Review 3.2 - European Pressure Ulcer Advisory Panel
Review 3.2 - European Pressure Ulcer Advisory Panel
Review 3.2 - European Pressure Ulcer Advisory Panel
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epuap<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Trustees of the <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong><br />
Mission Statement<br />
Executive Committee Members:<br />
Trustees:<br />
The <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong>’s objective is to provide the<br />
relief of persons suffering from, or at risk of pressure ulcers, in particular<br />
through research and the education of the public.<br />
Jeen Haalboom: President (Netherlands)<br />
Gerry Bennett: Recorder (England)<br />
Marco Romanelli: Vice President (Italy)<br />
Keith Harding: (Past President) (Wales)<br />
George Cherry: Secretary/Treasurer (England)<br />
Christine Cherry: Business Administrator (England)<br />
Michael Clark (Wales)<br />
Denis Colin (France)<br />
Christina Lindholm (Sweden)<br />
Joan-Enric Torra i Bou (Spain)<br />
Sue Bale (Wales)<br />
Brigitte Barrois (France)<br />
Andrea Bellingeri (Italy)<br />
Carol Dealey (England)<br />
Tom Defloor (Belgium)<br />
Jacqui Fletcher (England)<br />
Heinz Gerngross (Germany)<br />
Finn Gottrup (Denmark)<br />
Laszlo Gulacsi (Hungary)<br />
Ruud Halfens (Netherlands)<br />
Helvi Hietanen (Finland)<br />
Deborah Hofman (England)<br />
Agnes Jacquerye (Belgium)<br />
Germain De Keyser (Belgium)<br />
Maarten Lubbers (Netherlands)<br />
Sylvie Meaume (France)<br />
Zena Moore (Eire)<br />
Terence Ryan (England)<br />
Anne Witherow (Northern Ireland)<br />
EPUAP Business Office:<br />
Wound Healing Institute<br />
Department of Dermatology<br />
The Churchill Hospital, Old Road<br />
Headington, Oxford, OX3 7LJ, UK<br />
Tel: +44 (0)1865 228264<br />
Fax: +44 (0)1865 228233<br />
E-mail: <strong>European</strong><strong>Pressure</strong><strong>Ulcer</strong>Advis<strong>Panel</strong>@compuserve.com<br />
Volume 3, Number 2, 2001 33
epuap<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
From the President<br />
LETTER FROM THE PRESIDENT<br />
Dr Jeen Haalboom<br />
WITHIN two months the Fifth Conference of EPUAP will be in Le<br />
Mans France and Marco Romanelli will take over as President. The<br />
past two years were characterized by an ever increasing awareness<br />
of the problem of pressure ulcers in most of the <strong>European</strong> countries and the<br />
United States. The conferences we held in Amsterdam and Pisa were successful<br />
and the number of participants increased steadily. In Le Mans we will<br />
have a joint meeting with the French pressure ulcer organisation PERSE and<br />
the number of participants of this joint meeting will exceed 1000. I am sure<br />
that the results will be good, although such large numbers also bear the risk<br />
that personal contacts become more difficult and personal contacts and respect<br />
for each other are mainstays of the EPUAP. I think that especially the<br />
installation of working groups or if you wish task forces was important. Within<br />
relatively short periods of time difficult problems could be tackled and solved<br />
as far as possible. We now have a minimum data set for new studies, the<br />
criteria to which pressure relieving devices should perform have been extensively<br />
dealt with, a <strong>European</strong> prevalence study was developed. In Le Mans<br />
the first results of a group working on risk assessment will be presented and<br />
if I am allowed to lift up a corner of the veils, the results will be at least<br />
staggering. It could well be that the use of any risk assessment tool is not<br />
without risk. Next year we will start a similar group working on wound dressings.<br />
In summary, I think the EPUAP is healthy and bursting with energy and<br />
can be handed over to Marco in good shape. This is due to the hard work of<br />
the EPUAP Trustees and members. Thanks to you all.<br />
Jeen Haalboom<br />
President<br />
34<br />
Volume 3, Number 2, 2001
epuap<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
From the President Elect<br />
LETTER FROM THE PRESIDENT ELECT<br />
Dr Marco Romanelli<br />
IN my first letter as the new President of the <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong><br />
<strong>Advisory</strong> <strong>Panel</strong> I would like to welcome all the members of the society<br />
and also all the delegates attending the Fifth annual meeting of EPUAP<br />
in Le Mans (France). The theme of this year’s meeting ‘Education – Experience<br />
we can share’ is best giving the significance of confrontation in order<br />
to improve our knowledge in managing pressure ulcers. The conference will<br />
be held jointly with the PERSE (Prevention Education Recherche Soins<br />
Escarres), a French wound healing society which is holding its annual meeting<br />
in Le Mans. In the future I would like to encourage similar joint meetings<br />
between <strong>European</strong> and National organizations to avoid multiple conferences<br />
in the same year, and to enable our corporate members to collaborate<br />
more in the society activities. The annual meeting continues to be the<br />
most important event among the activities of EPUAP, but I would also like to<br />
mention the EPUAP <strong>Review</strong>, edited by Michael Clark, and the new EPUAP<br />
web site. These tools are real and attractive ways of communication and I<br />
would like to encourage all members to be part of the contributions needed<br />
to spread our mission on pressure ulcers.<br />
Our society is growing rapidly to achieve the highest level of care standard<br />
in the management of pressure ulcers. To date there has been a high<br />
level of interest in all the activities running inside our group which we hope<br />
will continue during the next few years. The countries represented inside<br />
EPUAP has reached a total number of sixteen, and this is a true manifestation<br />
of the global-<strong>European</strong> involvement of our group. There are many ongoing<br />
activities at this time inside the panel, from the pressure ulcer prevalence<br />
project to the various EPUAP working parties, which are going to update<br />
their studies in Le Mans.<br />
Finally I would like to thank the two past presidents of EPUAP – Prof<br />
Keith Harding and Prof Jeen Haalboom – for the outstanding impetus they<br />
gave to our panel, and to conclude with a statement which I think truly represents<br />
the spirit of our society:<br />
‘A well-conducted medical society may be of the greatest help in<br />
stimulating the practitioner to keep up habits of scientific study.’<br />
Sir William Osler (AEQUANIMITAS, 1903)<br />
Marco Romanelli<br />
President Elect<br />
Volume 3, Number 2, 2001 35
epuap Letter<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
from the Editor<br />
EDITORIAL<br />
Dr Michael Clark<br />
WELCOME to the latest issue of the EPUAP <strong>Review</strong>. By the time you<br />
read this, the 5th <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong> Open<br />
Meeting will be taking place in Le Mans, France. It hardly seems<br />
like twelve months since the EPUAP last met in Pisa – perhaps this is because<br />
the various working groups established over recent Open Meetings have been<br />
keeping many of us busy! In this issue there is an update of some of the<br />
activities of the various groups – perhaps you may be asking how can you get<br />
involved with this work The lead person within each group is identified in<br />
the progress report – contact them to discuss participation. EPUAP would<br />
encourage all members to get involved with the engine of the organisation –<br />
the working groups.<br />
This issue also sees publication of the second part of Dr Gulacsi’s article<br />
on Hungarian quality assurance activities related to pressure ulcers. This is a<br />
timely article for in 2002 the 6th EPUAP Open Meeting will take place in<br />
Budapest. We look forward to welcoming you to this historic city for what<br />
promises to be another high quality conference upon pressure ulcers.<br />
<strong>Pressure</strong> ulcer risk assessment continues to fascinate members of this organisation<br />
– however, there seems to be strong, but divergent, views upon<br />
how this is to be best performed and evaluated. Earlier this year a working<br />
group, led by Tom Defloor (Belgium), began to compile a position statement<br />
to identify just what was EPUAP’s stance upon risk assessment. The<br />
latest version of this statement is published in this issue, while those attending<br />
the Le Mans meeting will have the opportunity to discuss and vote upon<br />
its contents. For those readers who were unable to attend the Le Mans meeting,<br />
do not think that you have no opportunity to contribute to this position<br />
statement. Please forward any comments upon the proposed EPUAP statement<br />
on risk assessment direct to Tom Defloor.<br />
E-mail to: < Tom.Defloor@rug.ac.be><br />
Please do not hesitate to write or call the Business Office at Oxford with<br />
any comments or suggestions for this newsletter. I would also encourage all<br />
members to consider contributing short or long pieces upon any topic related<br />
to pressure ulcers, their prevention and management.<br />
Looking forward to seeing you in Le Mans.<br />
Michael Clark<br />
Editor<br />
36<br />
Volume 3, Number 2, 2001
epuap Prevention<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
and Treatment of <strong>Pressure</strong> <strong>Ulcer</strong>s<br />
EPIDEMIOLOGY, PREVENTION AND TREATMENT OF PRESSURE<br />
ULCERS IN HUNGARIAN HOSPITALS; 1992–1998. PART 2<br />
Dr László Gulácsi, President, Hungarian Wound Healing Society<br />
This article follows from Part 1 of Dr Gulacsi’s report published<br />
in Vol 3 (1) of the EPUAP <strong>Review</strong>. For the convenience<br />
of readers the abstract is reprinted to establish the<br />
context of the article.<br />
Abstract<br />
Objectives: This project held three objectives: (1) Within<br />
patients nursed in acute care hospitals and considered to be<br />
at risk of pressure ulcer (PU) development, what was the baseline<br />
prevalence and incidence of PU. (2) To establish the<br />
current patterns of preventive and treatment interventions<br />
and to investigate the economic burden imposed by the prevention<br />
and treatment of PU within the hospital population.<br />
(3) To improve the quality of both PU prevention and treatment<br />
through the creation, dissemination and implementation<br />
of quality assurance programmes in hospitals.<br />
Design: Data were collected from several sources: (1) Retrospective<br />
PU data gathered during the quality assurance<br />
activities undertaken within 17 (COMAC/QA/HSR Programme)<br />
and 20 (BIOMED/PECO Programme) general<br />
public hospitals between 1992 and 1997 (*). (2) Retrospective<br />
