieved. 

• PUNT is fully audited so all user actions can be 

identified to an individual. 

• Linked to the patient administration system for positive 

identification of patients and patient demographics. 

• All input data is validated to avoid invalid data input. 

• Improves legibility of information transferred between 

clinicians. 

• Improved reliability of data required by and reported to 

external agencies. 

Conflicts of Interest - None 

References 

[1] NHS Institute (2011) High Impact Actions - Your Skin 

Matters London 

[2] NICE (2005) Pressure Ulcer Management CG 29 London 

[3] EPUAP/NPUAP (2009) Pressure Ulcer Prevention and 

Management – Clinical Guidance NPUAP USA. 





The role of neuromuscular electrical stimulation in pressure ulcer prevention 

Kath Bogie 1* 

1* Case Western Reserve University, Cleveland, USa kmb3@case.edu 

Introduction 

Therapeutic neuromuscular electrical stimulation 

(NMES) has potential clinical application as a unique 

method for reducing the risk of pressure ulcer 

development in at-risk individuals by providing 

effective dynamic periodic weight shifting, essential for 

maintenance of tissue health. Regular use of an 

independent pressure relief regime also appears to 

have some positive impact on indirect measures of 

tissue health. 

Feasibility studies by our group have investigated the 

hypotheses that dynamic weight shifting produced by 

gluteal NMES will augment the efficacy of conventional 

pressure relief maneuvers and that long term exercise 

of paralyzed gluteal muscles will improve the intrinsic 

health of the tissue at the seating interface. 

Methods 

The efficacy of both surface stimulation and implanted 

systems has been investigated by our group. A multifactorial 

clinical assessment protocol has been 

developed to evaluate tissue health using direct and 

indirect measures. 

The effects of long-term use of sub-threshold surface 

electrical stimulation (ES) on indirect measures of 

tissue health has been evaluated. 

A prototype implanted gluteal NMES system was 

implemented using percutaneous electrodes placed 

bilaterally near the motor point of the inferior gluteal 

nerve innervating the gluteus maximus (caudal to the 

sitting interface). This system could be used reliably on 

a daily basis for a long period. A second generation 

system is now being developed that includes trunk and 

gluteus maximus NMES to provide increased postural 

stability for both pressure relief and functional 

reaching. 

Results 

Sub-threshold ES does not appear to have any 

sustained effects on tissue health status indicative of 

reduced pressure ulcer risk for individuals with SCI. 

Back 

Left 

Fig 1: LASR analysis maps showing areas of 

significant change over time, adjusted for simultaneous 

testing at multiple locations. 

131 

Positive changes were observed in indicators of tissue 

health with long-term use of the implanted gluteal 

NMES system, implying that the system was clinically 

effective (Fig 1). Sacro-ischial seating interface 

pressures were reduced bilaterally over time. The 

addition of truck stimulation facilitates stable forward 

leaning and can decrease mean sacro-ischial 

pressures by over 20% compared to forward leaning 

without use of NMES. 

Discussion 

The absences of changes following use of subthreshold 

ES implies that a contractile muscle 

response is critically important. Daily placement of the 

surface stimulation electrodes was found to be 

complicated and time-consuming, making it 

problematic to adhere to a surface gluteal stimulation 

regime. Surface ES thus has limited efficacy in this 

application both clinically and practically. 

Long-term use of gluteal NMES using implanted 

systems provides effective dynamic weight-shifting 

and long-term changes in multiple indicators of tissue 

health. This can reduce the risk of pressure ulcer 

development and allow users to participate more fully 

in activities of daily living. Due to continuing paralysis 

withdrawal of stimulation results in a reversal of 

improved tissue health. 


Findings to date imply that NMES may provide an 

adjunctive method for achieving a regular pressure 

relief regime for at-risk individuals. Regular daily use 

has a positive impact on multiple indirect indicators of 

tissue health and thus may reduce the risk of pressure 

ulcer development. Daily use of NMES is required in 

order to maintain hypertrophy of paralyzed muscles 

ted for individuals at high risk of pressure ulcer 

development. For increased ease and reliability of 

long-term use, fully implanted stimulation systems are 

indicated. 


All current and past members of the Skin Care & 

Tissue Health Research Lab, LSCDVAMC, Cleveland, 

USA. 

Funding for the studies to be discussed was provided 

by: the Spinal Cord Research Foundation/Paralyzed 

Veterans of America, the US Dept of Veterans Affairs 

Rehabilitation Research and Development Service and 

the VISN10 VISN 10 Emerging Technologies program. 


Dr Bogie has no conflicts of interest related to the 

content of my presentation 



132 



The role of the microclimate in new innovations 

Michael Clark 1* 

1* Visiting Professor in Tissue Viability, Tissue Viability Practice Development Unit, Faculty of Health, 

Birmingham City University, UK, reachmichaelclark@gmail.com 

Introduction 

The first conference on pressure ulcers held in Europe 

was clear upon the steps required to achieve 

successful pressure ulcer prevention - ‘We know how 

to avoid bed sores and tissue necrosis – maintain the 

circulation, avoid long continued pressure, abrasions, 

extremes of heat and cold, maintain a favourable 

micro-climate, avoid irritating fluids and infection’ (Roaf 

1976, reprinted 2006). The term 'micro-climate' was 

coined to reflect local heat and moisture at the skinsupport 

surface interface. However as time passed 

the support-surface debate moved away from 

considerations of micro-climate to discussion of the 

mechanical loads imposed by the mattress or cushion. 

In the last two to three years attention has returned to 

micro-climate perhaps initially prompted by the work of 

the US led Support Surface Standards Initiative 

(www.npuap.org/s3i.htm). This presentation will seek 

to summarize the S3I initiative's progress while also 

drawing upon the content of symposia presentations 

upon microclimate delivered at the Porto conference 

and from this review highlight several significant gaps 

in our understanding of the role of micro-climate in 

pressure ulcer prevention and management. 


References 

[1] Roaf R. The causation and prevention of bed sores. 

J Tissue Viability 2006; 16(2): 6-8. Reprinted from 

Bedsore Biomechanics, McMillan Press, 1976. 





THE ROLE OF STOCHASTIC RESONANCE IN WOUND HEALING 

E. Ricci 

UOA Difficult Wounds, Casa di Cura San Luca, Pecetto Torinese (Turin), Italy 

eliaricci@tin.it 

Introduction 

Medical research on endogenous alternating current 

(AC) has primarily focused on action or injury of 

nerves, but there has been a paucity of research on 

endogenous AC in wounds. It has been suggested that 

endogenous electrical phenomena observed in 

wounds play an active role in healing and that 

impaired sensory nerve function may lead to the 

development of non-healing wounds. However, the 

role of neuronal electric activity in wound healing is still 

under debate. Our goal was to explore the role of 

somatosensory nerve intervention in wound healing 

with focus on the phenomenon of stochastic 

resonance. Our specific aim was to indentify 

endogenous stochastic signals around wounds and to 

evaluate if they are specific. 

Methods 

We measured stochastic signals on more than 600 

human subjects by using an approved data acquisition 

system*. We recorded electrical signals in 

patients with tissue damages and healthy volunteers. 

The effect of stochastic resonance was further studied 

by treatment of chronic wounds with stochastic 

electrical noise stimulation (an approved device)**. 

Fig. 1: The stochastic signal. 

Results 

Chronic wounds patients (n=83) exhibited specific 

stochastic signals versus healthy subjects (n=48) p 




Innovative textiles in pressure ulcer prevention 

M.A. Carvalho 1* , E.R. Edelman, MIT 2 , L. Griffin 3 , L. Fontes 4 , P. Alves 5 

1* University of Minho, Portugal, migcar@det.uminho.pt 

2 MIT, USA, 3 University of Texas, USA, 4 University of Minho, Portugal, 5 Catholic University, Portugal 

Introduction 

Often overlooked aspects of disability are the 

possible harm and potential benefit of the fabrics that 

interface with people and their environment. Common 

types of clothing and support surfaces cannot meet the 

special needs of those with unique health conditions 

and body habitus. Bedridden people and wheelchair 

users are among those suffering from pressure ulcers 

(PU) – a huge and costly health care problem. 

Overlapping fabric, thick seams, and accessories in 

common clothes create high pressure points on body 

tissues especially over areas of bony protuberances. 

Pressure reduces tissue oxygenation and perfusion, 

causing discomfort and PU. 

Weadapt projects, FashionMe and Sense4me, 

have developed functional clothing and support 

surfaces adjusted to minimize the pressure 

concentrators that promote tissue injury and skin 

ulcers while maintaining comfort and aesthetic appeal. 

Methods 

The Weadapt program works with investigators 

from the University of Minho and more recently with an 

integrated international team of researchers from MIT 

and University of Texas. Studies are based on indepth 

anatomic and ergonomic investigations that 

bring together doctors, nurses, physiotherapists, 

occupational therapists, patients and their relatives 

and care providers. 

Clothing and devices produced are tested in their 

intended-use environment in hospitals, rehabilitation 

centers and disability associations and in the 

laboratory. Comfort and function are evaluated using 

first hand feedback and a model system that 

incorporates a thermal mannequin, a motion capture 

system, infrared video camera, physical and chemical 

experiments and use of different types of sensors 

(pressure, temperature and humidity). 

A multidisciplinary research program includes: 

innovative pattern design that considers users 

anatomic position (seated or laying down) and 

anthropometric data; clothing design to incorporate 

specific special needs like the ease of insertion of a 

catheter or housing of a fluid collection bag and ease 

of interaction between doctor/nurse and patient; 

Materials selection, materials structure and application 

of special finishing’s to address needs of sensitive skin 

and reduce the impact of critical factor in PU 

development, like temperature and humidity. 

134 

Results 

Fig. 1: Patented design of the Weadapt’s Functional trouser 

for urine bag users. 

A B 

Fig. 2: Comparison between Weadapt’s jeans (A) pressure 

points and standard jeans (B) in the same user. 

Weadapt’s trousers contribute to the prevention of 

PU with the ergonomic design, use of flat seams in 

joining panels, removal of pockets on the back (but still 

topstitched as in standard jeans for able-bodied 

people), removal of excess of fabric in critical areas 

like in the back of the knee (reducing temperature in 

this critical area for PU development), special tracks 

for tubes along the leg (avoiding obstruction and 

positioning bellow the leg). 


PUs are an enormous and significant source of 

morbidity and mortality. The costs of treating PU are 

massive, from direct needs for medical procedures 

and health staff intervention – and indirectly, as PU 

prolong hospital stays and prevent patients from 

carrying on normal lives. Weadapt programs offer the 

potential for novel fabrics and garments that remove 

the stimuli for PUs, reducing their impact and 

increasing the ability to treat once formed. Extensions 

of the Weadapt paradigm offer great promise for 

extending the options for the disabled – no longer 

sacrificing comfort, asthetics or dignity for safety. 


We appreciate the support of FCT- Portuguese 

Foundation for Science and Technology. 

References 

[1] Carvalho, M.A.F. et al., Inclusive Clothing Design - 

Proposal for Product Development for Mobility 

Impairment. Proceedings of the 25th International 

Conference on Disabilities - Pacific Rim 2009. 


POSTERS

Posters: Authors and Titles 

Number Presenting author Running Title Presentation 

1 Baptista Incidence of PU in a unit of clinical 3 min oral 

2 Baptista Evaluation of the implementation of 3 min oral 

3 Bernaerts Wound bed preparation with an enzyme 3 min oral 

4 Blanes Prevalence of PU amont elderly living in 

6 Call 2 Wound dressing Shear test method 3 min oral 

7 Call 3 An instrumental Indenter for measurement 3 min oral 

8 Carvalho, Rui Wound Commission of Oporto's Centro 3 min oral 

9 Cassino 1 How to improve the perfomances of 

10 Cassino 2 DACC in deep narrow pressure ulcers 

11 da Silva Vacuum Therapy on Sacral pressure 3 min oral 

12 Davies W e-learning and PU: Supporting best practice 3 min oral 

14 Hancock Results of an online survey investigating 

15 Hernandez FJ Professional ethics in the treatment of PU 3 min oral 

16 Verdu 3 Quality appraisal of Pressure Ulcer's 

17 Homem Regulation of he Assessment and Docum 

18 Ippolito A technological cushon for patients on 

19 Jimenez Diaz The therapeutic use of Aloe Vera 3 min oral 

20 Jimenez-Garcia Differential diagnosis between pressure 

21 Kremer Risk assessment and PU prevention 

22 Leijon PU - prevalence, preventive measures 

23 Gefen Modelling Deformation-Diffusion 

24 Lopez Casanova 1 Clinical prospective evaluation of a 

25 Lopez Casanova 2 Effectiveness and implementation of a PU 

26 Mohamud Multi-disciplinary approach for the 

27 Munoz Clinical cases evaluation of a continuous 

28 Nascimento Local Hyperbaric Oxygen therapy 3 min oral 

29 Nowicki 1 Prescribing beds: Electric profiling beds will 3 min oral 

30 Ohsugi Finite Element Analysis under the shear 

31 Pellegrino Translation into Portugues language, 

32 Pinto Wound management Quality project 

33 Quintana Is the education of the 'informal caregiver' 3 min oral 

34 Ramos Deep tissue injury a difficult diagnosis 

35 Rodriguez Bienvenida Special surfaces processing in patients 

36 Rodrigues Cecilia Multiple lesions in person with scleroderm 3 min oral 

37 Sousa prev & inc of PU in a medical dept 

38 Sterner Category 1 pressure ulcers - how reliable 

39 Tanaka Pressure distribution properties of the 3 min oral 

40 van den Mooter The views of nurses regarding prevention 

41 Verdu 1 Knowledge and implem prevention 

42 Verdu 2 Knowledge and implem treatment 

137

Poster #1 


Poster 1 



INCIDENCE OF PRESSURE ULCERS IN A UNIT OF CLINICAL SURGERY AFTER ESTABLISHMENT OF A 

PREVENTION PROTOCOL 

Noemi Marisa Brunet Rogenski 1 , Karin Emilia Rogenski 2 , Cleide Maria Caetano Baptista 3 , Paulina 

INTRODUCTION 

1 University Hospital of the São Paulo University (USP), Brazil. E-mail: cleideb@hu.usp.br, 

2.3 University Hospital, of the São Paulo University, Brazil, 4 School of Nursing, USP, Brazil 

Although much has been discussed about causes, 

pathophysiology and consequences of Pressure 

Ulcers (PU), it still remains a serious problem for 

institutionalized patients and for health institutions and 

community. In 2002, a study to determine the 

incidence of PU was developed at the Unit of Clinical 

Surgery (Cl Sur) of the University Hospital, USP, since 

it was empirically detected a high number of patients 

with PU in the unit. Due to the lack of protocols for 

preventing and treating these injuries, each nurse was 

in charge to choose the prevention approach to be 

adopted. 

After the end of this study ( 1 ), an incidence of 39.5% 

was observed in PU in the unit, and this result 

encouraged the Study Group on Nursing 

Stomatherapy of the institution to elaborate a 

prevention protocol of PU based on the guidelines of 

the National Pressure Ulcer Advisory Panel ( 2 ). The 

Protocol was implemented in the CL Surg Unit, in July 

2005, after sensitization and training of all nursing staff 

and acquisition of materials and equipment needed to 

make it feasible. Thereafter, the incidence of PU has 

been considered a quality of care indicator. However, 

after the implementation of the protocol, no systematic 

evaluation was carried out to verify its effectiveness. 

OBJECTIVE 

The objectives of this study were to determine the 

incidence of UP in Cl Surg, after implementation of a 

prevention protocol of PU and to identify factors that 

contributed most to its development. 

METHODOLOGY 

After approval by the Ethics and Research Committee 

of the UH-USP and signing the Free Informed 

Consent Form, data were collected on Mondays, 

Wednesdays and Fridays for three consecutive 

months extending, for another ten days for final 

evaluation of all patients. 

RESULTS 

Eight out of 51 patients developed PU, representing an 

incidence of 15.6%. 

Among the patients with PU, there was a 

predominance of Caucasian (87.5%) with mean length 

of stay greater than ten days (50.0%); nonsmokers 

(87.5%) and hospitalized mostly due to basic diseases 

in musculoskeletal (37.5%) and endocrine (75%) 

systems, similar findings regarding sex. 

There was also predominance PU in stage I and II 

(38.5%) and mainly located in the calcaneal tendon 

139 

and gluteus (23.1%). The mean age of patients with 

PU was 73.8 years and patients without PU, 62.1 

years. 

The sensory perception and moisture were the factors 

that contributed most to PU development 

CONCLUSION 

Although the incidence rate still remains high, the 

results showed significant reduction of incidence of PU 

in the unit, confirming that the use of PU prevention 

protocol is a fundamental and important factor to 

control incidence when systematically used. 

REFERENCES 

Rogenski NMB, Santos VLCG. Estudo sobre a 

incidência de úlceras por pressão em um hospital 

universitário. Rev Latinoam. Enferm. 2005;13(4):474- 

80. 

Agency for Health Care Policy and Research. 

Pressure ulcer in adults: prediction and prevention. 

Rockville, MD:U.S.Department of Health and Human 

Services;1992. 


Poster #2 


Poster 2 



EVALUATION OF THE IMPLEMENTATION OF BRADEN SCALE AGREEMENT BETWEEN 

OBSERVERS 

INTRODUCTION 

Noemi Marisa Brunet Rogenski 1 , Karin Emilia Rogenski 2 , Cleide Baptista 3 Caetano Maria Paulina Kurcgant 4 

1 University Hospital of the São Paulo University (USP), Brazil. E-mail: Noemi@hu.usp.br, 2.3 , 

University Hospital of the São Paulo University, Brazil, 4 School of Nursing, USP, Brazil 

The quality of health care has been extensively 

discussed nationally and internationally since the 80's 

due to the high cost of service maintenance, the 

restricted available funding, the overall population 

aging, and the epidemiological transition observed all 

over the world, where infectious and parasitic diseases 

yield to chronic degenerative diseases demanding 

more specific nursing care. For administrators of 

health institutions and nursing managers, Pressure 

Ulcers (PU) represent a serious problem in terms of 

personal and economic suffering for patients and a 

challenge for the entire interdisciplinary team since 

excessive resources of the health system was spent. 

OBJECTIVE 

The objectives of this study were to identify and 

analyze the prevalence of PU, in Medical Clinic and 

Surgical Units, Intensive and Semi Intensive Care Unit 

and general of the University Hospital, USP; to 

establish possible associations with sociodemographic 

and clinical characteristics of patients 

and to verify the agreement between observers in the 

clinical evaluation of patients by means of the Braden 

Scale. 

METHODOLOGY 

After approval by the Ethics and Research Committee 

of the UH-USP, collection of data was performed in 

only one day of the week. Six collaborators, properly 

trained performed the physical examination of all 

hospitalized patients and risk assessment for PU 

development using Braden Scale in clinical practice. 

Data obtained from assessments performed by nurses 

of the units were collected from clinical nursing 

documentation of the patient records. 

RESULTS 

Seventeen patients out of the 87 patients developed 

PU, resulting in an overall prevalence of 19.5% for the 

hospital. 

Partial prevalence: ICU - 63.6%, Surg. Cl. - 15.6%, 

Med Cl - 13.9%, Semi Intensive - Zero. 

Among patients who had PU, there was a 

predominance of: 

• males (58.8%) 

• Caucasian (76.5, %) 

• non-smokers (62.5%) 

• hospitalized mostly due to diseases of the 

cardiovascular or respiratory system (basic or 

associated diseases). 

140 

A predominance of ulcers in stage I (51.85%) and in 

sacral region (22.22%) was observed. The mean age 

of patients with PU was 62.9 (SD = 21.2) and patients 

without PU 54.2 years (SD = 19.5). There was a 

statistically significant difference between the time of 

admission of patients with and without PU, being 

higher in patients with PU. 

Regarding reliability of the Braden Scale inter- 

observers, the sub-scores moisture and nutrition had 

relatively low Kappa value, that is, only 68.8% and 

68.7%, respectively, of identical responses between 

observers, suggesting that these scores should be 

considered in a future training program for nursing 

professionals. Regarding the other sub-scores, it was 

noted strong to very strong agreements between 

observers, as well as the total score of the scale. 

CONCLUSION 

The results of this study contribute to improve 

information about these problems in the country and 

show the need for further research in this area. 

REFERENCES 

CB. Escalas de valoracion del riesgo de desarrollar 

ulcres por pression.Gerokomos,2008;19(3):136-144. 

Bergstrom N, Demuth PJ, Braden BJA.Clinical trial of 

the Braden Scale for predicting pressure ulcer 

risk.Nurs Clin North .1987;22(2):417-28. 


Poster #3 


Poster 3 



Wound bed preparation with an enzyme alginogel in the treatment of pressure ulcer 

category 4 

Kris Bernaerts 1 , Adinda Toppets 1 , Ingrid Keyaerts 2 , Marina Reynaerts 2 

1 CNS wound care, University Hospitals Leuven, Belgium, kris.bernaerts@uzleuven.be 

2 Support team wound care, University Hospitals Leuven, Belgium 

Introduction 

Wound bed preparation is an essential part of the 

treatment of pressure ulcers. Wound bed preparation 

focuses on debridement, bacterial balance, 

management of wound exudates and the overall 

health status of the patient 1 . The goal of wound bed 

preparation is to stimulate granulation tissue, to 

prepare the wound for surgical closure 2 or to complete 

closure of the wound. 

Enzyme alginogels address each of the four 

components that underpin wound bed preparation 

described in the T.I.M.E. framework. Flaminal ® Hydro 

and Flaminal ® Forte keep the wound moist, they carry 

out continuous debridement of the wound, they protect 

the wound edges and they restore the bacterial 

balance 3,4 . These items are important in the treatment 

of a sacral pressure ulcer. 

Case 1: an obese women, 72 years old with diabetes 

type II, arterial hypertension and chronic kidney 

insufficiency. 

Reason for admission was pneumonia, respiratory 

distress and multiple organ failure. She developed a 

sacral pressure ulcer category 4 due to bad overall 

condition. 

Case 2: a morbide obese man of 150kg, 44 years old 

with diabetes type II, hyperlipidemia, COPD and 

asthma. He developed a sacral pressure ulcer 

category 4 due to bad overall condition and limited 

mobilisation. 

Methods 

After surgical debridement we prepared the wound 

bed using negative pressure wound therapy. For 

different reasons (infection, bleeding) this therapy was 

stopped and we apllied an enzyme alginogel. 

The wound evaluation was monitored by pictures and 

by measuring wound surface reduction. 

Results 

Both wounds were clean and almost without debris 

within a week. The enzyme alginogel created the ideal 

condition for the development of granulation tissue. 

Exudate was managed by the alginates in the enzyme 

alginogel. Because of the presence of antibacterial 

enzymes no clinical signs of infection occurred during 

application of the enzyme alginogel . 

Due the bad overall condition and limited mobilization 

of both patients, flap surgery was not possible. The 

current therapy was continued. 

141 

Within a short period of time the wound evolution was 

positive in both cases with a spectacular development 

of granulation tissue and epithelial cells. 


The application of an enzyme alginogel is a very good 

adjuvent treatment to negative pressure wound 

therapy in the preparation of the wound bed. This 

ensures woundhealing from the point of debridement 

to re-epithalisation and meets all components of the 

T.I.M.E. framework. 

References 

[1] Sibbald R. et al., Ostomy Wound Manage; 46:14- 

35, 2000 

[2] Schultz G. et al., Wound Repair Regen; 13 

(4suppl): 1S-11S, 2005 

[3] White R., Wounds UK; 2(3): 64-69, 2006 

[4] Falanga V., Wound Repair Regen; 8: 347-52, 2000 


Poster #4 


Poster 4 



Prevalence of Pressure Ulcers Among the Elderly Livingin Long-Stay 

Institutions in São Paulo 

Leila Blanes 1* , Julieta Maria Ferreira Chacon 2 , Bernardo Hochman 2 , Lydia Masako Ferreira 2 

1* UNIFESP, Brazil, leilablanes@ig.com.br 

2 UNIFESP, Brazil 

Introduction 

The prevalence of pressure ulcers varies according to 

geographic region and population group, such as the 

institutionalized elderly. The aim of this study was to 

identify the prevalence of pressure ulcers among 

elderly people living in long-stay institutions. 

Methods 

Cross-sectional study in six long-stay institutions for 

the elderly in São Paulo, Brazil. Demographic and 

clinical data were collected in six long-stay institutions 

(LSIEs) on two visits to each institution between May 

and August 2007, during which all elderly patients with 

pressure ulcers were evaluated. The Braden scale 

was used to identify the risk of developing pressure 

ulcers and the National Pressure Ulcer Advisory Panel 

(NPUAP) stages for classifying the pressure ulcers. 

Statistical analysis was performed using the chisquare 

test, Student’s t-test and Fisher’s exact test. 

Results 

There was no significant difference in the results 

between visits. The population was 181 elderly people 

in May and 184 in August: 23 had pressure ulcers in 

May (prevalence of 12.7%) and 17 in August 

(prevalence of 9.2%). The mean age at the two times 

was 84 years, and the average length of stay was 32 

months. Pressure ulcers were found mainly in the 

sacral region (mean, 71.5%), and most commonly in 

stage II (mean, 41%). 

142 

Discussion 

Pressure ulcers are a common problem in various 

healthcare settings, and are frequently found in acutely 

or chronically ill patients living in LSIEs for long 

periods of time. 

The aging of the world’s population is a problem, 

and better knowledge of this dynamic and irreversible 

process is needed in order to address the resulting 

increase in vulnerability and fragility of this population. 

Pressure ulcers are an important cause of health loss 

that aggravate other health problems and inhibiting 

their cure, thereby increasing suffering, morbidity and 

nursing care time[1]. 

Studies in other countries have reported prevalences 

of pressure ulcers in LSIEs of between 7% and 

23%. In Brazil, only a few studies on the incidence and 

prevalence of pressure ulcers have been conducted in 

LSIEs, including the study by Souza and Santos, who 

reported an incidence of 39.4% in a study performed in 

four LSIEs in southern Minas Gerais[2]. 

The Braden scale scores ranged from 7 to 19, with 

means of 10.35 and 10.76 for the first and second 

visits, respectively. There was no significant difference 

between the visits. In this study, more than 50% of the 

patients had low scores on the sensory perception, 

mobility, nutrition and friction and shear subscales. 

Conclusion 

The prevalence of pressure ulcers was 10.95%. These 

data provide background information that may aid in 

developing protocols for applying best practices for 

prevention and treatment of pressure ulcers, 

consequently reducing the prevalence. 


The aim of the present study was to draw attention 

to the importance of developing protocols and using 

risk assessment scales for pressure ulcers. This study 

also highlights the need for a multidisciplinary team to 

help elderly people maintain their independence and 

autonomy for as long as possible, minimize their 

suffering and reduce the social and economic impact. 


None 

References 

[1] Allman RM. N Engl J Med. 320(13):850-3,1989 

[2]Souza DMST et al. Rev. Latino Am Enferm. 

15(5):958-64, 2007 


Poster #6 


Poster 6 



Wound Dressing Shear Test Method (Bench) Providing Results Equivalent to Humans 

Evan Call MS RSM (NRM) 1* , Justin Pedersen 2 , Brian Bill 3 , Craig Oberg PhD 4 

1* Weber State University, Ogden Utah, USA, ecall@weber.edu 

2 University of Utah, USA, 3 Weber State University, USA, 4 Weber State University, USA 

Introduction 

Shear stress has been identified as a risk factor in the 

development of pressure ulcers. Studies have 

demonstrated that the application of medical dressings 

can significantly reduce shear and ulceration [1,2,3]. 

Ohura et. al. reported a method for testing the shear 

reduction capabilities of medical dressings in the 

superficial and subcutaneous skin layers, however, the 

model did not reach loads typically found at the bodysupport 

surface interface. We report, a simple and 

repeatable bench method developed to simulate the 

shear forces observed in human subjects when 

transitioning from supine to 45° head of bed elevation. 

Methods 

Human Test: Molten Predia shear sensor was 

attached to the sacrum of a male human volunteer 

weighing 95.3 kg and clothed only in underwear and a 

cotton hospital gown. The volunteer was positioned 

on a viscoelastic mattress covered with a cotton bed 

sheet for 60 seconds, peak pressure and shear force 

was recorded. The head of the bed was raised from a 

supine to 45°, the peak pressure and shear, in mmHg 

and Newtons, were recorded. 

Bench Test: A steel casing was fitted around the 

outside of an HR 45 foam block (45.7x 45.7x7.6 cm) 

wrapped in a cotton bed sheet. A mounting plate was 

placed on the test fixture and weights added until the 

mass of the rig applied a force of 10.3 mmHg at the 

wound dressing test surface (Figure 1). 

Fig. 1: Test Rig Assembly. 

10.3 mmHg had previously been determined to be the 

average load in support surface testing on a 50 th 

percentile male. The Molten Predia shear sensor was 

attached to a 6 mm thick skin analog glycerin gel, and 

the wound dressing, weighted foam block sled was 

applied centered over the sensor and allowed to rest 

for 60 seconds before a shear force was applied. 

Shear displacement of 4 cm at a rate of 50 mm/minute 

was applied. The peak pressure (mmHg) and shear 

143 

(N), in were recorded before and after shear force 

application. 

Results 

Table 1: Peak shear and pressure values in both the human 

volunteer and the weighted foam sled model. 

Human Volunteer 

HR-45 Weighted 

Foam Sled 

Peak Peak Peak Peak 

Shear Pressure Shear Pressure 

(N) (mm Hg) (N) (mm Hg) 

Average 

Confidence 

Interval 

6.9 17 6.7 26 

(Alpha=0.05) 1.4 2 0.4 1 

Discussion 

This method allows for a simple and repeatable 

method of evaluating shear stresses at the superficial 

skin layer while applying a load, providing a more 

accurate description of shear forces at the patientmattress 

interface than previously described methods. 

The captivation of the elastic element (foam) in the test 

frame provides a shear displacement force that closely 

approximates that seen in humans at similar loading . 


A simple model for skin-mattress interface shear 

allows for the optimization of shear reducing medical 

dressings. Informed consent and IRB approval were 

obtained prior to testing with humans. 


This research was funded in part by a research grant 

from Molnlycke Health Care. 


None. 

References 

[1] Ohura, T. et al., Wound Rep Reg. 15:102-107, 

2008 

[2] Nakagami, T. et al. J Wound Ostomy Continence 

Nurs. 33:267-272. 2006. 


Poster #7 


Poster 7 



An Instrumented Indenter for Measurement of Pressure Distribution in Wheelchair 

Cushions 

Evan Call MS CSM (NRM) 1* , Dave McCausland 2 , Mark Greg 3 , Justin Pedersen 4 , Brian Bill 5 

1* Weber State University, Ogden UT, USA, ecall@weber.edu 

2 The Roho Group, USA, 3 Sunrise Med. USA, 4 University of Utah, USA, 5 Weber State Univ., USA 

Introduction 

A consortium of researchers and industry 

members undertook a six year project to address 

the need of a high quality, repeatable test system 

capable of measuring the distribution of 

pressures over the surface of a body when 

seated or lying upon a cushion or support 

surface. Validation results are now available. 

Pressure maps are frequently used in research 

and clinical settings to measure the performance 

of support surfaces and wheelchair cushions, 

however their reliability in certain measures has 

been challenged [1] [2]. An instrumented 

indenter utilizing highly accurate and highly 

repeatable, field interchangeable, strain gauges 

has been constructed. Testing of reliability and 

repeatability has been conducted in to 

independent laboratories. 

Methods 

The Instrumented Indenter is a bulbous indenter 

embedded with ¾” diameter pressure sensors. The 

sensors are distributed about the surface of the 

indenter to measure the pressure distribution or 

envelopment of the surface. Two different sized 

indenters were used: a small radius indenter and a 

large radius indenter. The test was performed by 

applying a normal load to the surface and allows the 

surface to accept the indenter for 120 seconds. 18 

Pressure sensors of known locations record the 

pressures for 10 seconds. The pressures are then 

analyzed to identify the envelopment and immersion of 

the indenter into the surface. See the two-semisphere 

indenter is seen in Figure 1, on an air filled 

cushion. 

Results 

Table 1. Graph of data from Sunrise and EC Service Labs 

144 

Fig. 1: Instrumented indenter on wheelchair cushion. 

The outputs of the Instrumented Indenter are 18 

pressure sensor readings and an immersion 

measurement for each trial. The test was performed 

between two labs, and the testing is repeatable 

between the labs. 

Discussion 

Significant differences were measured between the 

cushions with a confidence level of 99%. This test 

shows promise as a test method for research and 

standards work requiring higher accuracy and 

reliability than pressure maps can provide. 


This work provides the groundwork for higher accuracy 

pressure distribution research than pressure maps can 

provide. 


Funding for this work was provided by a consortium of 

Companies in the industry including (not limited to) 

The Roho Group, Sunrise Medical, Otto Bock, Vicair. 

Conflict of Interest All interests are disclosed above. 

References 

[1] Sprigle S. et al., Asst Technol 15:49-57 2003 

[2] Nicholson et al., Proc. RESNA 22 Jun 2001 pg. 286 


Poster #8 


Poster 8 



Wound Commission of Oporto’s Centro Hospitalar do Porto – What we do and how we do it 

Rui Carvalho 1* , Rosa Nascimento 1 , Rui Pedro Silva 1 , Cecília Rodrigues 1 , Patrocínia Rocha 1 

Introduction 

1* Centro Hospitalar do Porto, EPE, PORTUGAL, gptf.chp@gmail.com 

All authors are members of an Oporto’s central hospital Wound Commission 

Oporto’s Centro Hospitalar do Porto is a central 

hospital with more than 20 wards, more than 500 beds 

and almost all the major medical specialties. 

Therefore, it became important to create a Wound 

Commission in order to establish a bridge between all 

the wards and the Hospital’s administration. 

Methods 

The Wound Commission was created in 1999 and has 

in its nuclear has 3 nurses, 1 physician, 1 surgeon, 1 

vascular surgeon, 1 microbiologist, 1 pharmacist, 1 

dermatologist and 1 neuro-surgeon; will have also a 

nutritionist. 

The Wound Commission is responsible for the staff 

education and training towards better wound 

prevention and treatment. 

The Wound Commission is also heard for material 

choice and supply, complex wounds and wounds that 

need multidisciplinary approach. 

The Wound Commission presents monthly a case 

study in the hospital’s auditorium, where all the staff 

can participate in the case’s discussion. 

Finally, the Wound Commission approaches the 

wound prevention and treatment towards the 

international guidelines (mainly regarding pressure 

ulcers), creating protocols, procedures and information 

systems as needed. 

145 

Results and Discussion 

The creation of a Wound Commission in that hospital 

improved the wound prevention and treatment, most 

through the educational strategies towards the hospital 

staff, the development of protocols and procedures, 

and the optimization of the information systems. 

The monthly case studies brought the discussion of 

wound care to the daily clinical practice, improving the 

staff’s knowledge and judgment in that area. 


The creation of the Wound Commission was a positive 

step for better and evidence-based wound care, 

mainly regarding the pressure ulcers prevention and 

treatment. 


None 

References 

Wound Care Strategies – Wound Care 

Department Development – available on-line in 

6/4/2011 in 

http://www.woundcarestrategies.com/services_wo 

und_care_development.php 


Poster #9 


Poster 9 



How to improve the performances of any antidecubitus surface 

R.Cassino 1* , AM.Ippolito 1 , E.Ricci 2 

1* Vulnera - Italian Vulnological Center Turin, Italy, cassino@vulnera.it 

2 Critical Wounds Unit - S.Luca Clinic - Pecetto T.se (Turin), Italy 

Introduction 

The prevention of pressure sores involves the 

positioning of the patient and the use of mattresses / 

overlays that allow the pressure relief. In patients 

forced to stay in bed for a long time, it‘s very important 

to provide a prevention program and, after risk 

assessment, the use of technological antidecubitus 

surfaces [1]. 

Methods 

We used an inner tube overlay to evaluate the 

possibility of improving the performances of low 

technology antidecubitus mattresses at very low cost. 

We selected two low-risk mattresses (Standard Foam 

and Silicon Fiber) and before placing the inner tube 

overlay we measured the peak pressure; we repeated 

the procedure after positioning the inner tube overlay 

and compared the data. The pressure measurements 

were obtained using a computerized pressure imaging 

system (Xsensor ® ) [2]. 

Results 

Peak pressure: mean values after 20 measurements 

Standard Foam Silicon Fiber 

Without Inner Tube Overlay 110.65 mmHg 85.86 mmHg 

With Inner Tube Overlay 79.99 mmHg 51.11 mmHg 

146 

Discussion 

The results are very encouraging because we could 

demonstrate that a low-cost interventions can improve 

the performances of low-tech surfaces. Pressure 

reduction of 27% with the use of the Inner Tube 

Overlay on standard foam mattresses and 40% with 

the use of the Inner Tube Overlay on silicon fiber 

mattresses shows that the performance improvement 

is very significant. It is not wrong to say that good 

results in terms of pressure relief can be achieved 

using devices with low cost and easy to manage. 


To demonstrate the improvement of the performances 

of low-tech mattresses using a low-cost overlay means 

to confirm that there are new opportunities to prevent 

the development of pressure sores. 


We appreciate the help of Herniamesh that provided 

the Inner Tube Overlay (Aiartex) 

No conflict of Interest 

References 

[1] Bell J. et al., J. Wound Care. 14:185-188, 2005 

[2] Cassino R., Acta Vulnologica. 7:39-52, 2009 


Poster #10 


Poster 10 



DACC in deep narrow pressure ulcers 

R.Cassino 1* , P.Secreto 2 , P.Cuffaro 3 A.Corsi 4 

1* Vulnera - Italian Vulnological Center Turin, Italy, cassino@vulnera.it 

2 Fatebenefratelli Hospital - S.Maurizio C.se (Turin), Italy, 3 “Villa Grazia” Institute - S.Carlo C.se (Turin), 

Italy, 4 Vulnological Unit - ASL10 Florence, Italy 

Introduction 

Very often, pressure sores take a long time to heal and 

tissue repair is not satisfactory. The wound becomes 

chronic and the edges are blocked; the result is a 

small lesion, but deep enough to behave as a fistula. 

These lesions are most evident at the trochanters. It is 

therefore cavitary lesions with a small opening outside, 

but with considerable depth. 

Methods 

We used a DACC (DiAlchilCarbamoilChloride) ribbon 

shaped dressing to fill the cavity/fistula in 15 patients 

with a deep narrow pressure sore and followed them 

for 8 weeks. We assessed the wounds in terms of 

quantity/quality of exudate and depth, enrolling only 

moderate/heavy exuding, infectious, deep narrow 

wounds [1]. The protocol was to dress the ulcers every 

48 hours. After the treatment we evaluated the 

improvement (depth reduction or complete 

filling/healing of the wound). 

Results 

Table 1: results and depth reduction 

Patients Results after 8 weeks Depth reduction (%) 

01 Healed 100% 

02 Improved 68% 














Total Improved 60% - Healed 40% 81% (mean) 

147 

Discussion 

Lesions of this kind are certainly a big problem: a 

pressure sore that becomes chronic requires a rapid 

and reasonable intervention, especially if the main risk 

is infection. The DACC dressing has been shown to 

act as an antiseptic, to reduce the exudate and to 

stimulate the growing of the bottom of the lesion [2]. 

We can therefore confirm that the use of this dressing 

on long-standing complex wounds of this type can 

induce healing. Our goal is to reduce the healing time: 

the more time passes, the harder it will be to achieve 

healing and the easier will be the development of a 

deep narrow pressure ulcer. 


The use of DACC dressings may resolve many 

situations where antiseptic action should be combined 

with promoting granulation tissue [3]. To have 

demonstrated the effectiveness of this dressing in 

deep narrow pressure sores may change the approach 

to local treatment of this kind of wound. 


References 

[1] Ljung A. et al. J Wound Care (2006) 15/4:175-180 

[2] Hampton S. et al. Wounds UK, 2007 

[3] Cassino R. et al. AIUC, 2008 


Poster #11 




Poster 11 

Vacuum Therapy on Sacrum Pressure Ulcer - Case Study 


Introduction 



The vacuum therapy is based on applying a 

negative pressure wound, with the aim of 

effectively removing exudate and promote 

granulation. This work presents a case study of 

vacuum therapy in a large sacrum pressure sore, 

with important and positive development in a 

short time. 

Methods 

In CHP, EPE, in January 2011, was made the 

application of vacuum therapy in pressure ulcer in 

sacrum (approximately 20x15x 4 cm) with high 

exudate. In all treatments the photographic record 

was made. 