national data describing the prevalence of PU between<br />
1993 and 1998. (3) Retrospective chart review to identify<br />
PU management across 1,200 adult patient records drawn<br />
from 7 hospitals in 1994. (4) Analysis of the national financial<br />
reimbursement of the in-hospital PU cases in 1994. (5)<br />
Prospective active surveillance of 705 adult patients in one<br />
county hospital. (6) Prospective active surveillance of 2,702<br />
adult patients along with the costing of 100 PU patients<br />
(1,350 PU patient-days). (7) Changing PU prevention and<br />
treatment practices through the use of clinical protocols<br />
and guidelines.<br />
Main results: (1) The actual prevalence of pressure ulcers<br />
is estimated to be 16–27 fold higher (3.7%–5.7%) than the<br />
officially published rate (0.18–0.21%) in Hungary. (2) On<br />
average 1.0%–2.5% of the direct costs of PU treatment,<br />
along with the estimated one to five days prolonged hospitalisation<br />
are reimbursed under the current DRG financing<br />
mechanism. (3) As a result of this four-year PU study<br />
and quality assurance intervention, the Hungarian Wound<br />
Healing Society was created in 1997 in order to improve<br />
the quality of patient care through education, training, creating,<br />
disseminating and implementing guidelines and conducting<br />
surveillance in the field of prevention and treatment<br />
of PU.<br />
Conclusion: (1) In order to monitor the true incidence and<br />
prevalence of PU active surveillance has to be established.<br />
(2) Both the prevention and appropriate treatment of pressure<br />
ulcers are in the economic interest of the hospitals<br />
reimbursed under the current DRG mechanism, because<br />
they are not reimbursed for any additional costs incurred<br />
by the PU patients. (3) Appropriate PU surveillance and<br />
documentation, including risk assessment, PU guidelines,<br />
PU costing and disease forecast tools have to be implemented,<br />
in addition disease-specific PU quality of life tools<br />
have to be created, if health care professionals and managers<br />
want opinion leaders, media and financing organisations<br />
to be on their side. (4) Incidence and prevalence of<br />
pressure ulcers can be decreased by appropriate prevention<br />
and treatment.<br />
This study was part of the ‘Concerted Action Programme on<br />
Quality Assurance in <strong>European</strong> Hospitals (COMAC/HSR),<br />
1992–1994, and part of its follow-up programme, the ‘Cooperation<br />
in Science and Technology with Central and Eastern<br />
<strong>European</strong> Countries and with the New Independent States of the<br />
Former Soviet Union, Les Pays d’Europe Centrale et Orientale<br />
(BIOMED/PECO)’ of the the <strong>European</strong> Union, DG XII, between<br />
1994–1997, and This study was performed under the aegis of<br />
the Hungarian Society for Quality Assurance in Health Care<br />
and the Hungarian Wound Healing Society,<br />
The author express special thanks to <strong>European</strong> Union, DG<br />
XII., the Dutch Ministry of Health, Welfare and Sport, the<br />
Hungarian Ministry of Health and Mölnlycke Health Care for<br />
funding the study.<br />
Section numbering follows from Part 1 of this article.<br />
2. The epidemiology, prevention and treatment<br />
of PU in Hungary (continued)<br />
2.4 Phase 4: The reimbursement of hospitals for the care<br />
of patients with PU, 1994<br />
According to the Centre of Healthcare Information, Ministry<br />
of Health, Hungary, 3,710 PU cases were recorded into<br />
medical records and reported to the Centre in 1994. Overall<br />
2.115 million patients episodes were reimbursed in 1994<br />
giving a prevalence of PU cases of 0.18%.<br />
Economic incentives can be important as levers to improve<br />
the quality of care and to decrease unnecessary resource<br />
utilisation. According to the economic analysis of<br />
Phase 4, nationally in 1994, the extra payment approximated<br />
Volume 3, Number 2, 2001 37
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
only between 1–2.5% of the cost of treating PU cases in<br />
hospitals. This result shows that under the DRG system there<br />
are explicit financial incentives for hospitals to perform effective<br />
PU prevention given the high, and largely non-reimbursed<br />
costs of their treatment.<br />
2.5 Phase 5: Active prospective surveillance and risk<br />
assessment of 705 adult patients in one county hospital<br />
during 1995<br />
In 1995, the fate of 705 consecutive patients newly-admitted<br />
to four medical departments (3 active and 1 chronic)<br />
in one large county hospital was followed. At admission their<br />
current vulnerability to PU was documented using the<br />
Norton Scale with one nurse performing all assessments.<br />
The main aim of the study was to investigate any differences<br />
in both the distribution of patient age and PU occurrence<br />
between the acute and chronic care departments and secondarily<br />
to explore the sensitivity and specificity of the<br />
Norton Scale. The recruited subjects’ were largely elderly<br />
with 454 (64.4%) over 60 years old. Only 17 (2.4%) were<br />
under 30 years old with the remaining 234 (3<strong>3.2</strong>%) falling<br />
between 30 and 60 years. The prevalence of PU differed<br />
between the acute (prevalence 2.9%) and chronic (prevalence<br />
19.6%) departments. Overall, 40 patients (5.7%) were<br />
found to present with PU. Subjects were divided into two<br />
groups; Group A (at risk; Norton Score at admission 5–14,<br />
n=189, 16.8%) and Group B (risk free Norton Score of at<br />
least 15 at admission, n=516, 7<strong>3.2</strong>%). In Group B 3 subjects<br />
presented with PU (0.6%). Group A subjects were then<br />
divided into two further groups; Group C (medium risk,<br />
Norton Score at admission 13 or 14, n=52, 7.4%) and Group<br />
D (high risk, Norton Score at admission 12 or less, n=137,<br />
19.4%). Eight patients in Group C (15.4%) and 29 from<br />
Group D (21.2%) presented with PU.<br />
2.6 Phase 6: The cost of PU care based upon the fate of<br />
100 adult in-patients with PU within one county hospital<br />
In 1996, 100 consecutive patients with PU were recruited<br />
across 15 departments of one county general hospital. These<br />
patients either presented with PU at the time of admission<br />
(n=49) or developed their ulcers during their stay (n=51).<br />
The objective of the study was to define, and cost, the care<br />
allocated to patients with, or at risk of, PU. The direct hospital<br />
costs associated with PU prevention and treatment was<br />
collected by micro-costing. Data collection was structured<br />
using a standard instrument that recorded the location and<br />
grade of PU, the patient’s diagnoses, progress and other<br />
clinical circumstances, and finally any medical devices and<br />
nursing procedures allocated to help prevent or treat PU.<br />
All data was completed by a trained, specialist surveillance<br />
nurse. Patients were eligible for recruitment if they had a<br />
PU at the time of admission to hospital or developed a PU<br />
during their stay. All eligible patients had to be aged eighteen<br />
years or older, and admitted to one of the following<br />
specialities – Medical I–III, Surgery, Traumatology, Neurology,<br />
Urology, Oncology, Medical intensive, Surgical intensive,<br />
Central admitting, Chronic medical, Acute Psychiatry,<br />
Chronic Psychiatry and Rehabilitation.<br />
The specialist nurse who completed all patient assessments<br />
and who recorded all drug, device and medical investigation<br />
related to PU prevention and treatment was<br />
trained before the study began. On each participating ward,<br />
the nurse who first identified the presence of a PU informed<br />
the specialist nurse who then completed the resource utilisation<br />
data collection form daily. Upon admission to the<br />
study, a Norton Scale was completed and all body sites were<br />
observed to record the distribution of PU. The Norton Score<br />
was re-calculated upon any significant changes in the patient’s<br />
health status and was also recorded at the time of<br />
discharge from hospital. The specialist nurse was monitored<br />
weekly by the hospital’s nursing director.<br />
2.5.1 PU incidence and prevalence<br />
During the six-month duration of the investigation 2,711<br />
patients were admitted to the participating departments.<br />
Of these, 100 (3.7%) patients had PU with 41 patients presenting<br />
with PU at the time of admission. New PU developed<br />
in 59 subjects admitted to hospital without PU. The<br />
average age of the PU patients was 78.2 years with only 19<br />
aged under seventy. The 100 PU patients presented with<br />
308 co-morbidities (3.08 per patient). Of the 100 patients<br />
with PU, 73 died during their stay in hospital (mean age<br />
77.15 years, mean length of stay (LOS) 37.4 days), and these<br />
patients had an average of 3.18 co-morbidities each. The<br />
remaining 27 patients discharged alive (mean age 68.2 years,<br />
mean LOS 27.5 days) from hospital had fewer co-morbidities<br />
(2.77 per patient). Among the live discharges, 3 patients<br />
experienced complete healing of their PU, the remainder<br />
either showed some or no improvement in the status of<br />
their PU. The average age of the patients who died during<br />
the hospitalisation was 77.15 years, whereas the average age<br />
of those discharged home was 68.2 years. The reduced age<br />
of the patients discharged alive is consistent with other studies.<br />
Michocki et al (1976) reported an approximate fourfold<br />
increase in the probability of death following the development<br />
of a PU among elderly patients. The advanced<br />
age of the patients with PU has also been reported by others.<br />
Walldorf (1986) reported an annual incidence of PU<br />
in hospital of 3% with 96% of all affected patients being<br />
over 65 years, with 36% over 85 years old.<br />
The 100 patients with PU presented with 178 ulcers,<br />
with wounds located at the left and right aspects of each<br />
anatomical location treated as a single PU. The mean size<br />
of the encountered PU was 425.5 square cm, and 74% of<br />
PU classed as Grade 2 or more severe. The majority of PU<br />
(89%) were located caudal to the apex of the iliac prominence.<br />
Overall the total cost of PU treatment among the 100<br />
patients (1,350 PU patient days) was 721,164 HUF, an average<br />
of 534HUF per patient day. While the 100 subjects were<br />
followed for 1,350 patient days, this period excluded a) time<br />
spent in hospital prior to the start of the study and b) time<br />
passed in medical departments other than the participating<br />
specialities. Overall, the 100 PU patients remained in<br />
hospital for 2,287 days at an estimated total cost of 1,072,934<br />
HUF, an increase of 351,770 HUF above the study costing<br />