148 


The use of this therapy on an ulcer in sacrum with 

large dimensions allowed the rapid promotion of 

healing and effective management of exudate, 

with clear benefit to the patient and even for the 

nursing staff by reducing the frequency of the 

treatments. 

Regarding the costs, although the vacuum 

therapy seems a higher cost per treatment, it 

reduces the frequency of treatments and the 

healing time of the wound, which results in 

economic gains for the institution. 


The use of vacuum therapy in a sacrum pressure 

ulcer contributed very significantly to the positive 

development of its healing. 


None 

References 

EWMA - Topical negative pressure in wound 

management, disponível on-line em 6/4/2011 em 

https://docs.google.com/viewer?url=http%3A%2F 

%2Fewma.org%2Ffileadmin%2Fuser_upload%2 

FEWMA%2Fpdf%2FPosition_Documents%2F20 

07%2FEWMA_Eng_07_final.pdf 


Poster #12 




Poster 12 

e-learning and Pressure Ulcers: Supporting Best Practice Development 

Wendy Davies 1* , Samantha Holloway 2 

Introduction 

1* Section of Wound Healing, Cardiff University, UK, davieswl@cf.ac.uk 

2 Section of Wound Healing, Cardiff University, UK, 

Pressure ulcers are no longer being viewed as an 

inevitable event for the older person or those that are 

either acutely or chronically ill. The National Patient 

Safety Agency [1] has advised that there should be a 

zero tolerance approach to pressure ulcers and are of 

the opinion that in the majority of cases pressure 

ulcers can be prevented. Instead they are more likely 

to be viewed as a clinical incident with a rising 

numbers of compensation claims for negligence 

surrounding the development of pressure ulcers [2]. 

Walsh and Bennett [3] suggest that pressure ulcers 

are often the result of medical or nursing negligence 

because most ulcers can be prevented following 

thorough assessment, repositioning schedules and the 

use of pressure-relieving surfaces. Structured, 

organised and comprehensive education programmes 

in the prevention and management of pressure 

ulceration are vital to improve the outcomes of patients 

by ensuring practitioners develop the knowledge and 

skills to become competent in the assessment, 

delivery and evaluation of care for patients with, or at 

risk of, pressure ulceration [4]. 

Methods 

The development of a user-friendly, high quality elearning 

module for Pressure Ulcers (PU) was 

undertaken to promote evidence based practice. The 

educational curriculum is based on the fundamental 

principles of PU prevention and management to 

include the integration of National and International 

Guidelines for PU (Table 1). The students are 

encouraged to analyse their current practice and 

identify knowledge, skills and strategies to improve 

patient outcomes and quality of care for patients. 

Principles of Pressure Ulcer 

Assessment 

What are Pressure Ulcers 

Prevalence and incidence of pressure 

ulcers 

Pathophysiology of pressure damage 

Anatomy of skin 

Extrinsic / Intrinsic causes of pressure 

ulcers 

Quality of life 

Risk assessment tools 

Wound assessment 

Role of the Multidisciplinary Team 

Principles of Pressure Ulcer 

Management 

Clinical guidelines: prevention and 

management 

Wound bed preparation 

Role of dressings 

Skin care 

Management of incontinence 

Surgical interventions 

Alternative therapies 

Pressure relief and reduction 

Total bed management 

Clinical audit 

Table1: Foundation in Pressure Ulcer Module Curriculum 

This distance-learning module is provided via an 

integrated platform that contains a series of webbased 

tools to support a number of self-paced, 

student-led activities 

Results 

The flexibility of this learning environment has meant 

that learners from a variety of places within the UK and 

149 

Europe have undertaken the module as geographical 

location is not a limiting factor for attendance. 

Provisional evaluations of the outcomes of the 

experience via student feedback have suggested that 

this style of learning can help self-regulation of study 

skills and students appear to be more engaged as they 

are able to work through the materials at their own 

pace. 

Discussion 

The utilisation of e-learning and web-based instruction 

is steadily increasing with these being a flexible way of 

undertaking professional development in areas such 

as PU prevention and management. Such methods of 

study are learner-centered and are reported to support 

the development of skills such as planning, selfregulation 

and self-evaluation. For the future it is 

planned to evaluate the impact of this module on 

clinical practice as well as the overall students’ 

experience of this style of learning. 


Education in the management and prevention of 

pressure ulcers will enhance the student’s ability to 

provide and contribute to multi-disciplinary care for this 

group of patients. Placing pathophysiology alongside 

quality will enable the students to see the relevance of 

clinical effectiveness, audit and their legal and 

professional accountability. 


ConvaTec Wound Therapies and ConvaTec Medical 

Education provided an unrestricted educational grant 

for the website production of these modules. 

References 

[1] National Patient Safety Agency. NHS to adopt zero 

tolerance approach to pressure ulcers. Available from: 

http://www.npsa.nhs.uk/corporate/news/nhs-to-adoptzero-tolerance-approach-to-pressure-ulcers/ 

2010 

(accessed 11 March 2011) 

[2] Tingle J Pressure sores: counting the legal cost of 

nursing neglect. Br J Nurs 6: 13; 757-8, 1997 

[3] Walsh K and Bennett G Pressure ulcers as 

indicators of neglect. Nursing & Residential Care 2: 11; 

536-539, 2004 

[4] National Institute for Health and Clinical Excellence. 

Pressure ulcer risk assessment and prevention, 

including the use of pressure-relieving devices (beds, 

mattresses and overlays) for the prevention of 

pressure ulcers in primary and secondary care. NICE. 

London, 2003 


Poster #14 


Poster 14 



Results of an online survey investigating global variations in pressure ulcer prevention 

practices. 

Kate Hancock 1* 

1* Molnlycke Health Care, Sweden, kate.hancock@molnlycke.com 

Introduction 

A pressure ulcer may be defined as ’a localised injury 

to the skin and/or underlying tissue, usually over a 

bony prominence, as a result of pressure, or pressure 

in combination with shear. A number of contributing or 

confounding factors are also associated with pressure 

ulcers; the significance of these factors has yet to be 

elucidated.’(1) The prevalence of pressure ulcers is 

well reported in the literature and varies according to 

country and to care specialty. In one report which 

covered 5 European countries, the prevalence was 

stated at 18.1 %(2). Pressure ulcers place a major 

burden on healthcare systems worldwide. It was 

recently estimated that, in the UK, the cost of pressure 

ulcer treatment and prevention was equivalent to 4% 

of the total National Health Service expenditure at 

between £1.4-£2.1 billion annually.(3) therefore it is 

understandable that a number of healthcare systems 

are implementing prevention and awareness 

programmes. Recent decades have seen a growing 

body of knowledge and research leading to the 

development of practice guidelines, risk assessment 

tools, and preventative programmes however it is less 

clear how current prevention practices vary worldwide 

and the impact this may have on prevalence and 

incidence rates. 

The goal of this project was to identify standard 

practices in 9 countries selected and whether any 

practices varied between the 9 countries. 

Methods 

An online survey was created using QuickSearch, a 

web based automated survey tool (figure1). This tool 

allows for anonymous responses. The survey 

consisted of a series of questions regarding various 

pressure ulcer prevention practices. The survey was 

sent to 154 clinicians in 9 countries. 

Figure 1: The online survey tool. 

Results 

30 responses have been recorded. The survey results 

have identified clear preferences in terms of 

prevention practices worldwide including: 

Risk assessment tools of preference (figure 2) 

150 

Usage of equipment / devices for patients at risk 

Figure 2: Risk Assessment Tool Preferences 

Once the survey closes (due to close May 2011) the 

final results will be further analysed for variances in 

prevention practices between countries and 

continents. 

Discussion 

This survey is ongoing and will be completed during 

May 2011. However to date a number of interesting 

and potentially very useful facts have already been 

identified. There appears to be global consensus on 

the use of specific Risk Assessment tools and at least 

2 prevention actions, however wider prevention 

practice consensus or variance is to be analysed on 

survey closure. 


Prevalence figures for pressure ulcers vary 

significantly from country to country; gaining a better 

understanding of the variances in practices will enable 

clinicians, researchers and educators to investigate 

their own practices in comparison to other countries to 

identify potential prevention processes that may help 

to reduce prevalence rates. 


Kate Hancock is an employee of Mölnlycke Health 

Care. 

References 

[1] National Pressure Ulcer Advisory Panel and 

European Pressure Ulcer Advisory Panel. Prevention 

and treatment of pressure ulcers: clinical practice 

guideline. Washington DC: National Pressure Ulcer 

Advisory Panel; 2009. 

[2] Pressure Ulcer Prevalence Monitoring Project. 

EPUAP Review. Volume 4, Issue 2, 2002. 

[3] Bennett G et al. Age and Ageing. 33: 230–235, 

2004. 


Poster #15 


Poster 15 



Professional ethics in the treatment of pressure ulcers, a nursing work 

FJ Hernández*, BC Rodríguez, R Chacón, JF Jiménez, MP Quintana 

University of Las Palmas de Gran Canaria, Spain, fjhernandez@denf.ulpgc.es 

Introduction 

When devising a nursing care plan, it is essential to 

plan for the preventive action. This fact must be 

considered in patients who are affected by pressure 

ulcers, and especially in patients who are at risk of 

suffering from them [1]. 

Methods 

A transversal, quantitative, descriptive and 

observational study in hospitals in the intensive 

geriatric unit where bioethics principles are applied [2], 

in order to study its connection with the treatment of 


Results 

28% of professionals do not know that according to the 

principle of beneficence, we must bring up to date our 

knowledge of the prevention and treatment of pressure 

ulcers, in order to promote the well-being of others. 

With regard to the concept of non-maleficence, 88% of 

professionals acknowledged that our work must be 

based on scientific evidence, bearing in mind the fact 

of avoiding doing any conduct with pain. Regarding the 

principle of justice, in the treatment of pressure ulcers, 

the main criteria will consist of the efficiency (the best 

treatment at the lowest cost). In this respect, 98% of 

the professionals do not know the cost of materials 

and 99% of them do not care about the costs. When 

applying the principle of respect for autonomy we can 

not forget the right to be informed. This information 

must be clear, concise and understood by the patient. 

88% of the professionals do not inform about the cure, 

they just treat the ulcers; 11% of them explain the 

protocol to follow; and 1% of them do that only if they 

are asked to. 

Discussion 

Nursing staff must think about the ethical content and 

the professional implications that the nursing attention 

[1] means in respect of human rights. The fulfilment of 

the caring standards must carry implicitly the 

observance of ethical principles [2]. 


Bioethics principles applied at treatment of pressure 

ulcers, a nursing work. 

151 


Don’t to exist. 

References 

[1] EPUAP, Pressure Ulcer Classification. PUCLAS II. 

Meeting Berlin, 2006 

[2] WMA, Declaration of Helsinki, 1964 


Poster #16 


Poster 16 



Quality appraisal of Spanish guidelines on Pressure Ulcers 

Hernández Martínez-Esparza, Elvira 1 , Verdú, José 2 

1 Support team in geriatrics centers, MUTUAM, Barcelona. Spain. elviraherna@yahoo.es 

2 Community Nursing, Preventive Medicine, Public Health and History of Science Department. University of 

Alicante. Spain. Pepe.verdu@ua.es 

Introduction 

The Spanish Clinical Practice Guidelines (CPG) on 

pressure ulcers (PU) has proliferated in recent times 

but the quality and scientific rigor is doubted [1]. 

However, it is considered as a working tool for 

decision making in clinical practice. Today we have the 

AGREE instrument [2] that allows us to evaluate the 

methodological quality of the CPG, in terms of 

methods used in developing the content of the final 

recommendations and factors associated with the 

applicability. In addition, the implementation of the 

recommendations in the quality CPG can reduce the 

effects and prevalence of PU, as well as the costs 

involved in inappropriate practice [3]. Therefore, the 

objective is to evaluate the quality of Spanish CPG on 

PU and select those of higher quality. 

Methods 

A systematic review of Spanish CPG on PU to assess 

the methodological quality and scientific evidence that 

support them. 

Different search strategies were used to find the 

Spanish PU guidelines published and / or revised in 

the last 6 years (from 2003 to 2010). Two 

independently evaluators selected CPG that meet the 

inclusion criteria. 

Each selected CPG was identified with a number and 

quality was analised through the AGREE assessment 

tool [2], individually and independently by 2 experts in 

PU and the use of AGREE. If there were any 

significant difference in scores, advice was sought 

from a third party expert in the field. 

The joint analysis of the results were made by a third 

researcher, not knowing each equivalent CPG 

template. 

The quality of the guildelines was determined : 

1. Through the overall percentage obtained from 

the highest possible score in each of the 6 

areas of the AGREE instrument, as well as the 

level and the average score of evaluation. 

2. Through a general assessment of each 

assessor this establishes whether the CPG 

deserves to be recommended or not. 

We also analised the overall quality of all Spanish 

CPG on PU: establishing a ranking by using quartiles, 

based on the maximum percentage obtained in each 

of the 6 areas of the AGREE instrument. 

Results 

The data obtained from the analysis of the overall 

quality of all Spanish CPG on PU is shown in Table 1. 

152 

Percentage of 

Categorization into quartiles of percentage 

of maximum possible score 

guidelines < 25% 25%-50% 50%-75% > 75% 

(Very low) (Low) (High) (Very high) 

Areas 

Scope and Objective 8,3 0,0 8,3 83,3 

Participation 8,3 66,7 25 0,0 

Rigor 41,7 16,7 8,3 33,3 

Clearly 8,3 25,0 8,3 58,3 

Applicability 33,3 25,0 25,0 16,7 

Independence 0,0 25,0 33,3 41,7 

Table 1: Distribution of CPG according of scores obtained in 

each area of the AGREE tool 

The CPG recommended and considered of high 

quality were No. 1 (Andalusian Health Service) and 

No. 8 (Balears Health Service). 

Discussion 

The worst areas were the rigor, the participation and 

the applicability. There are only two areas in which 

more than 50% of the CPG achieve excellence: the 

scope and objectives and clarity. Only 3 CPG made 

comparisons between their recommendations and 

scientific evidence, but only No. 1 does so explicitly. 


The average quality of the CPG is low or very low. 

Almost half is very low quality in terms of rigor in their 

development. The CPG No.1 stands out from the 

others. 


We appreciate the help of Pablo López and Francisco 

Pedro García-Fernández. 


This study is a piece of work as candidate to a PhD by 

Elvira Hernández Martínez-Esparza 

References 

[1] Marzo M, et al. Med Clin (Barc). 2002; 118(Supl 

3):30-5 

[2] The AGREE Collaboration. 2002. Available in: 

www.agreecollaboration.org 

[3] Pancorbo, P.L, et al. Gerokomos 2007;18(4):188- 

96 


Poster #17 


Poster 17 



Regulation of the Assessment and Documentation of Chronic Wounds 

Patrícia Homem 1 , Sérgio Deodato 2 , Joana Lopes 1* Lúcia Araújo 1 Sílvia Moura 1 

1 Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Portugal, patricia.homem007@gmail.com 

Introduction 

Pressure ulcers and moisture lesions have become an 

important health issue among elderly people staying at 

hospitals, thus it is necessary to manage these 

wounds´assessment and treatment. The Medical Ward 

(3 rd Floor) frequently assists these elders with wounds, 

so we have considered the implementation of care 

strategies towards this problem. 

Methods 

This Ward needed 2 Rules of Procedure, first on 

chronic wound assessment, concerning measurement 

techniques and another on wound assessment 

documentation. We have designed an intervention 

project, which purpose was creating both procedures. 

Then, we have planned several activities to attain the 

determined objectives, such as explanatory meetings 

with the ward nurses, to implicate the whole team. The 

nurses’ fulfillment indicator was 50% for the wound 

assessment procedure and 50% also, for each item of 

the documentation procedure. Finally we employed 

both rules of procedure for 5 weeks. 

Results 

A total of 85 measurements were carried out during 

this period. The nurses´ fulfillment of the wound 

assessment procedure was 88, 24%. Regarding the 

documentation procedure, the nurses´ completion was 

(Fig.1) 56,5% for the measures, 76,5% for wound bed 

tissues, 94,1% for the anatomical wound location, 

64,7% for odour, 62,4% for pain, 70,6% for 

surrounding skin and 48,2% for the exudates’ item. 

Fig. 1: Fulfillment of the wound documentation procedure 

2 ESS – Instituto Politécnico de Setúbal, Portugal 

*Author´s affiliation when the project was implemented Copyright © 2011 by EPUAP 

153 

Discussion 

The completion of the wound assessment procedure 

was high because the measurement was already 

established in the team for 6 years and this work was 

supposed to improve its consistence. While the 

documentation procedure was fulfilled above our 

expectation for wound bed tissue, anatomical wound 

location and surrounding skin, the other issues didn´t 

attain similar results. 

Although its completion was above our indicator, we 

think pain is difficult to assess using the institutional 

pain scales, as most patients can´t express how 

much pain they feel, so we have decided to remove 

this item from the final documentation procedure. 

We know how important pain is, so in our opinion, it 

needs its own rules of procedure in a future working 

group project. 

The exudate´s item was above our primary indicator 

because it had to be added manually to the 

patient´s record. This problem could be solved if the 

documentation software was adapted specifically to 

record wound data. 

We have concluded that the primary application of 

both procedures was positive, even though the 

completion of the exudate´s item was beneath our 

expectation. 


The wound assessment process includes a very 

important aspect which is the measurement of wounds 

and it allows, for instance to monitor healing rates [1]. 

It is important that the methods used to assess the 

wound are applied in addition to the correct 

techniques, as consistency is a mandatory aspect in 

wound care. The measurement of the wound also 

helps to evaluate the treatment effectiveness [2]. 


We appreciate the help of the whole nursing team. 


None 

References 

[1] Flanagan M. Improving accuracy of wound 

measurement in clinical practice. Ostomy wound 

management. 2003;49(10):28-40 

[2] Gethin G. The importance of continuous wound 

measuring. Wounds. 2006;2(2):60-8

Poster #18 


Poster 18 



A technological cushion for patients on wheelchair 

AM.Ippolito 1* , M.T.Scalise 2 , M.Galleazzi 3 , S.Osella 4 , A.Galla 4 

1* Vulnera - Italian Vulnological Center Turin, Italy, ippolito@vulnera.it 

2 “Prince Oddone” Residence - Turin, Italy, 3 San Giovanni Battista Universitary Hospital - Turin, Italy, 4 “La 

Cittadella” Nursing Home - Saluggia (Vercelli), Italy 

Introduction 

The pressure ulcers are an additional suffering for 

people with already compromised health; whereas 

prevention is a key factor, we need to implement all 

necessary preventive measures to prevent its onset 

[1]. The purpose of this study was to evaluate the 

effectivness of a low-cost anti-decubitus cushion, 

really easy to manage by the patient. 

Methods 

We considered the problems of patients who spend 

most of their time sitting in a wheelchair; using a 

computerized pressure imaging system (Xsensor®) 

we could identify high risk areas of the patients and 

compare the peak and mean pressures detected using 

the normal surface of wheelchairs with the ones using 

a self-adjusting air cushion [2]. This device is led to 

inflation by pushing up on a reservoir; after positioning 

the patient, by pushing a button, the exceeding air will 

be automatically eliminated until it reaches the right 

pressure. 

We enrolled 50 patients that couldn’t walk and live on 

a wheelchair for more than 10 hours per day. 

154 

Results 

Table 1: Peak and mean pressures (avg) 

Patients Peak pressure Mean pressure 

Without Cushion 198.22 mmHg ± 21.7 119.37 mmHg ± 13.2 

With Cushion 90.01 mmHg ± 7.4 65.91 mmHg ± 5.2 

Discussion 

We have shown a remarkable effectiveness of the 

pillow, both in terms of pressure relief, both in terms of 

ease of management. In fact, both pressures (peak 

and mean) are reduced by about 30-40% and the load 

is evenly distributed on the cushion; on the contrary 

discrepancies in pressure are found without using the 

cushion. 


This cushion has proven to be a valuable aid in the 

prevention of pressure sores in patients confined to 

their wheelchair for most of the day. 

The clinical relevance of this work is to produce useful 

data to inform patients about new prevention 

technologies really easy to manage. 


References 

[1] Goode P.S. et al. Med Clin North Am, 1989 

[2] Cassino R. et al. Acta Vulnologica 7:39-52, 2009 


Poster #19 


Poster 19 

Introduction 

155 


Birmingham, United Kingdom 

The therapeutic use of Aloe vera L in pressure ulcers (PU) 

FJ Hernández, BC Rodríguez, JF Jiménez Diaz*, E Navarro, MP Quintana 

University of Las Palmas de Gran Canaria, Spain, jjimenez@denf.ulpgc 

The Aloe vera L is an excellent cleanser and natural 

antiseptic that easily penetrates the skin and tissues, 

with very active bactericidal, fungicidal, antiinflammatory, 

antipruritic, dilates blood vessels, breaks 

down and destroy dead tissue and promotes cell 

growth [1]. 

Methods 

Qualitative study of 59 patients with pressure ulcers 

admitted to a Geriatric Hospital, a protocol by priests 

with a poultice of Aloe vera L crushed. 

Results 

Average age 76,2 years. Sample distribution: 13 

patients with PU grade I, 21 grade II, 15 grade III and 

10 grade IV. 99% of grade I developed phenomenally 

to treatment with aloe, all disappeared between 3 and 

7 days. The 1% had an allergy to aloe crushed. 

UPP grade II listed improvement at 24 hours and 

every 12-14 days cured with a slight variation of skin 

color. Grade III and IV evolved differently from the 

previous. The 5% grade III finished healing, 95% 

remaining tissue changes were concerned, reducing 

the discharge and favoring the color. From 4 to 5 days 

the muscles and tissues involved in the PU, varied 

coloration and the bed was dry. In 98% grade IV 

appeared redness and burning after applying aloe. 

Discussion 

The Aloe vera L may help cure PU grade I and II. 

Unclear scientific evidence for use in grade III and IV 

pressure ulcers [2]. A small percentage has presented 

allergic-type reactions. 


The Aloe vera L may help cure PU grade I and II. 



References 

[1] Vogler BK, Ernst E. Aloe vera : a systematic review 

of its clinical effectiveness. Br J Gen Pract 1999; 49 

(447): 823-828 

[2] Vermeulen H et al. Dressings and topical agents for 

surgical wounds healing by secondary intention. 

Cochrane Database Syst Rev 2004 


Poster #20 


Poster 20 



Differential diagnosis between pressure ulcers and moisture lesions. A manifested 

difficulty among health professionals and caregivers. A pilot study. 

Jiménez García, Juan Francisco 1 ; Abad García, María del Mar 2 ; Verdú, José 3 ; Joan-Enric Torra i 

Bou 4 

1 Servicio Andaluz de Salud. Distrito Sanitario Poniente de Almería, Spain, juanfrajim@ono.com 

2 Servicio Andaluz de Salud. Distrito Sanitario Almería, Spain, 3 Community Nursing, Preventive Medicine, 

Public Health and History of Science Department. University of Alicante. Spain, 4 Clinical Department, 

Smith&Nephew Iberia. AWM. Barcelona. Spain. 

Introduction 

Due to the knowledge progress on the etiology of 

pressure ulcers and Incontinence associated lesions, 

the relations between those issues is becoming a 

problem in clinical practice. 

So, It is important to make a reliable differential 

diagnosis and to identify the etiology, because the 

approach and the treatment differ between them [1]. 

Based on previous studies [2] where was observed 

that nurses classification and diagnosis for these 

problems was biased, the objective of this study is to 

compare the knowledge level between different health 

professionals and caregivers in region of Spain. 

Methods 

A experimental, pre-post-test, design was performed in 

3 different groups of people: (Group 1) 10 nurses who 

are studying a Master on Nursing Science at 

University of Almeria, (Group 2) 10 homecare 

caregivers (not professionals) who attended a 

workshop on prevention and care of parents, and 

(Group 3 ) 10 Primary Health Care professionals (6 

doctors and 4 nurses). 

First was tested the level of knowledge for diagnosis 

and differentiation between lesions, subsequently, all 

attended a workshop on those topics and after a posttest 

was conducted. PUCLAS method was used for 

the workshop. 

As variables, were measured: Pressure ulcer 

classification, differentiation between Pressure ulcers 

and Moisture lesions over the range, normal skin, 

blanchable erythema, non-blanchable erythema, 

category 1, category 2, category 3, category 4, 

moisture lesion and combined lesion. 

Mean scores from a maximum of 10 points were 

calculated pre and post-test for the 3 groups. 

156 

Results 

Table 1: Summary of diagnosis pre and post-test 

Group Pretest (Mean/10) Posttest (Mean/10) 

Group 1 (n = 10) 3.6/10 8.4/10 

Group 2 (n = 10) 4.2/10 7.5/10 

Group 3 (n = 10) 4.4/10 8.5/10 

Table 2: Summary of differential diagnosis pre and post-test 

Group Pretest (Mean/10) Posttest (Mean/10) 

Group 1 (n = 10) 2.1/10 8.5/10 

Group 2 (n = 10) 2.2/10 7.4/10 

Group 3 (n = 10) 2.3/10 8.5/10 

As we could observe on tables 1 and 2, there is a poor 

knowledge on the 3 groups before the intervention and 

a high increase on the score after the intervention 

Discussion 

It is confirmed, in the same way that previous studies 

[2], that people classifies erroneously and that is 

independent 

experience. 

from the level of education and 


Training across all settings and level of education is 

important to enhance the skills to diagnosis accurately. 

If we make a good diagnosis we could apply better 

preventive or therapeutical care 


References 

[1] Defloor, T.; Schoonhoven, L.; Fletcher, J.; Furtado, 

K.; Heyman, H.; Lubbers, M. et al. Statement of the 

European Pressure Ulcer Advisory Panel-Pressure 

Ulcer Classification: Differentiation Between Pressure 

Ulcers and Moisture Lesions. Journal of Wound, 

Ostomy & Continence Nursing, 2005; 35(5):302-306 

[2] Beeckman, D.; Schoonhoven, L.; Fletcher, J.; 

Furtado, K.; Gunningberg, L.; Heyman, H.; Lindholm, 

C.; Paquay, L.; Verdú, J.; Defloor, T. EPUAP 

classification system for pressure ulcers: European 

reliability study. Journal of Advanced Nursing, 2007; 

60(6):682-691 


Poster #21 


Poster 21 



Risk assessment and pressure ulcer prevention in traumatological patients – the nurses’ perspective 

Laura Kremer 1 , Sylvia Mallison 1 , Anne Junghans 1 , Katrin Balzer 1 

1 Institute for Social Medicine, Universität zu Lübeck, Germany, katrin.balzer@uk-sh.de 

Introduction 

Traumatolgy ward patients have an increased risk of 

developing pressure ulcers (PU) [1][2]. Only about 

60 % of these patients are given adequate preventive 

interventions [1]. To improve this situation, the causes 

have to be identified. This study aims to identify factors 

which nurses hinder to detect traumatological patients 

at risk and to initiate proper preventive interventions. 

The main attention is turned on nurses’ risk 

assessment and subsequent decision-making. 

Methods 

This study uses a mix-method-design (“sequential 

transformative design”). It consists of three phases: 1) 

development of validated case vignettes, 2) semistructured 

interviews with nurses, based on case 

vignettes 3) triangulation. 

1. Eight case vignettes for 4 target scenarios (Table 

1) were developed based on a secondary analysis 

of data from a quasi-experimental trial (n=571 

patients). This trial originally evaluated the impact 

of use of the Braden Scale on allocation of 

preventive interventions in 2 traumatological wards 

and confirmed a considerable amount of undersupply 

of PU preventive care, despite use of the 

Braden Scale. Developed vignettes were validated 

by means of a small survey. 

Table 1: Target scenarios for case vignettes 

PU risk according to pre-defined 

risk factors (assessed by study 

assistants = reference standard) 

Risk assessment and 

allocation of prevention 

through nurses during the 

quasi-experimental trial 

No or low PU risk Patients’ risk over-estimated 

and over-supply of prevention 

Moderate or high PU risk Patients‘ risk underestimated 

and under-supply of prevention 

High PU risk Patients‘ risk correctly classified 

but under-supply of prevention 

High PU risk Patients‘ risk correctly classified 

and sufficient supply of 

prevention 

2. Semi-structured face-to-face interviews with nurses 

of both trial wards were conducted. Each interview 

started with unaided assessment and discussion of 

a randomly chosen case-vignette. A purposive 

sample of 16 nurses (8 per trial ward) was 

intended. Interviews were transcribed verbatim and 

analysed guided by the framework of Ritchie and 

Spencer [3]. 

3. In this phase, 2 prediction models will be developed 

and compared in subsamples of the data from the 

quasi-experimental trial: one model driven by risk 

157 

factors named by interviewed nurses, and one 

model based on empirically established PU risk 

factors for traumatological patients. Endpoint of the 

comparison will be presence of prevention during 

study follow-up in patients classified as being at 

risk by the respective model. Furthermore, clinical 

characteristics and outcomes (PU occurrence) of 

patients identified at risk will be compared. 

Results 

To date, 14 out of 16 interviews have been conducted. 

Concurrent analyses revealed that nurses appear to 

be aware of well-known risk factors. Most but not all 

nurses stated that information provided by the Braden 

Scale does not matter for their risk assessment; 

instead they seem to appraise patients’ risk 

continuously at the bedside. In most case scenarios, 

interviewees felt quite confident with their unaided 

clinical judgement. However, some uncertainness and 

inconsistencies became obviously, especially if fictive 

patients were not of old age. In both wards there 

seems to be a tendency to “watchful waiting” if patients 

are not extremely impaired. Furthermore, interviews 

suggest that individual nurses prioritise PU prevention 

differently, irrespective of patient’s level of risk. 

Discussion 

Due to the results from concurrent analysis specific 

attention was paid in the interviews to elaborate 

nurses’ motives for decisions on PU prevention. The 

results of the final content analysis and the remaining 

triangulation will be presented at the congress. 


This mixed-methods study provides a systematic 

insight into nurses’ PU risk assessment and 

subsequent decision-making. It will allow to identify 

strengths and weak spots in this area of nursing care. 


This study was funded by a grant of the foundation 

B. Braun Stiftung. All authors declare that they have 

no conflict of interest. 

References 

[1] Baumgarten M. et al., Gerontologist. 50: 253-262, 

2010 

[2] Campbell K.E et al., Ostomy Wound Manage. 

56:44-54, 2010. 

[3] Ritchie J., Spencer L. In: Bryman A. et al. (eds.) 

Analysing qualitative data. Routledge 1994, pp.173 


Poster #22 


Poster 22 



Pressure ulcers - prevalence, preventive measures and risk of mortality in a general inpatient 

population 

S. Leijon, RN, MSc 1 ., I. Bergh, RN, PhD 2 ., K. Terstappen, MD, PhD 1 . 

1 Department of Dermatology,Skövde Hospital,SE-541 85, Skövde, Sweden, siv.leijon@vgregion.se 

2 School of Life Sciences, University of Skövde, Box 408, SE-541 28 Skövde, Sweden. 

Introduction 

Pressure ulcers cause pain and restrictions in life for 

the patients who are affected and result in high costs 

for society. Improvements in quality of care are 

needed and in this process it is necessary to know to 

what extent pressure ulcers occur in the hospital in 

question. 

The overall aim of this study was to investigate 

pressure ulcer prevalence in a hospital in the Västra 

Götaland region of Sweden. 

Methods 

A point prevalence study was carried out using a 

modified version of the EPUAP-protocol. After twentyone 

months the data was complemented with a 

retrospective audit of the electronic records for 

patients identified with pressure ulcers. 

Results 

Among the patients (n = 258), 23% (n = 60) had one or 

more pressure ulcers grade 1–4, in total 85 ulcers. 

Almost half of the patients with ulcers had ulcer grade 

2-4 (i.e. not intact skin) (n = 28). Gender did not have 

any significant influence on the presence or severity of 

the ulcers.The most common location were sacrum 

(n=15) and heels (n=10). Only 3% (n=9) had during 

their current hospital stay been assessed with a risk 

assessment tool. There was a significant association 

(p

Poster #23 




Modeling Deformation-Diffusion Damage in Cultured Cells to Study Deep Tissue Injury 

Efrat Leopold, Amit Gefen 

Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv 69978, Israel 

E-mail: gefen@eng.tau.ac.il 

Introduction 

Deep tissue injury (DTI) is a serious pressure ulcer 

which initiates in skeletal muscle tissues overlying 

bony prominances, and which later on might spread 

into more superficial soft tissues. Individuals with 

impaired motosensory capacities are prone to DTI. 

Using finite element (FE) modeling, it has previously 

been shown by our group that compressive loads 

delivered by weight-bearing bony prominences 

translate to tensile loads at the cellular scale [1]. 

These cell-level tensile loads tend to stretch the 

plasmame membrane of cells and as a result may alter 

the permeability properties of the plasma membrane, 

which in turn could damage cellular homeostasis [1]. It 

is currently unknown how metabolites, including 

oxygen, might diffuse through a geometrically-distorted 

plasma membrane, and, accordingly, our objective in 

this ongoing study is to determine trends of 

relationships between externally-applied loads and 

build-up rates of oxygen in cultured skeletal muscle 

cells. We also consider the effects of mild temperature 

drops which may be associated with ischemic events 

[2], and affect transport of metabolites as well. 

Methods 

The Virtual Cell (VC) software was used to study the 

transport of oxygen into and within deformed cells. We 

have so far developed both two-dimensional (2D) [3] 

and three-dimensional (3D) myoblast cell models. The 

deformed shapes of the cells are pre-calculated using 

our confocal-based cell-specific FE modeling method 

[4]. We then export the deformed cell geometries into 

the VC software in order to determine the oxygen 

build-up rates within the cytosol and nucleus of the 

cells. A 3D cell model for deformation-diffusion 

calculations and a corresponding intracellular oxygen 

diffusion map are provided as examples in Fig 1. 

Fig. 1: A confocal-scan-based three-dimensional myoblast 

cell geometry imported to the Virtual Cell software (left) and 

a corresponding oxygen diffusion map in a horizontal crosssection 

through the cell body (right). 

159 

Results 

Our modeling shows that cellular deformation affects 

the build-up rate of oxygen intracellularly, and that this 

effect grows with the extent of cellular deformation. 

The set of 2D simulations of compressed myoblast 

cells, which has now been completed, indicated that 

the oxygen build-up rate was overall slower at both the 

cytosol and nucleus domains of the cell [3]. Mild 

temperature drops (~3°C) further slow down the 

intracellular oxygen transport. 

Discussion 

Using a combination of computational methods, cellspecific 

FE and VC, we were able to study the effects 

of cellular deformations and temperature changes at 

the cellular environment - which were both suggested 

to relate to DTI - on the build-up of intracellular oxygen 

[3]. In a real-world scenario, a combination of 

deformation and temperature factors is anticipated, 

and their combined effect might substantially impair 

cell respiration functions. Work is currently underway 

to study the effects of different loading regimes on 3D 

transport in 3D cell models. 


This work is helpful in characterizing physical and 

biomechanical factors that potentially contribute to DTI 

and can provide understanding of how DTI may 

develop at the cellular scale. 


We would like to thank Ms. Noa Slomka for her help 

with the confocal microscopy-based cell-specific FE 

modeling. 

References 

[1] Slomka N. et al., Cell Mol Bioeng. 2: 118-32, 2009 

[2] Linder-Ganz E. et al., Ann Biomed Eng. 35: 2095- 

107, 2007 

[3] Leopold E. et al., Med Eng Phys., accepted for 

publication, 2011 

[4] Slomka N. et al., J. Biomech. 43: 1806-16, 2010 


Poster #24 


Poster 24 



Clinical prospective evaluation of a continuous and reactive pressure mattress in the 

prevention of pressure ulcers in patients who could not be repositioned 

López Casanova P. 1* , Torra i Bou JE. 2 , Verdú Soriano J, 3 Martínez Castillo P. 4 

1,4* Unidad Integral de Heridas Crónicas, Departamento de Salud Elche-Hospital General, Elche, Alicante, 

Spain. lopez_pabcas@gva.es 

2 Clinical manager, AWM Division, Smith&Nephew Iberia 3 Departamento de Enfermería Comunitaria, 

Medicina Preventiva y Salud Pública e Historia de la Ciencia, Universidad de Alicante, Spain 

Introduction 

Repositioning is one of the most effective measures 

for preventing pressure ulcers but have some 

limitations as there are patients who can not be 

repositioned due to their specific health conditions. 

These patients are at an extreme risk of developing 

pressure ulcers and need special mattresees able to 

reduce pressure interface in effective levels. 

Methods 

In order to evaluate the clinical effectiveness of a 

continuous and reactive low pressure mattress (Carital 

Optima Classic) in patients that can not be turned we 

designed a prospective observational study in an 

intensive care population who could not be turned due 

to their health condition. 

These patients were placed in a continuous and 

reactive low pressure mattress (Carital Optima 

Classic) and were nursed also with hyperoxigenated 

fatty acids and an anatomic non adhesive 

hydrocelullar dressing (Allevyn Heel) for local presuure 

protection in their heels. 

Carital Optima Classic is a continuous and reactive 

local pressure special mattress that adapts 

automatically and continuously, due to a computer 

system, the internal pressure in cells according to the 

weight and shape of the patient in three differentiated 

sectors, head, medial section and legs-feet. It is not an 

alternating system, and so, has not the 

contraindications of alternating systems like 

politraumatic patients with unestable fractures, non 

fixed spinal cord injuries and pressure-related pain. 

Carital Optima Classic is indicated for patients up to 

extreme risk of developing pressure ulcers as well as 

for patients with maximum pain assessment with the 

EVA pain scale. 

Results 

15 patients have been included in the evaluation, 8 

(47,1%) were men and 7 (41,2%) women. The mean 

age of the patients was 61,42 +/- 17,38 (SD) years 

(median=63,5). 

8 patients (41,2%) died in the ICU and 7 were 

discharged to a hospital ward (47,9%). 

160 

Age 61,42 +/-17,38 

(SD) years 

Braden 9,78 +/- 1,21 

score (SD) 

Days of 

use of the 

mattress 

16,35 +/- 9,6 

(SD) days 

Median: Min: 28 

63,5 years Max: 83 

Median: 10 Min: 7 

Max: 12 

Median: 

13,5 days 

Min: 5 

Max: 41 

4 patients (23,5%) developed pressure ulcers. 

Incident of Non incident of 

pressure ulcers pressure ulcers 

Number 4 (23,5%) 11( 76,5%) 

Exitus 4 (100%) 4 (36,4%) 

Age (median) 70,5 years 59,5 years 

Braden score 

(median) 

Days of use of 

mattress 

(median) 

10 

10 

13 days 15 days 

The patients that developed pressure ulcers 

developed 2 pressure ulcers at the eighth day (median 

values). 3 pressure ulcers were located at occipital 

area, two in heels and the other one in saccral area. 

Of them 4 were of stage II and 2 of stage I. 


With the use of Carital Optima Classic we have 

reduced and expected 100% of incidence of pressure 

ulcers in patients who could not be repositioned to 

23,5%, and the incident patients, although being in a 

very severe health condition (all of them died), they 

only developed stage I and stage II pressure ulcers. 

The Carital Optima Classic continuous and reactive 

low pressure mattress seems to be an effective and 

proven resource for preventing pressure ulcers in 

extreme risk patients. 

References: 

Takala J, Varmavuo S and Soppi E. Prevention of pressure sores in 

acute respiratory failure: a randomised controlled trial. 

Clinical Intensive Care 1996; 7: 228-235 


Poster #25 


Poster 25 



Effectiveness and implementation of a pressure ulcer prevention protocol at a University 

Hospital. A cohort pilot study 

López Casanova P 1 , Verdú J 2 

1 Unidad Integral de Heridas Crónicas, Departamento de Salud Elche-Hospital General, Elche, Alicante, 

Spain. lopez_pabcas@gva.es 

2 Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia, 

Universidad de Alicante, Spain 

Introduction 

Defloor, Vanderwee and other colleagues [1,2], may 

be, are the researchers that, in the last decade, has 

made the best evidence based studies on this topic. 

Although there is limited amount of research, 

repositioning is considered as integral component in 

the practices of prevention of pressure ulcers (PU) and 

matresses are devices that need to probe it’s 

effectiveness. The objective of this study was to 

evaluate the effectiveness of a prevention protocol and 

the grade of recommendations implementation and its 

consequences. 