(based on a total of 1,350 patient days). Table 8.15 illustrates<br />
the size and cost of treatment of the encountered PU<br />
by their severity. Both the mean size and cost per day of<br />
treatment increased as PU became more severe.<br />
The presented costs related only to those directly incurred<br />
in PU prevention and treatment. Additional costs<br />
that may be incurred through any prolongation of the stay<br />
in hospital due to having a PU were not included. Such<br />
38<br />
Volume 3, Number 2, 2001
THE PREVENTION AND TREATMENT OF PRESSURE ULCERS<br />
hidden costs include hotel services and overheads. The estimated<br />
total hospital cost incurred by the 100 PU patients<br />
was 9,703,868 HUF. Presently the extent to which (if any) a<br />
PU extends LOS is unknown. However any extension of<br />
LOS due to pressure ulcers will be costly; for example in<br />
medical department I., a 1% increase in LOS would cost<br />
7,155 HUF.<br />
2.5.2 Estimating the burden and cost of PU at the<br />
national level<br />
In 1996, 2,250,000 people were admitted to hospital in<br />
Hungary. From the results of the current study, the estimated<br />
national prevalence of PU in 1996 was 3.7% (78,000<br />
PU patients). This should be contrasted with the information<br />
available through the Centre for Healthcare Information,<br />
Ministry of Welfare, which reported 4,139 PU patients<br />
in 1996 (national prevalence 0.18%). It is suggested that,<br />
based on the current investigation, a 3% (n=66,700 PU patients)<br />
to 5% (n=113,000 PU patients) can be expected<br />
within Hungarian hospitals.<br />
During 1996 the total reimbursement for PU patients<br />
was 24,844,514 HUF with a PU related DRG creep of only<br />
12,499 HUF. If hospitals had adopted excellent disease classification<br />
coding practices then PU reimbursement would<br />
have only increased by 0.05%. However, the reimbursement<br />
was based upon the data reported to the Centre for Healthcare<br />
Information, an estimated under-reporting of 78,020<br />
cases of PU patients! If hospitals had reported the likely<br />
true number of PU patients the estimated national reimbursement<br />
would have been 522,491,500 HUF. This calculation<br />
assumes that the distribution of PU by main nursing<br />
diagnosis, complication and co-morbidity was constant in<br />
both the reported and estimated populations. When calculating<br />
the cost of PU, the cost elements can be grouped<br />
into two categories: a) Direct costs of PU treatment amounting<br />
to 837,135,650 HUF in 1994 (cost estimated from sample<br />
population data), and b) Indirect costs of hospitalisation<br />
among patients who have PU among other diagnoses.<br />
This estimation clearly depends upon the daily cost of hospital<br />
care within different medical specialities. A one-day<br />
prolongation of LOS due to PU would cost 330,708,150 HUF<br />
(national level, 1996 costs). While there is no information<br />
upon the effect of PU on LOS in Hungary, it is more widely<br />
speculated that PU may extend LOS by five days.<br />
Assume that the prolonged LOS represents:<br />
• One day per PU patient: In this scenario the additional<br />
cost due to the prolonged hospital stay would<br />
be 330,708,150 HUF, and the total costs of all PU<br />
patients would reach 1,167,843,800 HUF. In 1996<br />
the total PU patient reimbursement to hospitals was<br />
24.844.514 HUF suggesting that only 2.5% of the<br />
total cost of caring for PU patients in hospital was<br />
reimbursed by the Health Insurance Fund.<br />
• Five day per PU patient: In this perhaps worst-case<br />
scenario the additional cost due to the prolonged<br />
hospital stay would be 1,653,540,700 HUF, and the<br />
total costs of all PU patients would reach<br />
2,490,676,300 HUF. If this extension of LOS was<br />
accepted then in 1996, only 1% of the total costs of<br />
caring for patients with PU in Hungarian hospitals<br />
was reimbursed by the Health Insurance Fund.<br />
These scenarios both assume that the costs of<br />
hospital care increase in a linear relationship with<br />
the extended LOS.<br />
2.7 Phase 7: Changing PU prevention and treatment<br />
practices through the use of clinical protocols and<br />
guidelines, 1997–1998<br />
One central effect of the overall study was to make health<br />
professionals aware that guidelines and local protocols on<br />
PU prevention and treatment were required to reduce local<br />
practice variations and so improve the quality of care.<br />
Consensus building conferences were organised with the<br />
participation of the hospitals involved in earlier stages of<br />
the study. These events resulted in the creation of Hungarian<br />
guidelines for PU prevention and treatment, based upon<br />
several published international PU guidelines (The Dutch<br />
Consensus Prevention of Bedulcers CBO, 1985; National<br />
<strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong>, 1995; <strong>European</strong> <strong>Pressure</strong><br />
<strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong>, 1998). Draft versions of the PU prevention<br />
and treatment guidelines were provided for comment<br />
through various multidisciplinary meetings involving<br />
nurses, physicians (surgeons, dermatologists, orthopaedists,<br />
intensive care specialists, etc) and the medical and nursing<br />
directors of Hungarian hospitals. The final versions were<br />
published in medical and nursing journals under the aegis<br />
of the Hungarian Wound Healing Society, and the Hungarian<br />
Society for Quality Assurance in Health Care. These<br />
guidelines were generally accepted and widely implemented<br />
across Hungarian hospitals. The Hungarian PU prevention<br />
and treatment guidelines are slightly modified versions of<br />
the <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong>’s PU prevention<br />
(1998) and treatment (1999) guidelines.<br />
3. Discussion and conclusion<br />
The relatively high number of study participants, patients,<br />
professionals and organisations, the high level of willingness<br />
of participation and the high completion rate suggest<br />
that we have now sufficient experience in this area to make<br />
some general conclusions about the current situation and<br />
possible future development of quality assurance in Hungary.<br />
Various quality measures were used in the presented<br />
study associated with structure, process and outcome. Results<br />
show that both structure and process quality improved.<br />
‘intermediate’ outcome was assessed.<br />
This project hold three main goals: a) to develop the<br />
baseline prevalence and incidence of PU in Hungarian hospitals;<br />
b) to establish the current patterns of preventive and<br />
treatment interventions and to investigate the economic<br />
burden imposed by the prevention and treatment of PU;<br />
and c) to improve the quality of both PU prevention and<br />
treatment through the creation, dissemination and implementation<br />
of quality assurance programmes in hospitals.<br />
a) Prevalence and incidence of PU in Hungarian hospitals<br />
The actual prevalence of pressure ulcers according to the<br />
Hungarian study presented in this chapter, is estimated to<br />
be 16–27 fold higher (3.7%–5.7%) than the officially published<br />
rate (0.18–0.21%) by the Centre for Healthcare Information<br />
Ministry of Health in Hungary. Compared with<br />
the international literature on PU prevalence the number<br />
of officially reported PU cases is very low, due to various<br />
Volume 3, Number 2, 2001 39
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
methodological problems including misclassification, incompleteness<br />
and inaccuracy of data collection, unchecked<br />
and mainly self-reported data.<br />
Baseline PU prevalence and incidence data is needed<br />
to properly evaluate the effect of any PU quality assurance<br />
initiative. This requires the availability of trained staff and<br />
a standardised approach to data collection.<br />
b) Current patterns of preventive and treatment<br />
interventions and the economic burden of PU<br />
The second aim of the study was to establish the current<br />
patterns of preventive and treatment interventions and to<br />
investigate the economic burden imposed by the prevention<br />
and treatment of PU. The study showed that there was<br />
a widespread local variation in the current patterns of preventive<br />
and treatment interventions among hospitals and<br />
hospital departments. One consequence of the wide practice<br />
variations was that it was practically impossible to identify<br />
either the results (outcomes) or the costs of different interventions.<br />
It is likely that these differences in nursing practice<br />
may result in differences in the recorded incidence of PU.<br />
The level of knowledge about PU was meagre and pressure<br />
ulcers were seldom viewed as a major problem in the<br />
hospitals. It was frequently unclear who is responsible for<br />
the prevention and treatment of pressure PU in the hospitals,<br />
the quality of PU care was depending in a large extent<br />
on personal initiatives. Practice guidelines and protocols<br />
were not created, disseminated and implemented in the<br />
hospitals. When PU quality assurance programmes began<br />
in Hungary it was widely accepted that PU were almost nonexistent<br />
and that this disease and its economic burden were<br />
not important. In contrast, according to the study presented<br />
in this chapter, the total cost of all PU patients would reach<br />
the level of 1,167–2,490 million HUF annually, which is 0.4–<br />
0.8% of the total health care budget in Hungary. Reliable<br />
PU prevention and treatment cost information can be obtained<br />
through micro-costing. On average 1.0%–2.5% of this<br />
direct costs of PU treatment are reimbursed under the current<br />
DRG financing mechanism. Economic incentives for<br />
creating better quality nursing care are required, while at<br />
present the cost of ‘poor quality care’ are not identifiable.<br />
c) To improve the quality of PU prevention and treatment<br />
Another aim of the study was to improve the quality of both<br />
PU prevention and treatment through the creation, dissemination<br />
and implementation of quality assurance programmes<br />
in hospitals. PU prevention and treatment technologies<br />
were often used inappropriately due to the lack of<br />
practice guidelines. Practice guidelines were required to<br />
decrease the use of ineffective interventions or those with<br />
low cost-effectiveness. One important result of the overall<br />
study was to make health professionals aware that guidelines<br />
and local protocols on PU prevention and treatment<br />
are required to reduce local practice variations and improve<br />
the quality of care. The study resulted in the creation of<br />