Methods 

A cohort study was performed with patients attended 

at hospital, over 18 years old and with PU risk, based 

on Braden Scale (score lower than 18). Here we are 

presenting a preliminary pilot study. The outcome is 

PU incidence. The independent variables studied 

were: Braden score, exposition to a different 

components of the PU prevention protocol at hospital 

(topical application of hyperoxigenated fatty acids, 

pressure relieving surfaces, pressure relieving 

dressings, sitting and schedule of sitting, nutrition, 

repositioning and schedule of repositioning) and the 

reasons for what no apply such recommendations. 

Results 

At the moment to send the abstract it was included 52 

patients on the cohort. Patients have a mean of 78 ± 

10 years old (median: 79, min: 46, max: 93), 

distributed by sex as 52% men and 48% women, with 

a Braden score of 11,8 ± 2,4 (median: 11, min: 7, max: 

17). Patients remain at hospital a mean of 5,4 ± 4 days 

(median: 4, min: 1, max: 22). On table 1 there is a 

summary of implementation of interventions. 

The incidence of PU was 3,8% (2 patients with PU of 

52). Occurred in women, both with 91 and 72 years 

old, with all the preventive measures applied. PU 

appearing at day 3. 

161 

Table 1: Summary of interventions implemented 

Intervention Percentage 

Repositioning 46,2% 

Frequency of repositioning 4 hours 20,8% 

6 hours 66,7% 

8 hours 12,5% 

Sitting 25,0% 

Hours sitting 1 hour 18,2% 

2 hour 54,5% 

Between 3-6 hours 27,3% 

Topical application of HOFA 100,0% 

Frequency of application 24 hours 92,3% 

Less than 24 hours 7,7% 

Foam dressings 73,1% 

Pressure relieving mattresses 80,8% 

Type of mattress Dynamic 78,8% 

Static 21,2% 

Nutritional supplements 11,5% 

Type of supplement Hyper-protein 66,7% 

Hyper-caloric 33,3% 

HOFA: Hyperoxigenated fatty acids 

Discussion 

We need a larger sample but it seems that in this 

prevention program presents low incidence. Questions 

arising are the relevance of repositioning in front of 

pressure relieving mattresses. Here there is a large 

group of patients with risk to develop PU, without 

repositioning or with long periods of frequency of 

repositioning, that not develop PU. 


The effectiveness of the prevention protocol applied is 

of very important relevance. 


This piece of work is a part of the PhD thesis of Pablo 

López Casanova. 

References 

[1] Defloor T, De Bacquer D, Grypdonck MH. The 

effect of various combinations of turning and pressure 

reducing devices on the incidence of pressure ulcers. 

International Journal of Nursing Studies 2005; 42:37- 

46. 

[2] Vanderwee K, Grypdonck MHF, De Bacquer D, 

Defloor T. Effectiveness of turning with unequal time 

intervals on the incidence of pressure ulcer lesions. 

Journal of Advanced Nursing 2007: 57:59-68 


Poster #26 


Poster 26 



Multi-disciplinary approach for the effective management of pressure ulcers 

Luxmi Mohamud 1* , Vincent Siaw-Sakyi 2 

1* Guys and St Thomas NHS Foundation Trust, UK, luxmi.mohamud@gstt.nhs.uk 

2 Guys and St Thomas NHS Foundation Trust, UK 

Introduction 

Two case study on patients who developed Stage 4 

pressure ulcer to the sacrum (EPUAP 2009). 

Both patients have several co-morbidities and different 

complex needs. 

High risk of sepsis identified 

Severe pain, discomfort, altered body image, stress, 

anxiety and reduced mobility on assessment. 

Objectives: 

To debride the wounds in the first instance and 

ongoing maintenance debridement 

To reduce bacterial load 

To minimize pain 

To promote patient’s comfort and satisfaction 

Aim: 

To improve quality of life in patients 

Methods 

Debridement: Autolytic and conservative Sharp 

debridement (Gray et al 2011). 

Maintenance debridement 

VAC Therapy 

Multidisciplinary involvement 

Pressure relief 

Outcome measurement: 

Use of photography for wounds 

Assessment of psychological improvement on patients 

Patients verbalized for feedback 

Results 

Clean granulating wound bed 

Enhanced patient’s concordance to care 

Increased mobility 

Reduced pain level 

Reduced risk of sepsis 

Improve sleep pattern 

Decreased anxiety and stress 

162 

Pictures: pre and post debridement for both patients 

Discussion 

Although patients had different complex needs, the 

management plans were highlighted on reflection as 

similar. 

On assessment: Autolytic and Conservative sharp 

debridement found appropriate in both cases 

Psychological stressors impacted on the 

management plan (Woo 2010). 

Psychological support provided through a Multidisciplinary 

approach. 

Improving patient’s experience using right dressing 

and methods. 

As new practitioners in Sharp debridement, it has 

increased our confidence in further utilization of this 

skill in complex wound management. 


Multi Disciplinary approach and patient’s involvement 

together with practitioner having good knowledge and 

skills in wound care can improve quality of life in 

patients significantly. 


We appreciate the help of Claire Acton, Tissue 

Viability Nurse Manager (Guys and St Thomas NHS 

Foundation Trust). 

Conflict of Interest- none 

References 

[1]EPUAP 2009 

[2] Gray et al. Wounds UK 7(1): 77-84 (2011) 

[3] Woo KY, Wounds UK 6(4):92-98 (2010) 


Poster #27 


Poster 27 



Clinical cases evaluation of a continuous and reactive pressure range of mattresses in the 

prevention of pressure ulcers in pediatric patients 

Muñoz García, L. 1* , Martín Alonso, MT. 2 , Bermudo Fernández, I. 3 Bravo Lopez, R. 4 Camarena 

Piñero, MA 5 

1* Clinical specialist, nursing, AWM Division, Smith&Nephew, Spain. leticia.munoz@smith-nephew.com 

2 Nursing, Hospital Universitario La Paz- Unidad uvi pediátrica 3,4,5 Nursing, Hospital Universitario La Paz- 

Unidad uvi neonatos 

Introduction 

Pressure ulcers prevention programmes must consider 

pediatric population as in national reference hospitals 

there use to be may children at high risk of developing 

pressure ulcers. The use of special mattresses for 

preventing pressure ulcers is probably (in conjuntion 

with other measures) the most important ressource for 

helping healthcare proffesionals in achieving good 

prevention results. 

In the case of pediatric patients alternating air 

mattresses for adults do not always work appropiatley 

as they need a minimum wheigt for being fully 

functional. Otherwise there are also (like in adults) 

pediatric patients that can not be repositionated due to 

their clinical condition. 

Our experience shows us taht although reinforcing and 

emphasysing the traditional pressure ulcers prevention 

measures (repositioning, skin care etc.) in our patients 

we had incident cases of pressure ulcers. 

Methods 

We designed a prospective observational study in 

different wards of the Pediatrics Department of the 

Hospital La Paz, a national reference hospital in 

Madrid, in order to evaluate the clinical effectiveness 

of a continuous and reactive low pressure range of 

mattresses in pediatric patients at high risk of 

developing pressure ulcers. 

Carital systems are continuous and reactive local 

pressure special range of mattresses that adapt 

automatically and continuously, due to a computer 

system, the internal pressure in cells according to the 

weight and shape of the patient in three differentiated 

sectors, head, medial section and legs-feet. They are 

not alternating systems, and so, have not the 

contraindications of alternating systems like 

politraumatic patients with unestable fractures, non 

fixed spinal cord injuries and pressure-related pain, 

neither the minimum weight requirements (30-40 Kg) 

for adult alternating air systems. 

They are indicated for pediatric and adult patients up 

to extreme risk of developing pressure ulcers as well 

as for pediatric and patients with maximum pain 

assessment with the EVA pain scale. 

163 

Carital range of products suitable for being used in 

pediatric population include: 

-Carital Neo. For neonates from 500 g up to 6 kg 

-Carital Juve. For children from 6 kg 

-Carital Optima Classic. For patients from 6 to 300 Kg 

Results 

10 kids, with a (median) risk according with Braden Q 

score of 12, have been included in the evaluation, 6 

with Carital Neo, 3 with Carital Juve and 1 with carital 

Optima Classic. Our evaluation covers 192 days of 

Carital systems use in several type of pediatric 

settings (6 in the pediatric intensive care unit, 3 in the 

neonatal intensive care unit, 1 in a pediatric ward) 

5 of the patients (45,5%) had existing pressure ulcers 

at the beginning of the use of the mattresses.None of 

the 10 kids developed pressure ulcers while using the 

continuous and reactive low pressure range of 

mattresses. 

4 of the 5 patients with existing pressure ulcers (6 

lesions) healed them, and the other (with 3 ulcers) 

improved them while using the mattress. There was a 

newborn with Epidermolisis Bullosa who although no 

having pressure ulcers improved the skin wounds due 

its process after using a Carital Neo system. 


With the use of the Carital range of mattresses we 

have not have had incidence of pressure ulcers in 

pediatric patients who were at very high risk of 

developing pressure ulcers and we have healed or 

improved the existing lesions. 

Carital continuous and reactive low pressure range of 

mattresses seems to be an effective and proven 

resource for preventing pressure ulcers in extreme risk 

pediatric patients. 

Acknowledgements: Special thanks to María José 

Cabrera Agüera 

References: 

Takala J, Varmavuo S and Soppi E. Prevention of pressure sores in 

acute respiratory failure: a randomised controlled trial. 

Clinical Intensive Care 1996; 7: 228-235 


Poster #28 




Poster 28 

Local Hyperbaric Oxygen Therapy - Case Study 


Introduction 



The hyperbaric oxygen therapy is already used for 

many years to treat wounds in people who have 

inhibitory factors in wound healing. However, the fact 

that this therapy must be performed in a hyperbaric 

chamber restricts the access and limits the number of 

beneficiaries (whether by the limit of space in the 

chamber either by physio-pathological 

contraindications of the hyperbaric chamber). 

The local hyperbaric oxygen therapy, through a 

chamber applied to the limbs or by specific dressing 

for the other body regions, allows the application of 

hyperbaric oxygen in any location that has the supply 

of O2 (even in the patient’s home). 

Methods 

In CHP, EPE, in January and February 2011, local 

hyperbaric oxygen was used in multiple wounds 

located on the right leg of a person with scleroderma 

and severe pulmonary hypertension under continuous 

iloprost IV by pump (which prevented the use of 

common Hyperbaric Oxygen Therapy). The 

photographic record was made in all treatments. 

164 


The use of local hyperbaric oxygen therapy, in 

conjunction with local treatment of wound dressing 

with honey, allowed a breakthrough in healing. 

However, the pain has emerged as relevant data, 

which led to adjustment of chamber parameters for an 

optimization of therapy. 


The use of Hyperbaric Oxygen Therapy in a person 

with severe scleroderma + pulmonary hypertension 

+ multiple wounds in his right leg led to a breakthrough 

in healing. 


None 

References 

JAMES PHILLIPS, MS P – “TOPICAL 

HYPERBARIC OXYGEN THERAPY FOR 

CHRONIC WOUNDS”, available on-line in 

6/4/2011 in 

http://www.woundcare.org/newsvol1n3/ar8.htm 


Poster #29 


Poster 29 



Prescribing Beds: Electric Profiling Beds Will Reduce Pressure Injuries! 

Tracy Nowicki, Clinical Nurse Consultant 

The Prince Charles Hospital, Australia, Tracy_Nowicki@health.qld.gov.au 

Introduction 

Despite the long history of hospital-bed use, only in 

the past decade have bed-related patient-safety hazards 

including falls, restraints, pressure injuries and lifethreatening 

entrapment been discussed publicly(1). 

The bed is where health care workers and patients 

spend most of their time. 

In the year 2011, worldwide healthcare is challenged 

with managing an ageing population, multiple comorbidities, 

increased acuity of patients, as well as the 

ever present bariatric population. To manage these 

challenges we need appropriate equipment: the bed is 

fundamentally at the forefront of the essence of 

care in all settings. 

Significant contributing factors to the development of 

pressure injuries are pressure, shear and friction. At 

the 2009 EPUAP and the Australian Wound 

Management Conference 2010, it was evident that 

research is indicating shear is coming to the forefront 

as a significant contributing factor in pressure injury 

development. 

Results 

Since the implementation of 200 profiling beds, 

along with extensive staff education on skin care 

and continence management, we have seen a 50% 

reduction in sacral pressure injuries during our 

last pressure injury prevalence study(2). 

Discussion 

Beds now have an option of a ‘profiling’ feature. 

Ensuring the knee bends as the head of the bed 

elevates. This reduces shear and friction; it reduces the 

need to drag the patient back up the bed and reduces 

the risk of the patient slowly sliding down the bed. 

Many beds on the commercial market continue to 

be basic and replicate bed from many decades 

ago. Some bed platforms only having a two joint 

movement. 

Many staff when trying to install appropriate 

equipment for pressure injury prevention and 

management fail to reflex on the relationship between 

the mattress and the bed. 

165 

Investing in electric profiling beds and 

complementary pressure relieving mattresses will 

reduce pressure injury development. 

As the patient advocate we encourage all nurses not to 

be locked into tradition and familiar ways, but to 

review and evaluate continued, quality improvement 

by going the extra mile on patient bed safety. 

References 

(1)Hospital Bed Safety WorkGroup (HBSW). 

Kendal Outreach. UK. 

(2) TPCH Pressure Injury Prevalence study 2010. 


Poster #30 


Poster 30 



Finite Element Analysis under the Shear Displacement with a New 3D3L Model 

Taro Ohsugi 1* , Makoto Takahashi 1 , Kiyoshi Miyazawa 2 

Yoshikazu Tanaka 2 , Akiyoshi Kinoshita 2 , Haruki Toda 2 

1* Grad. School of Information Science and Technology, Hokkaido Univ., 

JAPAN, Ohsugi_Taro@ist.hokudai.ac.jp 

2 Unicharm Corporation, JAPAN 

Introduction 

A few previous studies have determined the effect of 

shear stress on the development of pressure ulcers. 

We estimated the stresses in subcutaneous tissues 

using the finite element method. In past studies, we 

simulated using a simple 2-D or 3-D model (Fig. 1). 

However, to predict the stress distribution in 

subcutaneous tissues with greater accuracy, an 

advanced 3-D model is required. Therefore, the 

objective of this study is to develop a 3-D 3-Layers 

(muscle, fat, and skin) model (3D3L model) of the 

buttock and to determine the stress distribution in 

subcutaneous tissues in the sitting position. We 

accounted for the effects of shear stress and 

coefficient of friction in our new model. 

Fig. 1: Simple models in past studies 

Methods 

We developed a 3D3L buttock model using 3-D laserscanned 

computer-aided design data of a healthy 

male subject (Fig. 2). This model incorporates bones 

and soft tissue structures. The soft tissues in this 

model consist of three layers; ultrasound images of 

two subjects were obtained in order to construct these 

layers. It was observed that the thicknesses of the fat 

and the skin layers were relatively constant as 

compared to that of the muscle layer. Therefore, the 

fat and skin layers were defined as constant-thickness 

layers, and were modeled as linear elastic bodies. The 

bones were modeled as rigid bodies with air holes [1]. 

The cushion was also modeled as a rigid body. We 

analyzed the equivalent stress in subcutaneous 

tissues using a finite element analysis (FEA) software 

package, ANSYS 13.0. 

Fig. 2: 3D3L model developed in this study 

166 

We incorporated a 10-mm compression displacement 

and a 5-mm shear displacement in the model. The 

coefficients of friction between the body and the 

cushion were 0.1, 0.5, and 0.8. 

Results and Discussions 

We created a sophisticated 3D3L model of the 

human buttock. It's the first in the world's history. 

The proposed 3D3L model represents the first 

elucidation of stress distribution in the different layers 

of subcutaneous tissue. This model can potentially 

enable the investigation of stress distribution in each 

layer under shear stress. 

Stress concentration occurs at the boundary phase 

of each layer, but not at the surface of skin (Fig. 3). 

The different strain in each layer may be attributed to 

the stress convergence at the boundary phase, which 

indicates the concentration of stress under shear 

force. 

Fig. 3: Stress distribution in each layer 

The stress value varied linearly with the coefficient 

of friction. 

The stress value obtained at a coefficient of friction of 

0.8 was the largest value under all conditions. The 

results suggest that under an applied shear force, the 

coefficient of friction influences the magnitude of stress. 

References 

[1] Éric L. Wagnac et al., IEEE TRANSACTIONS ON 

BIOMEDICAL ENGINEERING. 55:774-783, 2008 


Poster #31 


Poster 31 



Translation into Portuguese language, cultural adaptation and validation of Braden Q Scale 

Pellegrino Donata MS 1 , Maia Ana CAR 2 , Blanes L 3 , Dini Gal M 4 , Ferreira, Lydia M 5 

1* Unifesp, Brazil donatas@uol.com.br 

2 Unifesp, Brazil 3 Unifesp, Brazil, 4 Unifesp, Brazil, 5 Unifesp, Brazil 

Introduction 

Pressure ulcer is an important theme in the area of 

health due to its complexity, which can be aggravated 

by infections that increase hospitalization time and 

treatment costs. The Braden Scale was adapted for 

pediatric use by Curley et al in 2004, using the specific 

risk factors in developing pressure ulcers in children. 

This scale was called Braden Q Scale[1]. 

Methods 

The study was conducted with approval from the 

Ethics Review Board of São Paulo Federal University, 

and approval was obtained from the São Paulo 

Hospital-pediatric unit and from parents of children. It 

was used the guide proposed by Guillemin, 

Bombardier, Beaton[2], on the process of translation 

and cultural adaptation. A multidisciplinary committee 

revised the translations of the instrument. Nurses 

assessed the cultural Adaptation and reproducibility. 

After the consensus, Braden Q Scale was submitted to 

a Portuguese language reviser. It was used the 

Cronbach Alpha and the Intra-class test for testing, 

respectively, the internal consistence and 

reproducibility. 

Results 

There was no difference between scales translated by 

different translators. On what concerns cultural 

adaptation, all the scale items were considered 

relevant, the Internal Consistence measured by 

Cronbach Alpha was of 0.936 and the intra-class 

correlation coefficient for intra-observers reproducibility 

was of 0.995 and for inter-observers reproducibility 

was of 0.998, demonstrating an excellent 

reproducibility. 

Discussion 

Acutely ill and immobilized children are at high risk for 

pressure ulcers. Pressure ulcer incidence rates as 

high as 27% have been reported among critically ill 

infants and children. The prompt Identification of atrisk 

children using a assessment tool is essential for 

accurate and timely implementation of prevention 

strategies and increases the intensity and 

effectiveness of interventions. Nurses' clinical trial is 

completed by the use of risk assessment scales. The 

Braden Q Scale has been tested in the pediatric 

population. The Braden Q Scale was developed in 

English-speaking country. It’s composed of seven 

subscales: mobility, activity, sensory perception, 

167 

moisture, friction/shear, nutrition and tissue perfusion e 

oxygenation[1]. The cross-cultural adaptation of this 

Scale for use in a new country, culture, and/or 

language necessitates that if measures are to be used 

in Brazilian culture, the items must not only be 

translated well linguistically, but also must be adapted 

culturally to maintain the content validity of the 

instrument at a conceptual level across different 

cultures[2]. High index of the relevance Scale 

Braden Q demonstrate good understanding of 

Brazilian nurses in the cultural adaptation 

phase. The study of the reliability of the scale was 

important because it was made by nurses, 

professional who will use the instrument. Nurses rated 

children similarly evidenced by correlation coefficients 

and the ability to reproduce. The scale can be applied 

in several Brazilian pediatric units. The score 16 

indicates risk for the development of Pressure Ulcer in 

children (sensitivity 0.88% and specificity 0,58%. 

Further testing of psychometric properties are still 

recommended, with larger sample sizes and 

homogeneous, also expanding its application to 

neonates and adolescents, and diverse groups within 

this population. 

Conclusion 

The translated and adapted Braden Q Scale has 

demonstrated being valid and reproducible for risks 

assessment of pressure ulcers development in 

pediatrics. 


Pressure ulcers in children not been studied in Brazil. 

The aim of this study was to equip nurses with the 

Brazilian pediatric version of the scale of risk 

assessment more used internationally for this 

population, providing comparable surveys, creation of 

protocols for preventing and monitoring the quality of 

care for hospitalized children. 


None 

References 

[1] Curley MAQ et al. Nurs Res. 52 (1): 22 – 3. 2004 

[2] Beaton DE et al. Spine. 25(24):3186- 91. 2000. 