Hungarian guideline for PU prevention and treatment,<br />
based upon several published international PU guidelines<br />
such as: The Dutch Consensus Prevention of Bedulcers CBO<br />
(1985), National <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong> (1995) and<br />
the <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong> (1998). This<br />
guideline was widely disseminated and implemented among<br />
Hungarian hospitals. The importance of the continuous<br />
education for all staff involved in PU prevention and treatment<br />
was recognised as well. Training for ‘<strong>Pressure</strong> <strong>Ulcer</strong><br />
Nurses’ was provided and a 350 member large professional<br />
society on PU prevention and treatment was created (Hungarian<br />
Wound Healing Society).<br />
This study provided evidences that the structure and<br />
process quality were improved as a result of this project.<br />
International literature shows that there is a direct link between<br />
structure and process quality and outcome in the field<br />
of PU prevention and treatment. Based on this conclusion<br />
from the literature and some indirect evidences from this<br />
study it seems to be fair to conclude that the outcome of<br />
the PU prevention and treatment was also improved. The<br />
project probably had a Hawthorn effect as well, where the<br />
quality of nursing care was improved purely by the fact the<br />
study was being performed.<br />
3.1 General conclusions and recommendations<br />
Based upon the officially available data by the Centre for<br />
Healthcare Information Ministry of Health in Hungary, on<br />
PU epidemiology in Hungarian hospitals policy and decision<br />
makers might fail to prioritise PU initiatives due to the<br />
apparently low prevalence of the condition. It would appear<br />
that some form of quality assurance activity has to be<br />
in place in order to identify the extent of the burden of any<br />
particular problem area. Overall, this seven-phase study has<br />
demonstrated that effective quality assurance programmes<br />
can be established to tackle PU prevention and treatment.<br />
PU quality assurance programmes along with practice guidelines<br />
can be created through consensus of the relevant<br />
health care professions. The implementation of such programmes<br />
can improve the quality of nursing care even during<br />
a time of transition within the Hungarian health care<br />
system.<br />
This programme provided direct evidence that quality<br />
assurance in the field of prevention and treatment of pressure<br />
ulcers can be implemented and used and the effectiveness<br />
of health care services can be improved in a group<br />
of Hungarian hospitals. In contrast, no empirical data of<br />
good quality have been yielded by the quality assurance studies<br />
presented in this thesis, concerning the question: ‘Do<br />
quality assurance initiatives in Hungary contribute to cost<br />
containment’ Cost containment is a very difficult issue to<br />
be discussed in the Hungarian health care system, due to<br />
the lack of agreement on the meaning of quality and cost,<br />
and because no standardised costing mechanisms are implemented<br />
in the Hungarian hospitals in general, and as<br />
part of quality assurance programmes in particular.<br />
Full References to Parts 1 and 2<br />
Clark M, Watts S (1994) The incidence of pressure ulcers<br />
within a National Health Service Trust hospital during<br />
1991, J.Adv.Nurs. 20,1, 33–6.<br />
Gulácsi L, Jakab Zs, Szloboda I (1993) <strong>Pressure</strong> Scores; A<br />
quality circle investigation, Health Management <strong>Review</strong><br />
31,5, 425–449<br />
Haalboom JRE, van Everdingen JEE, Cullum N (1997)<br />
Incidence, prevalence and classification, in: Parish<br />
LC, Witkowski JA, Crissey JT (1997) The decubitus ulcer<br />
in clinical practice, Springer: 12–23<br />
Jakab Zs, Gulácsi L (1993a) Prevention and Treatment of<br />
Bedulcers, Nursing Care 2,6, 20–28.<br />
40<br />
Volume 3, Number 2, 2001
THE PREVENTION AND TREATMENT OF PRESSURE ULCERS<br />
Jakab Zs, Gulácsi L (1993b) Prevention and Treatment of<br />
Bedulcers in a Group of Hungarian Hospitals, The<br />
Nurse 5,6, 33–59.<br />
Klazinga N (1994) Concerted Action Programme on<br />
Quality Assurance in Hospitals 1990–1993 (COMAC/<br />
HSR/QA), Global Results of the Evaluation, International<br />
Journal in Health Care 6,3, 219–230.<br />
Michocki RJ (1976) The problem of pressure ulcers in a<br />
nursing home population: statistical data, Journal of the<br />
American Geriatric Society 24, 323–326.<br />
National <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong>, (1995), <strong>Pressure</strong><br />
<strong>Ulcer</strong> Healing: Controversy to Consensus, Assessment<br />
methods and Outcomes, Springhouse Corporation.<br />
<strong>Pressure</strong> <strong>Ulcer</strong> Treatment Guidelines (1999) <strong>European</strong><br />
<strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong>, Oxford.<br />
<strong>Pressure</strong> <strong>Ulcer</strong> Prevention Guidelines (1998) <strong>European</strong><br />
<strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong>, Oxford.<br />
The Dutch Consensus Prevention of Bedulcers (1985)<br />
CBO, Utrecht.<br />
Treatment of <strong>Pressure</strong> <strong>Ulcer</strong>s Guideline <strong>Panel</strong>, (1994)<br />
Treatment of pressure ulcers, Rockville: Department of<br />
Health and Human Services, Agency for Health Care<br />
Policy and Research. Clinical Practice Guideline No<br />
15. Publication No. 95–0653.<br />
Visit the new EPUAP website . . .<br />
Volume 3, Number 2, 2001 41
epuap Fifth<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Oxford <strong>European</strong> Wound Healing Summer School, 2000<br />
MEDICAL MANAGEMENT OF PRESSURE ULCERS. PART 2<br />
Dr Mary Bliss, London, adapted from a talk given at the Fifth Oxford <strong>European</strong><br />
Wound Healing Summer School held at St Anne’s College, Oxford, 28 June – 1 July 2000<br />
P RESSURE RELIEF<br />
Grab bars and bed cradles<br />
Two simple measures which help pressure relief and make<br />
patients more comfortable which have largely been forgotten<br />
are the grab bar (or monkey pole) and the bed cradle.<br />
Providing it is carefully positioned above the patient with<br />
the arms at full stretch, the grab bar [Figure 5] is an invaluable<br />
aid to assisting a weak patient to lift himself and relieve<br />
his own pressure areas. Posture in bed, particularly<br />
assisting patients to sit upright when they experience discomfort,<br />
is vitally important. A bed cradle over the legs and<br />
feet removes the weight of the covers from these vulnerable<br />
areas and makes it easier for the patient to move to<br />
relieve pressure pain in the heels.<br />
Figure 1: A grab bar<br />
Repositioning<br />
If no part of the body remains in contact with a resistant<br />
surface for long enough, pressure necrosis will not occur.<br />
But it is important to realise that the length of time which<br />
the tissues can withstand ischaemia and recover may be<br />
much less in an acutely ill patient than in a healthy person.<br />
In a patient with a new spinal cord injury, less than half an<br />
hour of unrelieved pressure may be sufficient to cause a<br />
sore. 24 Thus, if a patient is found to have a red heel (a Grade<br />
1 pressure sore), it should immediately be propped off the<br />
bed surface, e.g., by means of a pillow under the calf.<br />
However, except in intensive care wards or private nursing<br />
homes with 1:1 nurse patient ratios, reliance on regular<br />
repositioning alone as a method of pressure relief is unlikely<br />
to be successful. Individual care should be the aim of<br />
every nurse, but it is impracticable for preventing sores in<br />
the very large number of patients at risk in geriatric and<br />
orthopaedic wards and in the long stay units and nursing<br />
homes. It is labour intensive and is often difficult or impossible<br />
for patients who have to sit up, or who have numerous<br />
catheters or monitoring lines, or unstable fractures. Elderly<br />
patients dislike being turned (or tilted) and usually beg<br />
to be returned to lie on their backs, or move out of position.<br />
The lateral position also causes high pressures over<br />
the greater trochanter. This can cause severe pressure injuries<br />
in sick patients if maintained for an hour or more.<br />
Longer periods may be safe if the patient is also nursed on<br />
an effective pressure relieving mattress. 25<br />
If it is practicable and the patient can tolerate it, repositioning<br />
should be carried out as often as possible whether<br />
he has a pressure relieving support or not. Changes of posture<br />
have many benefits besides relieving pressure, e.g.,<br />
improving lymph flow, 26 helping to prevent joint pain and<br />
contractures, and reducing stasis in the lungs 27 and bladder<br />
28 as well as providing an opportunity for personal care.<br />
<strong>Pressure</strong> relieving supports.<br />
An effective support which prevents prolonged pressure on<br />
the body is an invaluable aid for nursing a sick patient but<br />
it must be able to prevent tissue breakdown very ill as well<br />
as less ill patients. As we have seen, a patient’s condition<br />
can deteriorate rapidly so that there is no place for partially<br />
effective or ‘first line’ supports on which he is at risk of<br />
developing a tissue injury before he can be transferred to a<br />
more effective machine. This approach is like treating a<br />
patient with pneumonia with a cough linctus until he becomes<br />
sufficiently ill to be given an antibiotic.<br />
42<br />
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MEDICAL MANAGEMENT OF PRESSURE ULCERS<br />
Although the idea of giving a powerful support to all<br />
vulnerable patients in the first instance may seem expensive,<br />
the money saved by their more rapid recovery if they<br />
do not develop sores, and the reduced nurse time and cost<br />
of expensive dressings, to say nothing of the patient’s comfort<br />
and the risk of litigation, is likely to outweigh the initial<br />
cost. (The Touch Ross Report in 1993 29 which concluded<br />
that it was cheaper to treat than to prevent sores was based<br />
on calculation of the nurse time required for regular repositioning<br />
of at-risk patients assuming that there were no effective<br />
pressure relieving supports, which was and is untrue.<br />
25,30 Furthermore, pressure relieving machines do not<br />
need to be particularly costly or sophisticated to be effective.<br />
Simple alternating pressure overlays are not much more<br />
expensive than less efficient soft static supports if the latter<br />
are cared for and replaced in accordance with manufactures’<br />
instructions. 30 Finally, a pressure relieving support is<br />
usually only necessary for the first week of a patient’s illness<br />
whist he is most at risk. It can safely be removed once he<br />
has regained his normal level of mobility. Of course, if he<br />
has been allowed to develop a sore during this time, pressure<br />
relief and continued bed rest may be needed for much<br />
longer. Some chronically ill or dying patients may need supports<br />
indefinitely.<br />
If we exclude turning bed which are mainly only useful<br />
for spinal injury patients, pressure relieving supports fall into<br />
two categories: low pressure (soft) supports and alternating<br />
pressure supports. It is important to understand the distinction<br />
because they work on entirely different principles.<br />
Low pressure supports.<br />
Figure 6 shows a diagram of a low pressure support. These<br />
aim to adapt to the body contours so as to distribute the<br />
weight as widely as possible thus preventing high pressures<br />
over bony prominences. The oldest, and one of the most<br />
effective, was the waterbed. 31 Providing the bath was sufficiently<br />
deep and the cover protecting the patient from the<br />
water was sufficiently loose, so that patients were able to<br />
sink into it as if they were floating, pressures were equalised<br />
over the whole of the under surface of the body and they<br />
did not get sores. However, the water bed’s instability made<br />
it very difficult for nursing patients and it has since be superseded<br />
by the low air loss and air fluidised bead bed. 32<br />
These achieve a similar floating action by means of automatically<br />
inflated air sacs of air fluidised beads respectively.<br />
Their advantage over the waterbed is that their floating<br />
action can be controlled or stopped when necessary to<br />
permit nursing procedures. Their main disadvantages are:<br />
the enforced immobility of the patient which reduces reactive<br />
hyperaemia and lymph flow and their size and cost<br />
which prohibit their use for preventing sores in the very<br />
large number of patients at risk in hospitals and the community.<br />
They are mainly used for healing. Low air loss mattress<br />
replacements and overlays which are easier to manage<br />
than flotation beds are available but their effectiveness<br />
has not yet been tested in a clinical trial.<br />
Efforts have been made to find cheaper, more portable<br />
low pressure alternatives to flotation beds, e.g., slit foam,<br />
static air, fibre, gel, but none have shown to be able to prevent<br />
sores in very ill patients. 25,30,34 Although many appear<br />
to provide low interface pressure profiles in healthy volunteers,<br />
35 they are apparently unable to modify pressure over<br />
internal bony prominences sufficiently to prevent deep tissue<br />
distortion and ischaemia in illness. They should therefore<br />
be avoided unless they can be used in conjunction with<br />
regular repositioning.<br />
Alternating pressure mattresses<br />
Alternating pressure mattresses [Figure 7] work on a different<br />
principle to soft supports. They have more in common<br />
with the method of repositioning than that of reducing<br />
of pressure over bony prominences. Instead of preventing<br />
pressure, they aim to continually change the supporting<br />
areas of high pressure on the body so that no part remains<br />
ischaemic long enough to cause cell death. Alternate<br />
air cells inflate and deflate about every 5–10 minutes, thus<br />
constantly changing the points of support, and therefore<br />
pressure [Figure 8] on the body. The mattresses are not<br />
designed to be particularly soft: indeed they must have sufficient<br />
air pressure to lift the patient off the surface of the<br />
underlying bed or mattress so that areas overlying deflated<br />
cells are effectively relieved of pressure. The continual<br />
movement on the body also helps to stimulate reactive hyperaemia<br />
and lymph flow. 5 Simple large celled alternating<br />
pressure overlays (cells 10 cm or more in diameter) have<br />
been shown in randomised controlled trials to prevent pressure<br />
injuries in intensive care patients 3 and in deteriorating<br />
long term elderly patients. 25<br />
Alternating pressure overlays are light and portable and<br />
easy to install for patients at risk in hospital or in the community.<br />
They have a reputation for being uncomfortable,<br />
but this is largely because they are often used inappropriately.<br />
Most patients who are sufficiently alert to complain<br />
about the discomfort of alternating pressure are well enough<br />
not to be at risk of developing a pressure injury. Comfort is<br />
not important in an unconscious patient, and most geriatric<br />
patients, the largest group at risk, have so much sensory<br />
inattention that they are unaware that they are lying on<br />
special supports.<br />
However, some patients with non neurological diseases,<br />
such as cancer or rheumatoid arthritis cannot tolerate the<br />
continual movement of an alternating pressure mattress and<br />
for these a low pressure support such as a low air loss overlay<br />
may be more appropriate. As with other life support<br />
equipment, pressure relieving mattresses can safely be removed<br />
in the majority of patients when they have recov-<br />
Figure 6: Diagram of a low<br />
pressure support.<br />
Volume 3, Number 2, 2001 43
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Figure 7 (left): Diagram of an alternating<br />
pressure air mattress overlay.<br />
Figure 8 (below):<br />
Changes in interface pressure on the sacrum,<br />
hips and heels of a volunteer lying on a large<br />
celled alternating pressure air overlay.<br />
ered from their acute illness. This prevents unnecessary<br />
discomfort and facilitates rehabilitation as well as freeing<br />
the supports for use for other patients.<br />
Deep and double layered alternating pressure mattress<br />
replacements are available and are widely used for intensive<br />
care patients and for healing sores. However, they are<br />
less portable, and except for heavy or bony patients who<br />
are liable to ‘bottom through’ single layer supports, there<br />
is no evidence that they are move effective than good quality<br />
overlays to justify their considerable extra cost.<br />
Policy and education<br />
It is not sufficient simply to have pressure relieving supports<br />
which work. They must be immediately available, in<br />
hospital or in the community, whenever a patient is found<br />
to be at risk, and removed when they are no longer needed.<br />
Like all medical equipment, they must be correctly installed<br />
and continually checked to ensure that they are working<br />
properly. They must be robust enough to withstand constant<br />
use, have warning indicators in the event of failure<br />
and be regularly serviced.<br />
The National Health Service continues to fail on nearly<br />
all of these counts. Training in pressure care is still almost<br />
non existent for doctors and is deteriorating generally for<br />
nurses. In 1989, a British Standard for Alternating <strong>Pressure</strong><br />
Air Mattresses was published which resulted in stronger machines<br />
than had been previously available, but at the same<br />
time servicing was mainly relegated to manufactures. This<br />
has not only put up costs but has had the effect of putting<br />
pressure care largely into the hands of industry.<br />
As the use of support surfaces for preventing and treating<br />
pressure sores has become widespread, competition between<br />
manufactures has intensified. Marketing methods<br />
have become more subtle. Unfortunately, because doctors<br />
and nurses have a poor understanding of pressure injuries,<br />
manufacturers are able to make recommendations which<br />
are seldom challenged. Indeed, many health authorities and<br />
nursing schools have come to rely on manufacturers to provide,<br />
not only the supports, but a complete package of education<br />
and in-service training to go with them. Some firms<br />
have even had the temerity to offer to indemnify users if<br />
patients get patient sores. This means that they hope to<br />
prevent – and heal – sores, but at their own price.<br />
44<br />
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MEDICAL MANAGEMENT OF PRESSURE ULCERS<br />
Healthcare dynamics are complicated. Although we like<br />
to think that doctors and nurses and manufacturers are primarily<br />
interested in preventing pressure sores, this is not<br />
necessarily so. The challenges and status of healing sores<br />
may be more rewarding. Industry exploits this. It wants to<br />
help nurses and patients but also to make money. The latter<br />
is essential because otherwise businesses will fail. Thus<br />
manufacturers are not greatly interested in preventing sores.<br />
If patients develop sores on a ‘first line’ low pressure supports<br />
they can then sell the service more profitable low air<br />
loss or alternating pressure mattresses to heal them. They<br />
can also recommend that all very ill patients are nursed on<br />
‘second line’ mattress replacements or even on flotation<br />
beds from the start. As rental in the UK of an air fluidised<br />
bed is about £70 per day, compared with a purchase price<br />
of about £700 for an alternating pressure overlay which is<br />
likely to last for about five years, this can make a big difference<br />
to hospital budgets. Rental and purchase of pressure<br />
relieving equipment is now one of the three top items on<br />
the NHS purchasing bill, along with pacemakers and equipment<br />
for diabetics. The presence of sores also gives industry<br />
the opportunity for developing and marketing a ‘bewildering<br />
array of complex wound interventions’. 36<br />
Sadly, the NHS Centre for <strong>Review</strong>s and Dissemination<br />
did not help this situation when it published its Effective<br />
Healthcare Bulletin in 1996 37 in which it concluded that<br />
none of the clinical trials which had been carried out up<br />
until that time had been sufficiently rigorously controlled<br />
to prove that any system of pressure relief was better than<br />
another. This has not only discouraged further research but<br />
has given manufacturers carte blanche to say what they like<br />
about their products because there is no accepted evidence<br />
to the contrary. Worst of all, it has prevented nurses who<br />
have found particular supports useful in practice, from incorporating<br />
this knowledge into training schemes because<br />
‘there is no evidence’. As a result, despite a plethora of<br />
‘guidelines’, training in pressure care in the nursing profession<br />
is more confused than it has ever been. Few manuals<br />
contain any practical instructions about how to relieve<br />
pressure in a vulnerable patient, and least of all about the<br />
continually changing equipment which all nurses are expected<br />