Poster #32 


Poster 32 

Introduction 



Wound Management Quality Project - Wound documentation 

Pinto, J.C.M. 1* , Araújo, F. M. S. 2 

1* Hospital da Boavista, Portugal, jose.marinho.pinto@hppsaude.pt 

2 Hospital da Boavista, Portugal 

The nursing staff, as well as all clinical staff, needs to 

make records that are essential to assess, plan, 

intervene and evaluate outcome of interventions. It is 

also of utmost importance as legal support in case of 

dispute. A clinical record facilitates coordination of 

care, assess outcomes and provide a pathway for 

quality of care assessment [1]. 

Wound documentation, assume an essential 

component in the management of care by facilitating 

the planning process of nursing care and enabling 

efficient communication between professionals and 

institutions [2,3], proper management of nursing time 

and proper use of material resources [4]. A holistic 

approach to wound assessment, using the same 

terminology and the same evaluation system allows 

monitoring of the healing rate and efficiency of the 

care plan [2,4]. It have been suggested that an 

effective strategy for documentation of wound care 

must include a definition of terms to be used in clinical 

practice, clinical guidelines and algorithms/flowcharts 

to ensure consistency of care [5]. Such strategies 

have been tested and shown good results on 

documentation accuracy [6]. Nevertheless research on 

wound documentation continues to be inconsistent 

between health professionals [7]. The aim of this study 

is to evaluate the impact of an intervention program in 

wound documentation records. 

Methods 

This is a prospective intervention study. The study will 

be performed between March and December 2011. 

A standardized sheet was created to evaluate wound 

care electronic nursing records. The evaluation of 

wound care electronic nursing records will focus on 

documentation on admission and during dressing 

changes. The population will be subjects from the 

outpatients department. For the outpatient sample 

selection we will use systematic sample method 

selecting every 5 th patient. Criteria for inclusion in the 

sample are: a) have wound care electronic nursing 

records. 

A pre-intervention audit will be made to electronic 

nursing records using the standardized evaluation 

sheet, in 50 patients in the outpatient’s department. 

The intervention program will include an education 

program for all nurses that work in the outpatients 

department and the implementation of flowcharts that 

guide wound care documentation. 

Post-intervention evaluation will be done to nursing 

records in 50 outpatient’s clinic three months after the 

168 

intervention program using the same standardized 

evaluation sheet. 

Fig. 1: Procedure 

Results 

We expect that the intervention program will improve 

the quality of wound care documentation on admission 

and during dressing changes. 


Outpatient’s clinic 

Pre-intervention audit 

Intervention program 

3 months 

Post-intervention audit 

50 patients 

records 

NursingStaff 

50 patients 

records 

Good documentation allows continuity of care between 

professionals and the evaluation quality outcomes of 

wound care. 

References 

[1] Brown G. Skin and Wound Care. 19:155-165, 2006 

[2] Flanagan M. British Journal of Nursing, 6:6-11, 

1997 

[3] Dealey C. Climepsi Editores, Lisboa, 2006 

[4] Russel, L. British Journal of Nursing. 8:1342-1354. 

1999 

[5] Hess C.T. Home care Nurse. 23:502-513, 2005 

[6] Dahlstrom, M. et al., Joint Commission Journal on 

Quality and Patients Safety. 37:123-130, 2011 

[7] Gartlan, J. et al., Journal of Clinical Nursing. 

19:2207-2214, 2010 


Poster #33 


Poster 33 



Is the education of the “informal caregiver” necessary to prevent the appearance of 

pressure ulcers? 

Introduction 

FJ Hernández, MP Quintana*, BC Rodríguez, JF Jiménez, R Chacón 

University of Las Palmas de Gran Canaria, Spain, mpino@denf.ulpgc.es 

An improvement in the quality of life has increased 

longevity. This fact has caused an increase in the 

geriatric population who require home care. It has also 

increased the incidence of patients suffering from 

pressure ulcers in our country. Several predisposing 

factors (extrinsic and intrinsic) interfere in the genesis 

of pressure ulcers. This is the reason why Nursing 

plays a fundamental role in preventing these ulcers; 

and the informal caregiver is the key in patients who 

require home care. Education for health is a common 

practice in community nursing. They develop different 

strategies for the population to acquire knowledge 

about pressure ulcers caring [1]. 

Methods 

To reduce the incidence of pressure ulcers in patients 

who require nursing home care in the Canary Islands. 

Through meetings which are programmed in health 

centres, informal caregivers are informed and 

educated about what they must do to prevent pressure 

ulcers. This education and information is completed 

with organized home visits. 

Results 

45 relatives and informal caregivers attended the 

meetings. 94% of them are motivated and want to 

continue with the education. 90% of them understand 

why the “postural planned changes” and the use of 

SEMP are necessary. 85% asked for further 

information. 78% of them felt satisfied with their work. 

Discussion 

Nurses must assess the knowledge the informal 

caregiver or the family have about pressure ulcers 

prevention and their ability to prevent them. The 

education of informal caregivers facilitates the 

introduction of new aims in pressure ulcers prevention. 

The communication and exchange of information 

between nurse and informal caregiver has improved. 


Education of the informal caregiver is necessary to 

prevent the appearance of pressure ulcers. 

169 



References 

[1] EPUAP, Pressure Ulcer Classification. PUCLAS II. 

Meeting Berlin, 2006 


Poster #34 


Poster 34 



DEEP TISSUE INJURY – A DIFFICULT DIAGNOSIS: CASE STUDY 

Ramos, Paulo 1 , Resende, Tiago 1 , Peixoto, Palmira 1 , Alves, Paulo 1 

1 Instituto Ciências da Saúde – Porto - Universidade Católica Portuguesa 

Introduction 

Deep tissue injury (DTI) is a serious lesion typically 

involving necrosis of skeletal muscle and fat tissue 

under intact skin. This injury initiates in internal 

muscular tissue that overlies bony prominences as a 

result of sustained soft tissue deformations[1]. 

In clinical practice we are faced with pressure ulcers 

that increase steadily and show no apparent 

explanation, these are usually DTI that are difficult to 

detect. 

With this case study we intend to demonstrate 

the difficulty in identifying this type of injuries and 

list the different stages in the development of 

DTI. 

Methods 

Case study of 72 year old male, with multiple traumas, 

was admitted for 5 months in intensive care unit of a 

hospital's central city of Oporto. 

Results 

After 2 months of hospitalization was submitted 

to surgery for thoracic aortic valve replacement. 

The first 48 hours after surgery was identified a 

lesion of 4x2 cm (oval shape) in the Sacrum 

region, with granulation tissue. 

pauloasramos@gmail.com 

170 

Discussion 

With this case we can show how the evolution of 

such lesions can be insidious. 

We seek in this case study raise awareness among 

health professionals to this problem that is 

demonstrated to be complex requiring the much 

attention as possible to be correctly diagnosed and 

properly treated accordingly. 


DTI is therefore difficult to diagnose timely, and may 

cause death by sepsis, myocardial infarction, renal 

failure or multiple organ collapse [2]. 

Despite the long hospital stay of two months before 

the patient developed no lesion in the Sacrum region, 

however, postoperative DTI develops due to a long 

stay in high fowler position that determines a higher 

shear force in conjunction with pressure are in origin of 

this type of injury. The correct evaluation of all factors 

involved will help prevent the DTI. 


None 

References 

[1] Slomka, Noa et al.,2009, Bioengineering Research 

of Chronic Wounds, Volume I , Springer Berlin 

Heidelberg; 

[2] Sopher, Ran et al. J. of Biomechanics.43: 280-6, 

2010; 

[3]Shabshin, Nogah et al. 25: 402-8, 2010. 


Poster #35 


Poster 35 

Introduction 



Special surfaces processing in patients with pressure ulcers 

MA Ferrera, FJ Hernández, JF Jiménez, BC Rodríguez*, MP Quintana 

University of Las Palmas de Gran Canaria, Spain, brodriguez@denf.ulpgc.es 

Special surfaces provide essential factors required to 

develop a suitable treatment for patients who are 

affected by pressure ulcers (PU). These types of 

materials are used to supplement the care given to the 

patients, and they are part of the management of 

technical resources which help to solve this problem 

[1]. 

Methods 

To obtain information about the availability and 

usefulness of giving special surfaces to patients with 

pressure ulcers this study will be carried out by the all 

the different health-care areas in Gran Canaria island 

(hospital, community, social-health). A prospective and 

transversal epistemological study. A proportional and 

stratified population sample (402 patients) is to be 

studied, 3% of which will be allowed for sample error, 

with an estimation of a 95% of level of significance 

Results 

The types of special surfaces used in patients who are 

in bed affected by pressure ulcers are as follows: 32% 

are static and 40% dynamic. In 28% of cases, these 

materials are not used. In patients who are seated the 

percentages are as follows: 18% static and in 82% of 

cases, special support surfaces are not used. 

Discussion 

Considering the results obtained, it is necessary to 

develop an efficient procedure within the technical 

resources used with this aim. In this way, we need, not 

only to increase the availability of the resources 

mentioned above but also to develop protocols to use 

them. 


Special surfaces processing in patients with pressure 

ulcers is necessary. 

171 


We appreciate the help of the program Interreg IIIB – 

MAC (2005-2008) of the Union European and the 

program PCT-MAC (2007-2013) of the Union 

European for to finance this study. 



References 

[1] EPUAP, Meeting Berlin, 2006 


Poster #36 


Poster 36 



Multiple lesions in person with scleroderma and severe pulmonary hypertension: 

Application of dressing with honey - Case Study 


Introduction 



This work shows a person with scleroderma and 

severe pulmonary hypertension (on a continuous 

iloprost IV) with four wounds in his right leg. Given the 

failure of treatment of these wounds with several 

dressings, treatment was started with dressing with 

honey, with positive results. 

Methods 

In CHP, EPE, June to September 2010, was made the 

application of dressing wounds with honey in 4 

wounds located on the right leg of a person with 

scleroderma and severe pulmonary hypertension 

under iloprost IV with continuous infusion pump (which 

did not allowed the use of a common Hyperbaric 

Oxygen Therapy). In all treatments the photographic 

record was made. 

172 


The use of honey dressing allowed the control of nonviable 

tissue, reduced inflammation/infection and 

increased granulation tissue. However, the pain and 

maceration of the edges have emerged as relevant 

complications, which led to the adjustment of the 

concentration of honey used. 


The use of a dressing with honey in a person with 

severe scleroderma + severe pulmonary hypertension 

and multiple wounds on his right leg led to a positive 

development towards healing. 


None 

References 

JONES, Darren; RIPPON, Mark - “A Review of 

the Physical Performance Characteristics of 

Honey-based Wound Dressings and Ointments” - 

Wouds UK - Honey Supplement, available on-line 

in 6/4/2011 in 

https://docs.google.com/viewer?url=http%3A%2F 

%2Fwww.klinion.nl%2Ffiles%2Ffiles%2F%255BA 

lgemeen%255D%2520Clinical%2520review%252 

0Ingredients%2520Mesitran.pdf 


Poster #37 


Poster 37 



Prevalence and Incidence of Pressure Ulcers in a Medical Department 

Lígia Sousa 1,2 , Patrícia Homem 1,2 , Noélia Conceição 1,2 , Paulo Alves 2 

1 Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Portugal, ligialopessousa@gmail.com 

Introduction 

2 Instituto Ciências da Saúde – Porto - Universidade Católica Portuguesa 

Pressure Ulcers are an important cause of morbidity 

and mortality, thus afecting the patient’s quality of life. 

These patients contribute to the economical burden of 

the health services. Our aim was to know the pressure 

ulcer reality of the Medical Department, thus our 

intention was to establish the prevalence and 

incidence of Pressure Ulcers in our institution’s 

Medical Department. 

Methods 

This research involved the 282 in-patients of the 

Medical Department between 1 and 31 st May of 2010. 

The data collecting instrument was a formulary, which 

included demographic data, presence or absence of 

pressure ulcer, EPUAP pressure ulcer categories and 

its locations. These data were collected from the 

medical record using an electronic version of the 

International Classification of the Nursing Pratice 

during 3 days and was statistically analyzed with 

SPSS 17. 

Results 

This study had 282 individuals being 45% in Medical 

Ward 3 and 33,4% in Medical Ward 4 and 21,6% in 

Medical Ward 1. In admission 20,9% of the patients 

had pressure ulcer and 7,5% have acquired them at 

the facility. The period prevalence was 24,8% and the 

period incidence was 7,5%. 

Fig. 1: Prevalence and Incidence of Pressure Ulcers by 

Ward. 

173 

The most frequent pressure ulcer locations were the 

sacrum 52,1%, the heel 36,6% and the trochanter 

23,9%. 

Discussion 

We would like to point out a few aspects: 

The prevalence of this study (24,8%) was above the 

value (between 14 and 17%) obtained by 

Whittington e Briones (2004) [1]. 

The incidence value (7,5%) was similar to the one 

found by Bergstrom et al (1996) [2], with 8,5% and 

to the Whittington e Briones (2004) [1] study, 

ranging from 7 to 9%. 

For Thomas et al (1996; cited by Morison, Ovington 

& Wilkie, 2004) [3], the most susceptible locations to 

pressure ulcers are sacrum, buttocks and heels 

which are similar to the results from this research. 

A national pressure ulcer prevalence and incidence 

study would be relevant to nursing, to allow the 

implementation of measures for the prevention of 

pressure ulcers, especially where the incidence is 

higher. 


It is of the most importance to know the actual 

situation of the Medical Department, concerning the 

pressure ulcers problem because it is possible then, to 

implement strategies to improve the quality of care of 

those patients. In can be done in a departmental 

setting or as wide as at the institutional setting. 


None 

References 

[1] Whittington K, Briones R. National Prevalence and 

Incidence Study: 6-Year Sequential Acute Care Data 

[Abstract]. Advances in Skin & Wound Care. 

2004;17(9):490-4. 

[2] Bergstrom N, Braden B, Kemp M, Champagne M, 

Ruby E. Multi-site study of incidence of pressure 

ulcers and the relationship between risk level, 

demographic characteristics, diagnoses, and 

prescription of preventive interventions. Journal of 

American Geriatrics Society. 1996;44:22-30. 

[3] Morison M, Ovington L, Wilkie K. (Eds.) Chronic 

Wound Care. London: Mosby; 2004. 


Poster #38 


Poster 38 



Category 1 pressure ulcers- how reliable is clinical assessment? 

Sterner, E 1,2 , Lindholm, C 3 , Stark A 4 2, 4 

, Fossum, B 

1 Department of Molecular Medicine and Surgery, Karolinska Institutet eila.sterner@karolinska.se 

2 Sophiahemmet University College 3 Red Cross University College and Karolinska University Hospital 4 Department 

of Clinical Sciences at Karolinska Institutet and Danderyd Hospital all in Stockholm, Sweden 

Background 

Immobility is the only evidence based risk factor for 

pressure ulcer [1] Thus elderly patients´ undergoing 

surgery are at a high risk for developing pressure 

ulcer. The sacral area is most commonly affected in 

hospitals as well as heels. 

Early detection of category 1 pressure ulcers is 

essential for the prevention of more severe pressure 

ulcers [2,3,4]. Today observation and light skin 

pressure is state of the art to separate blanching 

erythema from non-blanching (category 1 pressure 

damage) [5,6,7,8] The present classification is, 

however, subjective, and a reliable and clinically 

applicable method for correct classification is urgently 

needed. 

Purpose 

The purpose of the present study was to investigate 

degree of agreement/disagreement between two 

independent observers who assessed skin condition in 

the sacral area of patients undergoing hip fracture 

surgery. 

Methods 

Seventy-eight patients with hip fractures were followed 

daily, from the first day post surgery and to a 

maximum of five days. The sacral area was assessed 

independently by two nurses and category as 

a) normal skin 

b) blanching or 

c) non-blanching erythema 

(category 1 pressure ulcers). 

After ocular skin assessment, blanching/ non 

blanching test with the thumb was performed. The 

correlation between the results of the two observers 

was analyzed using kappa statistics for categorical 

variables. 

Results 

Seventy-eight patients were followed and investigated 

day one and two, 77 patients’ day three, 64 patients’ 

day four and 52 patients’ day five. In the sub-set of 

patients where the assessors agreed on the visual 

assessments of category 1 and category 2 ulcers the 

kappa value varies from 0.43 first observation day to – 

0.12 the last observation day (Table 1). Twenty-one 

percent (n= 21) of the patients had pressure ulcers in 

the sacral area, upon arrival, and 56% (n= 44) at 

discharge (see Table 2). 

174 

Table 1: the subset of patients where the assessors agreed 

on the visual assessment of Category 1 and 2 ulcers 

Group Kappa (simple)* 95% CI 

Day 1 (N=24/34) 0.43 0.15-071 

Day 2 (N=26/42) 0.19 -0.10 to 0.48 

Day 3 (N=18/40) -0.15 -0.43 to 0.14 

Day 4 (N=18/35) 0.04 -0.27 to 0.34 

Day 5 (N=13/29) -0.12 -0.45 to 0.21 

*No agreement 0.0 -0.20, Slight agreement 0.21-0.40, Fair 

agreement 0.41-0.60, Moderate agreement 0.61-0.80, Substation 

0.81-1.00 [9] 

Table 2: patients with pressure ulcer at admission and 

discharge, grouped by sex and age. 

Sex /year 


category 1 at 

admission 

Pressure ulcer at 

discharge (Category 1/2) 

Category I Category II 

Female / < 70 0 0 1 

Female / > 70 17 30 7 

Male / < 70 1 0 0 

Male / > 70 3 4 2 

Total 21 34 10 

N=44 (56%) 

Conclusions 

This study demonstrated a high degree of 

disagreement between clinical observations of 

reactive hyperaemia and non-blanching erythema 

(category 1 pressure ulcers). A more reliable test to 

identify the different stages of erythema seems 

necessary. Early detection of pressure ulcers category 

1 is a crucial factor for prevention strategies. 

Education might facilitate a more structured 

assessment, and other tools for this identification 

should be developed. 


This study was supported by a grant from 

Sophiahemmet University College, Stockholm, 

Sweden. 


None 

Reference 

[1] Sharp et al., Int Wound Journal, 2006 

[2] Halfens et al., J. Clinical Nursing, 10:748-57, 2001. 

[3] Lyder et al., Ostomy Wound Management. 48:52-62, 2002. 

[4] Duncan. Joint Commission journal on quality and patient 

safety, 33:605-10, 2007. 

[5] Bliss. J Tissue Viability 8:4-13, 1998. 

[6] Bethell. Nursing times, 99:73-5, 2003 

[7] Sharp et al., Available at: 

http://www.worldwidewounds.com/2005/october/Sharp/Discourse 

-On-Pressure-Ulcer-Physiology.html, 2005 

[8] Vanderwee et al,. J. Clinical Nursing, 16:325-35, 2007 

[9] Landis et al., Biometrics, 33:363-74, 1977 


Poster #39 




Poster 39 

Pressure distribution properties of the cushions using shear-stress relief foam 

Makiko Tanaka 1* , Miaki Shibaya 2 , Michio Omura 2 

1* Yamaguchi Prefectural University, Japan, maki@n.ypu.jp, 2 Kaneka Corporation, Japan 

Introduction 

Shear-stress relief foam was developed for wheelchair 

cushions in order to decrease the shear stress. In 

our former study [1], the shear modulus of the cushion 

materials was evaluated using the compressive 

stress-supplied shear test assuming practical usage. 

As a result, it became evident that shear-stress relief 

foam had a low shear modulus in comparison with 

polyurethane foam (PUF) and gel material. This 

study consists of two phases: one measuring the 

pressure distributions of the cushions used by healthy 

subjects and the other carrying out a long-term test 

with 8 elderly subjects using wheelchair cushions with 

shear-stress relief foam. 

Method 

Figure 1 shows the three cushion samples used in the 

f9rst phase of the study. The PUF and gel cushions 

are the types generally commercialized in Japan. 

The pressure distribution properties of these samples 

were measured using the Clinseat and the BIG-MAT 

(Nitta Corporation). The subjects were three healthy 

individuals (two males and one female). The sitting 

time was 20 minutes at one position, and the positions 

were changed three times (based on the 90-90-90 

rule) from a normal position to 10 cm and 20 cm in 

front of the normal position. The interval between the 

sitting positions was 5 minutes. The sitting posture was 

assumed on the sacral bone. Then the maximum 

contact pressure and the contact area were calculated, 

and a statistical analysis was conducted using 

A N N O V A w i t h m u l t i p l e c o m p a r i s o n s . T h e 

significance level was at .05. 

The second phase, the long-term test, was carried out 

using wheelchair cushions with shear-stress relief 

foam. The subjects were 8 elderly individuals from 

three geriatric care facilities with their average age 

being 77.5 years. The test was conducted for three 

months from July to September 2010. The wheelchairs 

were adjusted for each subject and cushion, and the 

pressure distribution was measured once each month. 

The subjects were interviewed on how they felt about 

sitting on the cushions on a monthly basis. 

Results 

gel 

Shear stress relief foam 

PUF 

PUF 

(a) Gel type (b) PUF type (c) shear stress 

Fig. 1: Sample cushions 

relief foam type 

Table 1: Pressure distribution properties 

Average PUF type Gel type 

Shear stress 

relief foam type 

Max. pressure 

(mmHg) 

91.5 102.9 108.1 

Contact area 

(cm 2 ) 

1277.6 1143.9 1248.5 

Table 1 shows the results of the first phase: pressure 

distribution properties with the average of maximum 

175 

contact pressure and the contact area of the three 

subjects. 

A statistical analysis did not show any significant 

differences in the maximum pressure between the 

three samples. On the other hand, the contact area 

of the PUF type was significantly larger than that of the 

gel type. However, the shear-stress relief foam type 

did not show any significant difference from the other 

types in this regard. In relation to the sitting positions, 

there were no significant differences in the pressure 

distribution properties. The maximum pressure 

increased while the contact area decreased as the 

sitting position moved towards the front. 

In terms of the second phase of the study, no adverse 

effects took place on the subjects but the data of two 

subjects were removed from the statistical analysis 

because of their significant weight loss. For the 

maximum pressure change, a t-test was carried out on 

the background information of the subjects. As a result, 

it became evident that the maximum pressure of the 

males changed more significantly than that of the 

female subjects (p=.021). There was no significant 

difference between the beginning and the end of the 

testing period in terms of the t-test for the maximum 

pressure and the contact area, respectively. The six 

remaining subjects commented that they felt good 

using the cushion with the shear-stress relief foam. 

Four of them further indicated that their buttock pain 

was alleviated. Moreover, among three subjects, their 

daily sitting time had increased by about 2 hours. 

Finally, one subject stated that the condition of the 

pressure ulcer improved. 

Discussion 

As the sitting position moved forward from the normal 

position on the sacral bone, the maximum contact 

pressure increased. It is therefore considered that 

the risk of pressure ulcer increased. Based on the 

results of the pressure distribution measurement of the 

healthy subjects, it seems that the cushion with 

shear-stress relief foam has effects on the pressure 

distribution, similar to the other types of cushions. In 

the long-term test with the elderly subjects, the 

maximum contact pressure of the males decreased 

more significantly than the females. Since there was 

no significant difference in their BMIs, it seems that the 

causal factor might have been the differences in the 

soft tissues of the buttocks between the males and the 

females. Hence, it is suggested that the cushions 

with shear-stress relief foam can improve the pressure 

distribution for cushion users with thin and soft buttock 

tissues. Finally, the insignificant difference in the 

pressure distribution between the beginning and the 

end of the testing period might be due to the fact that 

the conditions remained the same for the cushions 

with the shear-stress relief foam whereas those of the 

PUF cushion changed. 


This study was sponsored by Kaneka Corporation. 

References 

[1] Tanaka M. et al., Abstracts of 13 

Copyright © 2011 by EPUAP 

th Annual EPAP 

Meeting: 158, 2010

Poster #40 


Poster 40 



The views of nurses regarding prevention material for occipital pressure ulcers 

Annabelle Van den Mooter 1* , Nancy Van Genechten 1 , Erik Franck 1 

1* Karel de Grote University College, Belgium, annabelle.vandenmooter@kdg.be 

Introduction 

Pressure ulcers are a major concern in bedridden 

patients. Occipital pressure ulcers (OPU) are less 

common but entail specific risks. At the occipital region 

there is very little subcutaneous tissue. Therefore, 

these pressure ulcers can progress quickly into more 

severe stages [1]. Occasionally, these severe sores 

can even evolve into scarring alopecia [2]. OPU are 

mostly observed in intensive care units (ICU) both in 

adults and infants [3]. Existing preventive aids are 

aimed at the prevention of pressure ulcers in general, 

and fail in the prevention of OPU. The prevention of 

OPU in immobilized patients requires specific 

demands concerning the type of preventive aid and 

the technology and materials used. In a TETRA project 

that is financed by the Flemish government, Karel de 

Grote University College and University College Gent 

conducted a research project regarding the prevention 

of OPU. The ultimate objective is to develop and test 

preventive tools for OPU. Aim of the present study was 

to explore nurses’ views towards prevention material 

for OPU. 

Methods 

All hospitals located in Flanders and Brussels with 

more than 10 beds on the ICU were contacted. Of 

these 33 hospitals, 17 were willing to cooperate in the 

study. Using a survey, we investigated the views of 

nurses concerning preventive materials for OPU. 2 

questionnaires were developed: one for the head 

nurses and one for the nurses. The survey of the head 

nurses was more extensive and collected information 

about the type of pressure ulcer prevention material 

and the prevalence rate of pressure ulcers and OPU at 

their ICU. A total of 33 head nurses and 157 nurses 

completed the survey. Data were analyzed using the 

Statistical Package for the Social Sciences (SPSS) 

19.0. The study was performed between December 

23, 2010 and January 31, 2011. 

Results 

The prevalence rates of pressure ulcers varied 

between 2% and 30%, with an average prevalence 

rate of 14% (SD=8.8). Although OPU are not a 

common problem, 62.50% of the head nurses had 

been confronted with OPU on their ICU. Only 3 head 

nurses answered the question regarding the 

prevalence rate of OPU. The prevalence rate varied 

between 1% and 3%. The views of nurses’ regarding 

several features of prevention were assessed. The 

most important results are discussed hereafter: 

Size: 45% of the (head) nurses prefer a pillow that is 

as big as a regular pillow. 

Weight: 49% of the (head) nurses do not attach 

importance to this feature. 

176 

Volume: 40% of the (head) nurses want a pillow as 

thick as a regular pillow. 

Headrest: a considerable percentage of the (head) 

nurses (77%) prefer a pillow with a headrest. 

Alternating: 61% of the (head) nurses have a 

preference for an alternating pillow. 

Adaptable: 67% of the (head) nurses prefer a pillow 

that is adaptable to the needs of the patient. 

Integrated: 69% of the (head) nurses do not want a 

pillow integrated into the mattress. 

In the survey there was one open-ended question: 

“Suppose that you, as a (head) nurse, could develop 

material to prevent OPU, what issues would be of 

interest to you?” 72% of the head nurses and 70% of 

the nurses completed this question. We classified all 

answers into several categories. The results are 

presented in Table 1. 

Table 1: Summary of the most important data 

TOP 5 HEAD NURSES TOP 5 NURSES 

1. Cleaning and maintenance 1. Cleaning and maintenance 

2. Usability 2. Usability 

3. Comfort of the patient 3. Comfort of the patient 

4. Alternating 4. Headrest (head support) 

5. Cost 5. Adaptable to the needs of 

the patient 

Discussion 

The results show that (head) nurses prefer prevention 

material that is similar to a classic pillow and that can 

be adapted to the needs of the patient. Furthermore, 

the prevention material has to be separate from the 

mattress. Analysis of the open question revealed that 

cleaning and maintenance, usability and comfort are 

the most important features of prevention regarding 

OPU. There is a need for research regarding 

prevention material for OPU. The next step is to 

develop prevention material and test it via a 

randomized clinical trial. 


In this study we gathered information concerning 

standards towards prevention material for OPU. 


We appreciate the help of the participating hospitals. 


None 

References 

[1] EPUAP, pressure ulcer prevention, quick reference 

guide, 2010 

[2] Gershan et al., Arch Dis child. 68: 591-3, 1993 

[3] Kottner et al., Int J Nurs Stud. 47: 1330-40, 2010 


Poster #41 


Poster 41 



Knowledge and implementation of recommendations on Pressure Ulcer prevention in 

Andalucía, Spain. A pilot study. 

Verdú José 1* , Hernández Martínez-Esparza Elvira 2 


Alicante. Spain. pepe.verdu@ua.es 

2 Support team in geriatrics centers, MUTUAM, Barcelona. Spain. 

Introduction 

Clinical Practice Guidelines (CPG) are 

recommendations sistematically developed to assist 

health professionals to take better clinical decision 

making in specific clinical situations. However, in 

prevention and treatment of pressure ulcers (PU), 

nursing proffesionals, not always knows such 

recommendations [1] and remain as a question: how 

many times they use such recommendations in 

practice. The implementation of recommendations 

from quality CPG allow to reduce incidence and 

prevalence of PU, also, to diminish costs associated to 

inadequacy of clinical practice [2]. With this study, the 

objective is to analyze if CPG with the best quality 

appraissed [3], really, are useful and known by health 

professionals at different clinical settings and if they 

apply such recommendations in clinical practice. 

Methods 

This a pilot survey conducted between health 

profesionals, workng in different health levels across 

Andalucía (Spain), where, as was stated in a previous 

study, exist the best quality appraised CPG in Spain.It 

was elaborated an anonimised and voluntary survey to 

get the data. The survey include: Professional data 

and questions about the recommendations from the 

CPG in two ways (adequacy of intervention to 

measure knowledge and use in clinical practice to 

measure implementation). Questions were randomly 

ordered for recommended and not recommended 

interventions. The survey is used to refine the final 

questionnary and to calculate final sample for the 

whole study. 

Results 

38 questionnaires were collected for pilot purposes. 

95% of the sample was nurses, 75% women with a 

median of 45 years old (min: 35, max: 62). Related to 

years of experience: 65% more than 20 years of 

profession, 13% between 15-20 years and 22% 

between 10-15 years. 55% working at Primary Health 

Care and the others at hospitals. The entire sample 

said that had specific training on PU, only 8% received 

at pre-graduated education and the majority on postgraduate 

courses (of them, 46% on courses with more 

than 20 hours). Only 34% said that had attended 

congresses or meetings related to Pressure ulcers. 

177 

Table 1: Percentage (%) of correct responses. 

Recommendation A I 

Apply a risk assessment scale on admission 92,1 68,4 

Risk assessment scale when patient state change 92,1 54,1 

Register and document risk assessment 89,5 73,0 

Daily skin inspection 78,9 71,1 

Use soaps or cleansers with low potential of … 86,5 76,3 

Maintain skin clean and dry 89,2 81,1 

Absorption of moisture creams must be confirmed 78,4 58 

Apply alcohol products on the skin 92,0 97,4 

Massage over bony prominences 68,4 78,9 

Apply HOFA to intact skin 91,9 76,3 

Apply barrier products for exposed to incontinence 81,6 55,3 

Remove zinc oxide creams with oil products 47,4 42,1 

Schedule a mobility-activity plan 92,1 68,4 

Repositioning frequently 92,1 71,1 

Avoid direct contact between bony prominences 92,1 94,7 

Training the patient to repositioning when possible 97,4 86,8 

Avoid shear and friction when mobilize patients 92,1 81,6 

Use lowest bed elevation and during lowest time 65,8 55,3 

Repositioning when lying on side more than 30º 76,3 73,7 

Use specific static mattresses for low risk patients 65,8 47,4 

Use dynamic mattresses for medium-high risk… 86,8 57,9 

Is not necessary to use PURS when sitting 55,3 31,6 

Use PUR seats with Medium-high risk patients 73,7 34,2 

Register the interventions 89,5 68,4 

Pressure relieving surfaces is a substitute of all 

other measures 

76,3 81,6 

Foam dressings over prominences to reduce 

pressure 

71,1 44,7 

Protect heels with foam dressings 84,2 78,9 

Protect heels with cotton bandages 47,4 42,1 

Use “donuts” for sitting patients 73,7 76,3 

Assure adequate dietary intake 89,5 60,5 

Asses nutritional status 92,1 60,5 

When deficiencies, support with nutritional suppl. 86,8 60,5 

A: Adequacy. I: Implementation. In yellow not recommended 

Discussion 

In general, there is a good knowledge of 

recommendations but implementation is lower. 


Highlights where need to improve information and 

education. 


We appreciate the help of Francisco Pedro Garcia- 

Fernández, Juan F. Jimenez and Manuel Montalbo. 


This study is a piece of work the PhD Thesis of Elvira 

Hernández Martínez-Esparza. 

References 

[1] Zamora J.J; Gerokomos 2006;17(2):100-110 

[2] Pancorbo et al. Gerokomos 2007; 18(4):188-96 

[3] Hernández E,et al.Gerokomos 2012;(1). [Epub ahead of print] 


Poster #42 


Poster 42 



Knowledge and implementation of recommendations on Pressure Ulcer treatment in 

Andalucía, Spain. A pilot study. 

Verdú José 1* , Hernández Martínez-Esparza Elvira 2 


Alicante. Spain. pepe.verdu@ua.es 

2 Support team in geriatrics centers, MUTUAM, Barcelona. Spain. 

Introduction 

Clinical Practice Guidelines (CPG) are 

recommendations sistematically developed to assist 

health professionals to take better clinical decision 

making in specific clinical situations. However, in 

prevention and treatment of pressure ulcers (PU), 

nursing proffesionals, not always knows such 

recommendations [1] and remain as a question: how 

many times they use such recommendations in 

practice. The implementation of recommendations 

from quality CPG allow to reduce incidence and 

prevalence of PU, also, to diminish costs associated to 

inadequacy of clinical practice [2]. With this study, the 

objective is to analyze if CPG with the best quality 

appraised [3], really, are useful and known by health 

professionals at different clinical settings and if they 

apply such recommendations in clinical practice. 

Methods 

This a pilot survey conducted between health 

profesionals, workng in different health levels across 

Andalucía (Spain), where, as was stated in a previous 

study, exist the best quality appraised CPG in Spain.It 

was elaborated an anonimised and voluntary survey to 

get the data. The survey include: Professional data 

and questions about the recommendations from the 

CPG in two ways (adequacy of intervention to 

measure knowledge and use in clinical practice to 

measure implementation). Questions were randomly 

ordered for recommended and not recommended 

interventions. The survey is used to refine the final 

questionnary and to calculate final sample for the 

whole study. 

Results 

38 questionnaires were collected for pilot purposes. 

95% of the sample was nurses, 75% women with a 

median of 45 years old (min: 35, max: 62). Related to 

years of experience: 65% more than 20 years of 

profession, 13% between 15-20 years and 22% 

between 10-15 years. 55% working at Primary Health 

Care and the others at hospitals. The entire sample 

said that had specific training on PU, only 8% received 

at pre-graduated education and the majority on postgraduate 

courses (of them, 46% on courses with more 

than 20 hours). Only 34% said that had attended 

congresses or meetings related to Pressure ulcers. 

178 

Table 1: Percentage (%) of correct responses. 

Recommendation A I 

Asses periodically the ulcer, at least one/week 94,7 94,7 

Consider the use of opiaceous gels for local pain 34,2 15,8 

Establish a standard schedule to treat pain 73,7 44,7 

Clean with saline, distilled or potable water 92,1 89,5 

Apply a pressure of cleansing that remove … 94,7 92,1 

Use routinely antiseptics to cleansing 65,8 71,1 

Priories cleansing and debridement in wounds … 86,8 86,8 

Select a debridement method based on clinical … 92,1 86,8 

Systematically remove scars located on heels 28,9 26,3 

Use new gloves in each patient… 28,9 31,6 

If multiple ulcer exist, start by less contaminated 94,7 94,7 

Protect lesions from external contamination… 92,1 86,8 

Apply silver dressings in infected ulcers 86,8 73,7 

Treat lesions with signs of critical colonization as 

infected 

89,5 78,9 

Use silver dressings until healing 50,0 55,3 

Topical antibiotics when ulcer not progress … 39,5 31,6 

Apply topical antibiotics with signs of infection 28,9 31,6 

Systemic antibiotics only when dissemination of … 68,4 63,2 

Systemic antibiotics as prophylaxis, systematically 76,3 78,9 

Bacterial cultures when no response to … 71,1 55,3 

Get culture samples by aspiration, mainly 44,7 18,4 

Get culture samples by swabs, mainly 18,4 23,7 

Use gauze dressings to treat 47,4 52,6 

Use moist wound healing dressings to treat 73,7 71,1 

Select the product based on different elements … 94,7 86,8 

Fill in deep, cavitated or tunelized ulcers 86,8 86,8 

Use minimal mechanical load to periwound clea… 76,3 71,1 

In case of apply silver sulfadiazine, each 12 h. 26,3 7,9 

Daily cleansing and debridement when infected 60,5 63,2 

Re-assess each 48-72 h when treating with silver 81,6 81,6 

Register and document wound state 84,2 71,1 

Register and document the treatment used 89,5 63,2 

A: Adequacy. I: Implementation. In yellow, not recommended 

Discussion 

In general, the knowledge for treatment is lower than 

for prevention. Also, there is more variability on 

implementation. Worst results are related to infection. 


Highlights where need to improve information and 

education. 


We appreciate the help of Francisco Pedro Garcia- 

Fernández, Juan F. Jimenez and Manuel Montalbo. 


This study is a piece of work the PhD Thesis of Elvira 

Hernández Martínez-Esparza. 

References 

[1] Zamora J.J; Gerokomos 2006;17(2):100-110 

[2] Pancorbo et al. Gerokomos 2007; 18(4):188-96 

[3] Hernández E,et al.Gerokomos 2012;(1). [Epub ahead of print] 


SPONSORS

EPUAP Exhibitors 

181

Advancis Medical 

Advancis Medical is a UK based company offering a choice of dressings to promote progressive and 

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wound care products and provide solutions to wound management challenges. Our products are split into 

three product categories: 

Activon® medical Manuka honey dressings 

Advancis Medical is the leading medical honey product company and was the first to introduce Manuka 

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are antibacterial, debride and deslough, combat malodour and promote healing, the range now includes a 

new moisturising balm with Activon honey called Actibalm®. 

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This range comprises of Silflex®, Episil®, Episil Absorbent®, Advasil conform®, and Eclypse Adherent®. 

These are atraumatic wound dressings, addressing the issue of pain at dressing change. Wound contact 

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Other Advancis Medical dressing technologies include high exudate management, fluid management, 

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Tel: 01623 751500 

Email: info@advancis.co.uk 

www.advancis.co.uk 

AOTI Inc. 

AOTI is a global manufacturer of innovative solutions for closing Chronic and Acute wounds completely. 

We are dedicated to improving the quality of life for wound care patients while reducing the cost of care for 

providers and budget howlders alike. 

The AOTI product portfolio is spearheaded by our patented non-invasive Topical Wound Oxygen (TWO 2 ) 

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TWO 2 therapy utilizes a unique cyclical pressurized approach that provides both oxygen enrichment 

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stimulating the multiple mechanisms needed to help heal all types of wounds and is especially effective on 

chronic; Venous, Diabetic and Pressure ulcers. 

Address :AOTI, Qualtech House, Parkmore Business Park West, Galway, Ireland 

Tel: +353 91 660310 

Fax +353 1 6849936 

Email: sales@aotinc.net 

Website: http://www.aotinc.net 

183

…with people in mind 

ArjoHuntleigh 

ArjoHuntleigh is a global medical equipment supplier offering our customers a broad range of integrated 

solutions for the care of people with reduced mobility and related conditions. 

At the centre of our activities, we place the residents and patients that are cared for using our equipment. 

We also place great value on the welfare of the healthcare professionals that care for them. Our products, 

programmes and services are designed with these people in mind. 

We offer solutions covering these interrelated areas of care: 

Patient handling – patient lifters, hygiene systems and disinfection 

Therapy and prevention – therapeutic surfaces, DVT prevention, wound healing and therapy 

Medical beds – beds, stretchers and couches for all healthcare applications 

Diagnostics – assessment and monitoring products for clinicians 

Bariatric care – comprehensive solutions for heavier patients 

Our aim is to provide solutions that: 

- improve the quality of life for residents/patients 

- create a better working environment for the nursing staff 

- reduce the cost of care 

To support these aims ArjoHuntleigh focuses on working in partnership with the customer to provide the 

very best clinical outcomes for their residents/patients. The best outcomes are achieved by educating the 

resident/patient and carer, by providing appropriate evidence-based therapeutic devices and by assisting 

the customer in measuring the economic and clinical success of their strategies. 