to use.<br />
Both the medical and nursing professions need to return<br />
to the patient. For patients, the primary need is to prevent<br />
illness, or, if they are ill, to recover as quickly and safely<br />
as possible. Every clinical observation and every strategy<br />
must be harnessed to achieve this. Effective antibiotics are<br />
prescribed by doctors as first line treatment for sick patients<br />
(has penicillin ever been tested in a randomised controlled<br />
trial) so why not effective pressure relieving supports<br />
References<br />
1–23 can be found with the first part of this essay, on page<br />
21 of the EPUAP <strong>Review</strong>, Volume 3/1.<br />
24. Gunnewicht BR. Management of pressure sores in a<br />
spinal injuries unit. Journal of Wound Care 1996; 5(1):<br />
36–39.<br />
25. Bliss MR. Preventing pressure sores in elderly patients:<br />
a comparison of seven mattress overlays. Age<br />
and Ageing 1995; 24: 297–302.<br />
26. Ryan TJ. Cellular responses to tissue distortion. In:<br />
Bader DL (ed). <strong>Pressure</strong> sores. Clinical practice and<br />
scientific approach. Basingstoke: Macmillan Press 1990:<br />
141–152.<br />
27. Summer WR, Curry P, Haponik EF, Nelson S, Elston<br />
R. Continuous mechanical turning of intensive care<br />
patients shortens length of stay in diagnostic related<br />
groups. Journal of Critical Care 1989; 4: 45–53.<br />
28. Guttman L. The prevention and treatment of pressure<br />
sores. In: Kenedi RM, Cowden JM, Scales JT<br />
(eds). Bedsore biomechanics. London: Macmillan Press<br />
1976: 153–159.<br />
29. Touch Ross and Company: The costs of pressure sores.<br />
Report to the Department of Health December 1993.<br />
30. Gebhardt KS, Bliss MR, Winwright PL, Thomas JM.<br />
<strong>Pressure</strong> relieving supports in an ICU. Journal of<br />
Wound Care 1996; 5(3) :116–121.<br />
31. Editorial: Hydrostatic beds for invalids. London<br />
Medical Gazette 1832: 10: 712–714.<br />
32. Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical<br />
utility and cost effectiveness of an air suspension bed<br />
in the prevention of pressure sores. Journal of the<br />
American Medical Association 1993; 269: 1139–1143.<br />
33. Allman RM, Walker JM, Hart MK et al. Air fluidised<br />
beds or conventional therapy for pressure sores – a<br />
randomised controlled trial. Annals of Internal Medicine<br />
1987; 107: 641– 648.<br />
34. Hofman A, Greelkerken RH, Hamming JJ et al.<br />
<strong>Pressure</strong> sores and pressure decreasing mattresses:<br />
controlled clinical trial. Lancet 1994; 343: 568–571.<br />
35. Rondorf-Klym LA M, Langemo D. Relationship<br />
between body weight, body position, support surface<br />
and tissue interface pressure at the sacrum. Decubitus<br />
1993; 6(1): 22–30.<br />
36. Harding K. Challenges for skin and wound care in the<br />
New Century. Advances in Skin and Wound Care 2000;<br />
13(5): 212–215.<br />
37. Cullum N, Deeks L, Fletcher A, Long A, Mouneimne<br />
H, Sheldon T, Song F. The prevention and treatment<br />
of pressure sores. Effective Health Care 1995; 2(1)<br />
(Churchill Livingstone).<br />
Volume 3, Number 2, 2001 45
epuap <strong>Pressure</strong><br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
<strong>Ulcer</strong> Risk Assessment<br />
A DRAFT EPUAP POSITION STATEMENT<br />
On Risk Assessment in <strong>Pressure</strong> <strong>Ulcer</strong> Prevention and Management<br />
THE following text outlines a draft EPUAP position<br />
statement upon pressure ulcer risk assessment. This<br />
document will be discussed in depth during the Le<br />
Mans Open Meeting of the EPUAP. However, we would urge<br />
all members to consider this document and to e-mail suggestions<br />
or amendments to Tom Defloor at:<br />
Tom.Defloor@rug.ac.be<br />
The position statement is intended to reflect the stateof-the-art<br />
in risk assessment based upon the best available<br />
evidence. The text is accompanied by a supporting reference<br />
list outlining the breadth of material considered by<br />
the Working Group when developing the draft statement.<br />
<strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong><br />
Draft Position Statement on Risk Assessment in<br />
<strong>Pressure</strong> <strong>Ulcer</strong> Prevention and Management<br />
Authors:<br />
Defloor T, Schoonhoven L, Clark M, Halfens R, Nixon J.<br />
Comments received from:<br />
Dealey C, Jacquerye A, MacLeod A, Scott E, Torra i Bou<br />
JE, Weststrate J.<br />
THIS document sets out a draft statement and rationale<br />
for the <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong><br />
<strong>Panel</strong> upon the issue of risk assessment in pressure<br />
ulcer prevention and management. This draft will change<br />
upon receipt of comments from EPUAP members, and<br />
should not be considered as the definitive document. The<br />
purpose of this statement is to guide clinicians towards the<br />
most appropriate course of action when considering the<br />
implementation of risk assessment. The statement is set out<br />
in two sections; firstly a series of propositions are offered,<br />
while in the second section the evidence base supporting<br />
each proposition is explored.<br />
Actual risk<br />
PROPOSITION 1<br />
The purpose of risk assessment is to identify those patients<br />
who are in need of measures to prevent pressure ulcers.<br />
PROPOSITION 2<br />
Patients with an actual risk of developing pressure ulcers<br />
and/or with existing non-blanchable erythema or pressure<br />
ulcer lesions (grade 2 and higher) should receive appropriate<br />
preventive measures.<br />
Risk assessment scales<br />
PROPOSITION 3<br />
Current risk assessment scales often over and under represent<br />
the risk of pressure ulcer development.<br />
PROPOSITION 4<br />
It is not possible to recommend a specific risk assessment<br />
scale.<br />
Elements of Risk Analysis<br />
PROPOSITION 5<br />
While the origin of pressure ulcers is undoubtedly multifactorial,<br />
reductions in activity and/or mobility are observable<br />
factors that have been consistently shown to increase<br />
the risk of pressure ulcer development. Patients with existing<br />
pressure ulcers (non-blanchable erythema or grade 2<br />
and higher) have a higher risk of developing new pressure<br />
ulcers on other anatomical sites. The importance of other<br />
potential risk factors is less clear.<br />
PROPOSITION 6<br />
Acknowledging the limitations in both the reliability and<br />
validity of risk assessment scales there are indications that<br />
the risk of pressure ulcer development may be best assessed<br />
by means of a risk assessment scale in combination with<br />
assessment of skin and the clinical judgement of the nursing<br />
staff.<br />
PROPOSITION 7<br />
Assessment of risk should be a continuous process where<br />
changes in patient condition and/or skin appearance<br />
prompt formal re-assessment using a risk assessment tool<br />
and clinical judgement. In addition a formal risk assessment<br />
should take place on a regular basis, the frequency depending<br />
on the patient population.<br />
Background to the Propositions<br />
<strong>Pressure</strong> ulcer prevention is typically considered to begin<br />
with the formal, or informal, assessment that an individual<br />
client may be vulnerable to developing these wounds, these<br />
processes are described as ‘Risk assessment’. The presumed<br />
value of risk assessment lies in reducing the probability that<br />
the client will develop a pressure ulcer following the implementation<br />
of preventive measures upon the perception that<br />
a ‘risk’ exists.<br />
Preventive measures should (at least) be taken immediately<br />
if an non-blanchable erythema (grade 1 pressure ulcer)<br />
and/or pressure ulcers develop. Non-blanchable erythema<br />
is reversible in the majority of cases if preventive<br />
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PRESSURE ULCER RISK ASSESSMENT<br />
measures are implemented in good time (135). If these<br />
measures are not taken, non-blanchable erythema may develop<br />
into a more serious injury in many cases (7, 74).<br />
Patients with existing pressure ulcers have a higher risk of<br />
developing new pressure ulcers on other sites (65; 189).<br />
Therefore, when a pressure ulcer has developed, immediate<br />
preventive measures should be taken to prevent pressure<br />
ulcers on other sites of the body.<br />
A variety of risk assessment scales are used (1, 13, 17,<br />
21, 28, 36, 51, 53, 55, 61, 75, 112, 184, 80, 99, 124, 132, 206,<br />
217). Frequently used scales are the Norton scale (155),<br />
the Braden scale (155) and the Waterlow scale (206). Most<br />
scales have not been scientifically studied for reliability and<br />
validity (65, 147). The research available is aimed at sensitivity<br />
and specificity of the risk assessment scales. However,<br />
sensitivity and specificity are influenced by the preventive<br />
measures taken, the length of the observation period and<br />
the nature of the group of people studied. Therefore, the<br />
sensitivity and specificity figures are not straightforward<br />
measures that can be used to judge the performance of the<br />
risk assessment scales (65, 111, 69, 70).<br />
Use of preventive measures in patients at risk has the<br />
effect of lowering the risk of the individual. Vice versa, stopping<br />
preventive measures in patients at risk has the effect<br />
of increasing the risk of the individual.<br />
The risk assessment scales include some items for which<br />
the link to pressure ulcers has not been established in longitudinal<br />
research. The individual numeric value, which is<br />
given to these items, has also not been validated (183). In<br />
addition the items in many risk assessment scales are not or<br />
only vaguely described and to be completed by the nursing<br />
staff subjectively.<br />
Despite the limitations the use of risk assessment scales<br />
may lead to the systematic assessment of the risk of pressure<br />
ulcers (98, 202). However, it is not possible to recommend<br />
any one risk assessment tool over its alternatives (180,<br />
181).<br />
Informal assessment of risk also occurs in clinical practice;<br />
this reflects the clinical judgement, primarily of nursing<br />
staff. There is a lack of evidence to show whether the<br />
exercise of clinical judgement or use of a risk assessment<br />
tool provides the most accurate prediction of vulnerability<br />
to pressure ulcer development. (202, 118).<br />
There is limited evidence to suggest that the use of a<br />
risk assessment scale may help develop the clinical decisionmaking<br />
skills in the nursing staff (98, 202). The use of a<br />
risk assessment scale may not be the only criterion used<br />
when making a decision on taking preventive measures. It<br />
is recommended to use the risk assessment scale as an aid<br />