Care of Sweden develops and markets high-quality mattresses for the health care sector. Our mattresses 

are used for pain management, pressure ulcer prevention and as an aid in the treatment of pressure ulcers. 

Our range offers alternating pressure mattresses, foam mattresses and bedding accessories such as 

pillows and cushions for pressure relief, positioning and stabilization. All products meet health care sector 

requirements for hygiene, quality and safety. 

We have focused on care beds for over 17 years and are now one of the leading Scandinavian companies 

in this field. We carry out extensive testing of our products, and our staff are skilled and knowledgeable. 

We hold courses and lectures for our customers on a variety of topics such as pressure relief, positioning, 

nutrition etc. 

Comfort and safety for the patient are top priority in the development of our mattresses, but it is also 

important to build-in features and capabilities that facilitate the work of staff. We know that if a patient’s 

condition can be improved with the aid of our products, and staff are happy with them, this will benefit 

the entire care chain. For many years we have operated structured environment and quality management 

systems, and are certified to ISO 9001, ISO 13485 and ISO 14001. 

184


European Pressure Ulcer AdvisoryPanel 

“The European Pressure Ulcer Advisory Panel’s objective is to provide the relief of persons suffering from, 

or at risk of, pressure ulcers, in particular through research and the education of the public” 

The EPUAP was formed in 1996 with representatives from thirteen European countries meeting in London. 

An announcement of the foundation of this society was made in the Lancet. 

The success of the EPUAP has been made possible through our members and commercial support from 

our corporate sponsors. 

The EPUAP has had thirteen Annual meetings in the following countries: Belgium, England, Finland, France, 

Hungary, Germany, Italy, Netherlands, Scotland. Its next meeting in September 2011 will be in Oporto, 

Portugal. 

Educational activities include the development of guidelines for Pressure Ulcers on prevention and 

treatment as well as prevalence studies in Belgium, Italy, Portugal and UK and the Pressure Ulcer 

Classification system, PUCLAS 

History in Brief 

About EWMA 

The European Wound Management Association (EWMA) was founded in 1991, and the association works 

to promote the advancement of education and research into native epidemiology, pathology, diagnosis, 

prevention and management of wounds of all aetiologies. 

EWMA is an umbrella organisation linking wound management associations across Europe and a 

multidisciplinary group bringing together individuals and organisations interested in wound management. 

EWMA works to reach its objectives by being an educational resource, organising conferences, contributing 

to international projects related to wound management, actively supporting the implementation of existing 

knowledge within wound management and providing information on all aspects of wound management. 

Objectives 

1. To promote the advancement of education and research into epidemiology, pathology, diagnosis, 

prevention and management of wounds of all aetiologies. 

2. To arrange conferences on aspects of wound management throughout Europe. 

3. To arrange multi-centre, multi-disciplinary training courses on topical aspects of wound healing. 

4. To create a forum for networking for all individuals and organisations interested in wound management 

FLEN PHARMA 

FLEN PHARMA, specialized in developing wound care products, successfully launched a new class in 

wound healing, ENZYME ALGINOGEL®. 

Enzyme alginogels are an exciting new class of wound care product. They combine the benefits of 

hydrogels and alginates in an innovative wound care product, an alginogel, and incorporate unique broad 

spectrum antibacterial enzymes that are effective against a range of clinical isolates, including MRSA. 

185

Interestingly, enzyme alginogels exert their antimicrobial effect without damaging skin cells involved 

in wound healing. Enzyme alginogels address each of the four components that underpin wound bed 

preparation described in the T.I.M.E. framework: Tissue management (T), Inflammation and Infection control 

(I), Moisture balance (M), Epithelial (Edge) advancement (E). Enzyme alginogels keep the wound moist, 

they carry out continuous debridement of the wound, they protect the wound edges and they restore the 

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FLAMINAL® HYDRO and FLAMINAL® FORTE are first-in-class enzyme alginogels. 

HARTMANN 

Our Mission 

We help people to manage health more easily and effectively. Professionally and privately. Through passion, 

partnership and professionalism. 

Our Products and Services 

The HARTMANN GROUP is a company with international operations in the field of medical and healthcare 

products. Our success is based on our longstanding medical expertise and the ongoing dialog with our 

customers. 

The well established HARTMANN brand is the core of our product portfolio, which consists of professional 

system solutions for wound treatment, infection protection and incontinence hygiene. Our medical and 

healthcare lines are complemented by supplementary products and supporting services. Our solutions are 

based on in-depth medical knowledge, longstanding practical experience, and profound understanding of 

our customer’s workflow. The driving force behind our success is our highly motivated and qualified staff, 

following a clear customer focus. As a reliable partner, we are constantly seeking for long term customer 

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Our Goal 

We want to be the preferred solution partner for our customers in medicine and healthcare. We offer 

innovative all-in solutions made up of user-friendly products and fit-to-purpose services. In this way we help 

our customer’s to enhance patients’ well-being, and to improve everyday’s work towards more efficiency 

and cost-effectiveness. With our key product assortments, we build and maintain leading positions in major 

European markets. 

Hill-Rom 

Hill-Rom® is a leading worldwide manufacturer and provider of medical technologies and related services 

for the health care industry, including patient support systems, safe mobility and handling solutions, noninvasive 

therapeutic products for a variety of acute and chronic medical conditions, medical equipment 

rentals, and information technology solutions. Hill-Rom’s comprehensive product and service offerings 

are used by health care providers across the health care continuum and around the world in hospitals, 

extended care facilities and home care settings to enhance the safety and quality of patient care. 

In EMEA Hill-Rom® has locations in France, UK & Ireland, Germany, Italy, Netherlands, Austria, Switzerland, 

Sweden, Spain, Belgium, Emerging Europe, Middle East & Africa. 

Visit Hill-Rom® at EPUAP 2011 and learn more about 

• New pressure ulcers guidelines presented by the European and National Pressure Ulcer Advisory Panels. 

186

• Hill-Rom® I-mmersion Therapy provides effective pressure ulcer prevention and treatment, in line with 

new EPUAP guidelines. 

• Hill-Rom® “Pressure Ulcer Education Module” as part of the new “Hill-Rom® e-learning Safe Skin 

programme”. 

• Hill-Rom P280 Overlay – using alternating low pressure technology. 

• ClinActiv® MCM + MicroClimate Management - Next Generation Low Air Loss Surface System using 

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Hill-Rom®. enhancing outcomes for patients and their caregivers. 

Invacare 

Invacare Corporation is the world’s leading manufacturer and distributor in the $8.0 billion worldwide market 

for medical equipment used in the hospital and home. The company designs, manufactures, and distributes 

an extensive line of health care products for both the acute and non-acute care environment, including the 

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When the company was acquired in December 1979 by Mal Mixon and a small group 

of investors, it had $19.5 million in net sales and a limited product line of standard 

wheelchairs and patient aids. 

Today, Invacare has reached approximately $1.5 billion in net sales and is the leading company 

in each of the following major medical equipment categories: power and manual 

wheelchairs, home care bed systems, posture and pressure care and home oxygen systems. 

The company sells its products to over 25,000 home health care and medical equipment providers, 

distributors, and government locations in the United States, Australia, Canada, Europe, New Zealand, 

and Asia. The company has 5,700 associates and markets its products in 80 countries around the world. 

Kinetic Concepts, Inc (KCI) 

Kinetic Concepts, Inc. (NYSE:KCI) is a leading global medical technology company 

devoted to the discovery, development, manufacture and marketing of innovative, 

high-technology therapies and products for the wound care, tissue regeneration 

and therapeutic support system markets. Headquartered in San Antonio, Texas, 

KCI’s success spans more than three decades and can be traced to a history 

deeply rooted in innovation and a passion for significantly improving the 

healing and the lives of patients around the world. The company employs 

approximately 7,100 people and markets its products in more than 20 countries. 

For more information about KCI and how its products are changing the practice of 

medicine, visit www.KCI1.com. 

For your convenience and future use, these assets are available on KCI Central’s 

“Brand Central”: http://kcicentral.kci.com/brandcentral/Pages/default.aspx 

187

Inspiring confidence 

Mölnlycke Health Care 

Mölnlycke Health Care is a world leading manufacturer of single-use surgical and wound care products and 

services to the professional health care sector. 

The Surgical Division offers safe and efficient surgical solutions through a number of services and a wide 

range of high quality single-use surgical products. 

The Wound Care division offers a wide range of wound care solutions, including products with Safetac® 

technology and the AvanceTM Negative Pressure Wound Therapy System, providing gentle and effective 

wound healing to patients and caregivers. Safetac® is available exclusively on Mepitel®, Mepiform®, 

Mepitac®, and Mepilex®. The Wound Care assortment also has supplementary portfolios in compression, 

dermatology, and orthopaedics and includes market leading brands such as Mepore and Tubifast, as well 

as a product for hard-to-heal wounds, Xelma®, an extracellular matrix protein. 

Mölnlycke Health Care started operations as an independent company in 1998 and was acquired by 

Investor in January 2007. The company has about 6700 employees and manufacturing plants in Belgium, 

the Czech Republic, Finland, France, Malaysia, Thailand, Poland, the UK, and the US. 

Mölnlycke Health Care is committed to best practice in wound care. 

For more UK information Tel: 0800 7311 876 

Info.uk@molnlycke.com 

www.molnlycke.co.uk 

For more global information - Mölnlycke Health Care AB (publ), Box 13080, SE-402 52 Göteborg, Sweden. 

Phone +46 (0) 31 722 30 00 www.molnlycke.com 

Nutricia 

Nutricia is a specialised unit of Danone, with a mission to lead the use of Advanced Medical Nutrition in 

disease management. With its focus on innovative, science-based nutrition delivering proven consumer 

benefits and better clinical outcomes for patients, Nutricia supports Danone’s broader mission to bring 

health through food to the greatest number of people. Nutricia was acquired by Danone in 2007. 

Nutricia is committed to advancing medical nutrition in partnership with customers and other key 

stakeholder groups. Nutricia prides itself on constant innovation whilst, at the same time, developing costeffective 

solutions and promoting the appropriate use of its products. 

Nutricia leads the way in the use of advanced medical nutrition, focused on delivering nutritional solutions 

and services in partnership with healthcare professionals, to improve clinical outcomes and patient 

care. The company’s dedication, expertise, products and services make it uniquely placed to support 

its customers by constantly improving the quality of service offered to patients, whilst providing value for 

money across the whole health care economy. 

Products 

Nutricia offers a wide range of medical nutrition products for: 

• Dietary support: for individuals who need nutritional support as a result of illness, injury or age 

• Nutritional support with added benefits: products linked to specific nutritional deficiencies 

• Disease-targeted nutrition: products focused on the dietary management of specific conditions 

188

Nutricia medical nutrition products (under the Nutricia, SHS and Milupa brands) are now distributed in 

more than 40 countries. They are most commonly available on recommendation or prescription by medical 

professionals and pharmacies, for consumption in hospitals, care homes and in the community. 

PolyMem 

PolyMem is a unique multifunctional dressing specifically designed to reduce a patient’s total wound pain 

experience, while actively encouraging healing. 

In appearance it may look like a foam, but unlike foams it contains added components – each placed in the 

dressing so that they separately and in synergy (very importantly) can facilitate for healing and pain relief in 

a very different way than other wound care dressings. 

PolyMem is available in different configurations including wound fillers and silver dressings. It is produced in 

Chicago (USA) and distributed worldwide by a network of carefully selected regional partners. 

More information on: www.polymem.eu 

Redactron 

Redactron International B.V. is part of the Redactron Group, which was founded in 1987 in the village of 

Eersel, The Netherlands, close to the Belgian border. At that time, the core activity was designing and 

manufacturing of an Air Fluidisation Therapy bed. Over the years Redactron® grew rapidly and now it 

belongs to the leading European companies in the field of patient support systems. 

Nowadays, due to customers requests and new technologies, the air fluidisation bed of Redactron®, named 

Fluidos, is considered as one of the best solutions for patients with severe burns, bed sores, wounds 

from(plastic) surgery or oncology. Various aspects of this bed are patented world-wide and therefore unique 

to Redactron®. 

Over the years product development set forth and resulted in a broad range of patient support systems, 

such as our Low Air Loss therapy systems systems. These systems are portable and can be used to 

replace the conventional hospital mattresses, using the hospital bed as the basis. 

During the past years many of our products have found their way to a variety of customers around the word 

which resulted in solid distribution partnerships in over 50 countries worldwide. 

We are proud to mention that Redactron International B.V. is globally recognised as a company which 

stands for quality products, excellent service and commitment to their customers. 

Sage Products 

Sage’s core belief is prevention—that evidence-based interventions will lead to improved outcomes. This 

belief led to the birth of Interventional Patient Hygiene, a nursing action plan focused on fortifying patients’ 

host defenses with evidence-based care. By promoting a return to the basics of nursing care, our advanced 

patient hygiene products and programs help healthcare facilities improve clinical outcomes by reducing the 

risk of hospital-acquired infection and skin breakdown. By providing simple, low-cost interventions with 

bathing, oral hygiene, incontinence care, pressure relief, and source control, Sage can help you meet 

your patient safety initiatives.” 

189

The Sage name is synonymous with quality. Our customers expect it, and we go out of our way to deliver it. 

This includes not only how we develop our products, but also how we manufacture and release them to our 

customers. Our exhaustive battery of tests and rigorous inspection processes ensure our products exceed 

all quality standards. 

Sage is a respected, market leading manufacturer with more than 500 associates and a portfolio that 

includes health and personal care products for the entire healthcare continuum. Innovation, manufacturing 

expertise, and the most responsive sales and service in the industry are the catalyst for progressive growth 

as we work to provide simple, low-cost interventions that yield extraordinary outcomes. 


Smith & Nephew is a global medical technology business specialising in Orthopaedic Reconstruction, 

Orthopaedic Trauma, Endoscopy and Advanced Wound Management. 

At Smith&Nephew we believe it is time to reduce the human and economic cost of wounds. That’s why we 

develop advanced woundcare products, backed up with thorough education and training, to ensure that the 

most appropriate dressing is used in the most appropriate way, at the most appropriate time. 

Key stages in wound care include the preparation of the wound environment where we have introduced the 

VERSAJET Hydrosurgery system to maximise tissue preservation and provide precise debridement. 

We have also recently introduced PICO, the first pocket-sized, single-use Negative Pressure Wound 

Therapy system. With the RENASYS EZ and RENASYS Go devices we provide efficient delivery of 

Negative Pressure Wound Therapy in a simple, gentle and affordable way. In addition, Smith & Nephew 

have a range of advanced dressings including ALLEVYN Hydrocellular Foam Dressing and ACTICOAT 

antimicrobial barrier dressings with SILCRYSTTM Nanocrystalline… Silver, to support the management of 

the wound environment. 

Smith & Nephew produce many other market-leading advanced wound management dressings to support 

our belief that it is time to reduce the human and economic cost of wounds. Everything we do is aimed 

at helping clinicians and health systems managers realise this objective. We offer a full range of effective 

wound care products, combined with a deep understanding of best-practice techniques for the prevention 

and healing of wounds. Building on this knowledge, we seek imaginative solutions that improve wound 

outcomes for patients and at the same time conserve resources for healthcare systems. 

Wound Management 


Medical Ltd 

101 Hessle Road 

HULL 

HU3 2BN 

Tel: +44 (0) 1482 225181 

Fax: +44 (0) 1482 673106 

Email: wound.conferences@smith-nephew.com 

Trademark of Smith & Nephew 

TMSILCRYST is a Trademark of NUCRYST Pharmaceuticals Corp., under license 

®Nanocrystalline Silver is a patented technology of NUCRYST Pharmaceuticals Corp 

190


Stryker Medical makes hospital beds, surfaces and stretchers for the comfort and security of patients, 

which has made us an undisputed industry leader in patient handling equipment. We’re dedicated to 

improving patient outcomes and reducing the cost of care through products that can help protect against 

patients falls, healthcare-associated infections and pressure ulcers while maintaining caregiver safety via 

advanced ergonomic product designs. Products and features such as the Zoom® Motorized Transport 

found on our beds and stretchers, which virtually eliminates manual pushing, are hallmarks of Stryker’s 

history of innovation. Stryker designs products with the caregiver in mind, because we believe beds, 

surfaces and stretchers need to be more than just pieces of equipment. They need to aid care giving, 

improve safety and enhance healing. More information can be found at http://www.med.stryker.com/. 

Stryker Corporation has acquired privately held Gaymar Industries, a company that specializes in a broad 

range of support surfaces and pressure ulcer management solutions as well as temperature management 

products. Stryker’s Medical division and Gaymar have had a successful 10-year partnership highlighted by 

the introduction of the Isoflex® and XPRT® support surfaces, both of which have been widely adopted in 

the market. 

This acquisition enables Stryker to deliver a more robust, comprehensive solution to our customers in the 

following ways: 

• Enhances the Spectrum of Care that Stryker can provide with a complementary portfolio of diverse 

products across a broader range of clinical applications and price points 

• Advances Our Prevention Philosophy of developing innovative products and services designed to help 

prevent adverse events, which improve clinical and financial outcomes 

• Provides A Stronger Clinical Foundation of education, research and training that supports clinicians in 

their delivery of evidence-based patient care 

XSENSOR Technology Corporation – “Innovators in Pressure Imaging” 

Since 1996 XSENSOR has been providing world-leading pressure imaging technology to hospitals around 

the world. These systems provide vital information to aid health care practitioners to identify excessive 

pressures that can otherwise lead to skin breakdown and pressure ulcers. For individuals at risk, pressure 

imaging provides information for diagnosis, intervention and prevention that can ensure they maintain, or 

quickly return to, their active lifestyle. Clinical practitioners and medical product designers from leading 

organizations such as Mayo Clinic, Mt Sinai Hospital, Walter Reid Military Hospital, Veteran’s Hospitals, Hill- 

Rom, Stryker, KCI, Huntleigh and ROHO use our sensors to understand interface pressures on wheelchair 

cushions and hospital beds. 

XSENSOR’s latest innovation enables nurses to better manage turn intervals by visually identifying 

the location of persisting pressures. Using this information the nurses can ensure that patient turns 

are providing effective relief to sensitive areas. The system can be installed on any hospital bed and 

continuously monitors bed surface pressure. Nurses are presented with easy to interpret bedside visual 

images and an adjustable turn interval timer. 

XSENSOR Technology Corporation 

Phone: 1-866-927-5222 

Website: www.xsensor.com 

E-mail: sales@xsensor.com 

191


Advancis 

AOTI 

ArjoHuntleigh 



EWMA 

FlenPharma 

Hartmann 

Hill-Rom 

Invacare 

KCI 

Molnlycke 

Polymem 

Redactron 

Sage Products 



Wounds UK 

XSENSOR

I-mmersionTM Therapy 

How Hill-Rom’s I-mmersionTM Therapy 

aligns with the EPUAP Guidelines 

Delivering the lowest required surface pressures prevents compression of vulnerable tissues. 

Unique pressure control technologies in all Hill-Rom ® dynamic surfaces ensure adequate 

immersion at all times – without impacting on patient’s mobility, and without creating peak 

pressures in alternating modes. That’s what Hill-Rom’s unique concept of I-mmersionTM Therapy 

takes care of. Together with our advanced micro climate management option, this provides a 

holistic solution which supports you managing your patients’ risk of skin damage. 

Thus, Hill-Rom’s I-mmersionTM Therapy is in alignment with the recommendations expressed 

in the NPUAP/EPUAP Consensus Guidelines published in 2009. 

www.hill-rom.com 

Enhancing Outcomes for Patients and their Caregivers.TM 

Less immersion distributes high pressure on tissue. 

Hill-Rom’s I-mmersionTM Therapy redistributes 

pressure to a larger area, significantly reducing 

compression of vulnerable tissue.





















Trustees 


Dan Bader UK 






Jane Nixon UK 





EPUAP Office 







Tel & Fax +44 (0)1865 791725 

www.epuap.org 


Advancis 

AOTI 

ArjoHuntleigh 



EWMA 

FlenPharma 

Hartmann 

Hill-Rom 

Invacare 

KCI 

Molnlycke 

Polymem 

Redactron 

Sage Products 



Wounds UK 

XSENSOR

FOURTEENTH ANNUAL EUROPEAN PRESSURE ULCER ...

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