in combination with the clinical judgement of the nursing<br />
staff. The total score cannot be a criterion for taking preventive<br />
measures, if the nursing staff judges differently. The<br />
score is only indicative for the degree of risk and not for<br />
the preventive methods to be used.<br />
<strong>Pressure</strong> ulcers are caused by an oxygen deficit due to<br />
tissue-deformation. The tissue-deformation is caused by<br />
pressure and shearing forces. Immobility and reduced activity<br />
are observable parameters of pressure and shearing<br />
forces (155, 65). For this reason preventive measures must<br />
be taken to prevent pressure ulcers in patients for whom it<br />
is difficult to change position independently and are bed<br />
or chairbound (155, 65).<br />
Primarily these interventions are likely to be directed<br />
towards the management of tissue deformation resulting<br />
from localised applied forces.<br />
The frequency of risk assessment requires consideration.<br />
A clientís condition will not remain static and the frequency<br />
of assessment (both formal and informal) will be driven by<br />
the nature of the client population. For this reason it is<br />
necessary to assess the changes in health status of the patient<br />
daily. The frequency for formal risk analysis (i.e. using<br />
a risk assessment scale in combination with clinical judgement)<br />
depends on the population. Times when a formal<br />
risk analysis should definitely take place: if a patient becomes<br />
bed or chairbound, if the patientís condition seriously<br />
deteriorates or improves, if there is a sudden change<br />
in punctuations.<br />
Risk assessment may be inappropriate where specific circumstances<br />
exist. For example in Intensive Care preventive<br />
measures are probably a universal requirement given the<br />
nature of the client population. Other specific circumstances<br />
can be identified where preventive measures may<br />
not require formal risk assessment – where a client presents<br />
with non-blanchable erythema (grade 1 pressure ulcer) or<br />
any other grade of pressure ulcers then preventive measures<br />
are required. Non-blanchable erythema is likely to be<br />
reversible if preventive measures are implemented in a<br />
timely manner. Furthermore clients with existing pressure<br />
ulcers have a higher risk of developing new pressure ulcers<br />
at other body locations. Therefore, where a pressure ulcer<br />
has developed, immediate preventive measures should be<br />
taken to prevent further pressure ulcer developing upon<br />
other parts of the body.<br />
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202. VandenBosch, T., Montoye, C., Satwicz, M., Durkee, L. K.<br />
and Boylan, L. B. (1996). Predictive validity of the Braden<br />
Scale and nurse perception in identifying pressure ulcer<br />
risk. Applied Nursing Research, 9, 80–86.<br />
203. Vernon, M. J. (1996). The Norton score and pressure<br />
prevention. Critique II. J. of Wound Care, 5, 96–97.<br />
204. Wai-Han, C., Kit-Wai, C., French, P., Yim-Cheung, L. and<br />
Lai-Kwan, T. (1997). Which pressure sore risk calculator A<br />
study of the effectiveness of the Norton scale in Hong Kong.<br />
Int. J. Nursing Studies, 34, 165–169.<br />
205. Wardman, C. (1991). Norton v. Waterlow. Nursing Times,<br />
87(13), 74, 76, 78–74, 76, 78.<br />
206. Waterlow, J. (1985). <strong>Pressure</strong> sores: a risk assessment card.<br />
Nursing Times, 81, 49–55.<br />
207. Waterlow, J. (1996b). <strong>Pressure</strong> sore assessments. Nursing<br />
Times, 92, 53–6,58.<br />
208. Waterlow, J. (1996a). The Norton score and pressure<br />
prevention. Critique I. J. of Wound Care, 5, 93–96.<br />
209. Waterlow, J. (1987). Calculating the risk… preventing<br />
pressure sores. Nursing Times, 1987. Sep.30 Oct.6; 83.(39.):<br />
Tissue Viability: 58., 60.(14.ref.), 83, Tissue.<br />
210. Waterlow, J. (1996). Operating table. The root cause of<br />
many pressure sores Br. J. Theatre Nurs, 6, 19–21.<br />
211. Waterlow, J. (1998). Wound care. The history and use of<br />
the Waterlow card. Nursing Times, 1998. Feb 18 24; 94.(7.):<br />
61., 63 4., 66.7.(11.ref.), 94, 61,63.<br />
212. Watkinson, C. (1996). Inter-rater reliability of riskassessment<br />
scales. Prof. Nurse, 11, 751–2,755–6.<br />
213. Watkinson, C. (1997). Risk assessment tools [letter]. Prof.<br />
Nurse, 12, 600.<br />
214. West, B. J., Brockman, S. J. and Scott, A. (1991). Action<br />
research and standards of care. The prevention and<br />
treatment of pressure sores in elderly patients. Health Bull.<br />
(Edin.), 49, 356–361.<br />
215. Weststrate, J. T. and Bruining, H. A. (1996). <strong>Pressure</strong> sores<br />
in an intensive care unit and related variables: a descriptive<br />
study. Intensive Crit. Care Nurs., 12, 280–284.<br />
216. Weststrate, J. T., Hop, W. C., Aalbers, A. G., Vreeling, A. W.<br />
and Bruining, H. A. (1998). The clinical relevance of the<br />
Waterlow pressure sore risk scale in the ICU. Intensive Care<br />
Med., 24, 815–820.<br />
217. Williams, C. (1991). Journal of wound care nursing.<br />
Comparing Norton and Medley. Nursing Times, 87, 66, 68.<br />
218. Willson, D., Ashton, C., Wingate, N., Goff, C., Horn, S.,<br />
Davies, M. and Buxton, R. (1995). Computerized support of<br />
pressure ulcer prevention and treatment protocols. Proc.<br />
Annu. Symp. Comput. Appl. Med. Care 646–650.<br />
219. Wolfswinkel-de Jong, C. J. A. & Halfens, R. J. G. (1995).<br />
Decubituspreventie : het effect van een scorelijst.<br />
Verpleegkunde, 10, 29–36.<br />
220. Xakellis, G. C., Frantz, R. A., Arteaga, M., Nguyen, M., &<br />
Lewis, A. (1992). A comparison of patient risk for pressure<br />
ulcer development with nursing use of preventive interventions.<br />
J. Am. Geriatr. Soc., 40, 1250–1254.<br />
221. Zulkowski, K. (1998). Construct validity of Minimum Data<br />
Set items within the context of the Braden Conceptual<br />
Schema. Ostomy Wound Manage, 44, 36–4, 46.<br />
52<br />
Volume 3, Number 2, 2001
epuap News<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
from the Working Groups<br />
EPUAP WORKING GROUPS AND PEPUS STUDY<br />
Progress Reports<br />
OVER the past few months, three EPUAP Working<br />
Groups have been particularly active. In April,<br />
members met in the Netherlands to progress discussions<br />
upon contact pressure measurements upon beds<br />
and mattresses. This group, led by Dr Alastair McLeod (England,<br />
e-mail: alastair.mcleod@ hunhcare.co.uk), will report<br />
their progress during the Le Mans Open Meeting with a<br />
position paper published in the EPUAP <strong>Review</strong> next year.<br />
The last meeting of the working group (Photograph 1) was<br />
attended by Dr Steve Reger (USA) reinforcing that the activities<br />
of the EPUAP are well respected world-wide.<br />
One major action for the EPUAP in 2001 has been the<br />
implementation of a <strong>European</strong>-wide pressure ulcer prevalence<br />
survey. In May 2001, National Co-ordinators from the<br />
participating countries met in the Netherlands (Photograph<br />
2) to receive their training for the study. At this time the<br />
survey date has been set for 8 November 2001 when a minimum<br />
of 700 adult hospital in-patients per country will be<br />
surveyed. This pilot study is intended to explore the robustness<br />
of the data collection instrument and the training<br />
materials across different countries. Full details of the survey<br />
methodology will be presented at Le Mans with the survey<br />
results issued in the EPUAP <strong>Review</strong> early in 2002. To<br />
participate in this exciting venture please contact the Working<br />
Group chair (Gerrie Bours) at the following e-mail address:<br />
G.Bours@ZW.UNIMAAS.NL.<br />
As reported elsewhere in this issue, the most recently<br />
formed Working Group has prepared a position statement<br />
on pressure ulcer risk assessment on behalf of the EPUAP.<br />
This group, led by Tom Defloor (Belgium, e-mail:<br />
Tom.Defloor@rug.ac.be), met in Belgium in June (Photograph<br />
3) to agree word-by-word upon the text of the draft<br />
position statement! This document will be presented, and<br />
voted upon, during the Le Mans Open Meeting.<br />
While not constituted as an EPUAP Working Group, the<br />
Pan-<strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> Study (PEPUS) has been hard<br />
at work arranging ethical approval for the project within<br />
the participating countries.<br />
The primary objective of the PEPUS study is to record<br />
the care currently received by patients across 12 <strong>European</strong><br />
Photograph 1<br />
Volume 3, Number 2, 2001 53
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Photograph 2<br />
Photograph 3<br />
countries where these individuals have been admitted to<br />
hospital for surgery following sustaining a hip fracture. The<br />
secondary goal is to seek to identify consistent risk factors<br />
for pressure ulcer development within this patient population.<br />
If common risk factors can be identified then a future<br />
development of the project may be to test a pressure ulcer<br />
risk assessment instrument specific to patients with fractured<br />
hips. The project is co-ordinated by Christina Lindholm<br />
(Sweden) with national co-ordinators within each of the<br />
participating countries.<br />
54<br />
Volume 3, Number 2, 2001
epuap <strong>Pressure</strong><br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Mattress Overlays<br />
NATIONAL SPECIFICATION FOR ALTERNATING PRESSURE<br />
MATTRESS OVERLAYS<br />
NHS Purchasing and Supply Agency<br />
OVER the life of the EPUAP to date, there has often<br />
been debate regarding the need for formal<br />
specifications of pressure redistributing beds, mattresses<br />
and cushions. Within the UK the National Health<br />
Service Purchasing and Supply Agency recently released<br />
such a draft specification covering alternating pressure<br />
mattress overlays. This draft specification is printed in full<br />
in this issue of the EPUAP by kind permission of the NHS<br />
Purchasing and Supply Agency. We hope that the publication<br />
of this specification will generate debate among EPUAP<br />
members – are there other specifications currently in development<br />
(or indeed been finalised!) within other countries<br />
If other specifications exist, we would be delighted to<br />
reprint them in the EPUAP <strong>Review</strong> to allow members to<br />
see the current state of play of specification development<br />
across Europe. Members may wish to consider whether we<br />
as a <strong>European</strong> organisation should be seeking to work with<br />
public bodies to develop such specifications Please send<br />
any specific comments upon the UK draft specification direct<br />
to Nikki Aylward (nikki.aylward@doh.gsi.gov.uk).<br />
SPECIFICATION FOR ALTERNATING<br />
PRESSURE AIR MATTRESS OVERLAY FOR<br />
ADULTS<br />
1. Construction<br />
a) Mattress overlay<br />
(i)<br />
Constructed in one layer of either replaceable cells<br />
individually attached to manifold or of two or more<br />
sheets welded together, whichever more economical<br />
overall. 16–19 cells, all alternating. All connections<br />
to be secured (e.g., glued over barbed connector or<br />
clipped over groove, not push-fit) to resist pull force<br />
of 25kg.<br />
(ii) Construction will allow profiling, without any loss of<br />
function.<br />
(iii) Fully enclosed within waterproof cover zipped at<br />
least on two short and one long sides. Zip protected<br />
with skirt. Cover will not hammock between alternating<br />
cells.<br />
(iv) Dimensions inflated: length and width to comply<br />
with specifications for hospital bed dimensions as<br />
specified by National and International regulations<br />
(v)<br />
when supplied for hospital use; otherwise a range of<br />
sizes suitable for domestic use should be provided;<br />
depth 13–15cm.<br />
Rapid deflation for CPR by disconnection of air<br />
tubes from the mattress at the normal point of<br />
attachment deflation for the thorax should be<br />
achieved within 15 seconds for an individual of 70kg<br />
and normal BMI.<br />
(vi) Attached to underlying mattress by head and foot<br />
end flaps which are secured in place by continuous<br />
elasticised bands miming from the long edges of the<br />
mattress under the underlying mattress.<br />
(see Figure 1)<br />
(vii) Maximum weight not to exceed 15kg<br />
b) Connecting tubes<br />
(i)<br />
Tubing of a durable, kink resistant material (e.g.,<br />
EPDM rubber), at least 60cm and not more than<br />
100cm long.<br />
(ii) Attached to motor with high quality positive mechanical<br />
latch connectors (e.g., plastic Colder<br />
connector at least 1.9cm external diameter or<br />
equivalent). Plastic to plastic or metal to metal but<br />
not mixture. Connectors on the pump unit to be<br />
attached and secured (e.g., glued over barbed<br />
connector, clipped over groove or screwed in, not<br />
push-fit) to resist pull force of 25kg. Attached to<br />
pump unit with adequate separation between<br />
connectors to allow easy connection and disconnection<br />
of mattress.<br />
(iii) Tubing permanently attached to mattress and<br />
secured (e.g., glued over barbed connector or<br />
clipped over groove, not push-fit) to resist pull force<br />
of 25kg.<br />
c) Pump unit<br />
(i)<br />
Dimensions: not more than 13cm deep, 33cm wide.<br />
Height should not impede use of bed stripper when<br />
pump unit is suspended from foot board of bed.<br />
(ii) Box constructed of impact resistant, smooth, easily<br />
decontaminated material. Recessed control panel to<br />
protect from accidental damage. Rounded internal<br />
corners to facilitate cleaning.<br />
(iii) Attachment to foot end of bed by hook built into<br />
Volume 3, Number 2, 2001 55
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Figure 1 (left):<br />
Attachment of mattress overlay to<br />
underlying mattress.<br />
Figure 2 (below):<br />
Side view of pump unit to show<br />
hook for hanging from bed end.<br />
box top (see figure 2). Alternative option of placing<br />
on the floor in an upright position.<br />
(iv) Controls:<br />
on/off switch back lit to show when power is on,<br />
override for ‘power off alarm.<br />
(v)<br />
Alarms audible and visual. Different lights for each<br />
alarm preferred:<br />
power off,<br />
‘patient grounding (mattress not supporting<br />
patient above base)’,<br />
Automatic reset of alarms in event of power failure<br />
or power surge.<br />
(vi) Electrical connection: wire at least 510cm long,<br />
permanently attached to motor, with live ends<br />
insulated with plastic jackets (which insulate the wire<br />
ends if pulled out of the motor casing).<br />
(vii) Maximum noise output not to exceed 40 dB (A)<br />
when measured 100cm from pump unit. (viii)<br />
Maximum weight not to exceed 8kg.<br />
2. Performance<br />
a) Mode of action<br />
The overlay will operate by cyclically changing the<br />
air pressure in individual cells from a minimum<br />
between 0–5 mmHg and a maximum between 80–<br />
120 mmHg. The time for individual cells to complete<br />
one inflation and deflation cycle should be 8–<br />
15 minutes.<br />
b) Lifting capacity<br />
The overlay will lift a 100kg patient of normal BMI<br />
at least 2 cm above an underlying solid surface and<br />
maintain function.<br />
c) Mechanical reliability<br />
Not more than one breakdown caused by manufacturing/design<br />
faults per year per mattress is permitted<br />
in the first year of usage (excludes user error/<br />
accidental damage).<br />
d) Transport mode<br />
Activated by disconnection from power supply.<br />
Overlay will continue to alternate or pressure will be<br />
equalised between the two cell sets and be maintained.<br />
In transport mode, the overlay will lift a<br />
100kg patient of normal BMI at least 2 cm above an<br />
underlying solid surface for at least 4 hours.<br />
3. Instructions<br />
a) Essential installation, user, cleaning and safety<br />
instructions printed on mattress cover and pump<br />
unit. Manufacturer contact number on mattress and<br />
pump unit.<br />
b) Detailed maintenance manual available on request.<br />
c) CPR instruction to be attached to connecting tubes<br />
and pump unit so that they are visible when bed<br />
made up.<br />
4. Warranties<br />
a) The product will comply with Medical Devices<br />
Directive 93/42/EEC June 14 1993 and any subsequent<br />
amendments.<br />
b) Product will be manufactured for at least 5 years in<br />
identical external form unless mandated for or<br />
required to by an adverse incident report. Spare<br />
parts will be available for at least 5 years after<br />
termination of product manufacture.<br />
56<br />
Volume 3, Number 2, 2001
PRESSURE MATTRESS OVERLAYS<br />
5. Additional items, which must be available on request<br />
a) Carrying bags (not zip fastened).<br />
b) Spare parts available individually from a part’s list.<br />
c) Extension tube set of 2–3m.<br />
6. Additional features<br />
The above specification is for a baseline model.<br />
Before agreeing to any additional features the<br />
purchaser should consider whether they are necessary<br />
and whether any additional cost is justified by<br />
the benefits. They should also be aware that additional<br />
features may in some circumstances render<br />
the alternating overlay less clinically effective, less<br />
mechanically reliable or more prone to misuse and/<br />
or mismanagement.<br />
Additional features not included in specification<br />
– Listed for discussion<br />
1a) Construction of mattress<br />
(i) Mattress to have non-alternating head set<br />
Potential benefits:<br />
more comfortable for patients nursed without<br />
pillow.<br />
Potential disadvantages:<br />
increased risk of pressure ulcers on the head<br />
and also on heels if mattress accidentally used<br />
head to foot reversed.<br />
(ii) Specify vapour permeable, two way stretch cover<br />
Potential benefits:<br />
thought to increase patient comfort.<br />
Potential disadvantages:<br />
no clinical evidence of benefit or improved<br />
comfort.<br />
(iii) Construct mattress in a fashion which allows the mattress<br />
to be its own ‘carrying case’ when rolled up (i.e., provide<br />
straps etc., to hold it rolled together, plus carrying handles)<br />
so that a need for carrying cases is eliminated.<br />
Potential benefits:<br />
no need for separate carrying cases which are<br />
frequently lost in some areas. Reduced costs.<br />
Potential disadvantages:<br />
not required in many areas – additional expense.<br />
Infection control issues if soiled mattresses are<br />
carried around without being first placed in<br />
another container.<br />
(iv) Provide ventilation holes in mattress<br />
Potential benefits:<br />
improves patient comfort by increasing air at the<br />
patient/mattress interface.<br />
Potential disadvantages:<br />
requires battery back-up for transport mode.<br />
(v) Bottom of mattress clearly printed with message “Turn<br />
mattress over. It must be used other side up”.<br />
Potential benefits:<br />
reduced chance of incorrect positioning of<br />
mattress<br />
Potential disadvantages:<br />
increased cost<br />
2a) Mode of action:<br />
Maximum operating pressure pertinent to a given, set either<br />
by the user or by internal mechanisms (i.e. have either a<br />
manually set or automatically adjusted ‘comfort control’).<br />
Potential benefits:<br />
Mattress can be made softer and therefore more<br />
comfortable for some lighter patients.<br />
Potential disadvantages:<br />
In practice, rarely set correctly if manual. Thus<br />
usually no benefit for lighter patients but risk of<br />
pressure sores for heavier patients as they can<br />
bottom through mattress. Automatic systems<br />
expensive to date. More potential for mechanical<br />
failure with both systems, more complicated<br />
maintenance.<br />
2 b) Lifting capacity:<br />
Maximum lifting capacity of 150kg.<br />
Potential benefits:<br />
Can carry heavier patients. Average patient mass<br />
is increasing year on year.<br />
Potential disadvantages:<br />
Inflation pressures would need to be higher,<br />
increasing discomfort problems for lighter<br />
patients. Shorter working life for mattress and<br />
pump unit.<br />
Alternative solutions:<br />
Nurse patients >150 kg in weight on mattress<br />
replacement systems<br />
Volume 3, Number 2, 2001 57
epuap CD<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
<strong>Review</strong> and Letter to the Editor<br />
WOUND MANAGEMENT CD ROM REVIEW<br />
THE East London Wound Healing Centre has produced<br />
a very comprehensive study guide to the assessment<br />
and management of Leg <strong>Ulcer</strong>s and <strong>Pressure</strong><br />
<strong>Ulcer</strong>s. This educational package has very clear objectives<br />
and is divided into two levels, level one is designed as a<br />
core text and is aimed at undergraduate students. It includes<br />
literature guides, case studies and questions. Level two is at<br />
a more advanced level and is aimed at qualified nurses and<br />
doctors.<br />
Within Level 2 there are links to the Tower Hamlets<br />
own Wound Care Manual and Leg <strong>Ulcer</strong>/<strong>Pressure</strong> <strong>Ulcer</strong><br />
Programmes which provides the user with valuable information<br />
to enable them to expand their knowledge base.<br />
There are also hyperlinks included to vitual websites and<br />
company web-sites for further product/equipment data.<br />
Further sections address related areas such as, nutrition,<br />
radiological investigations, wound infection and microbiology<br />
and patient information. These sections complement<br />
the text and provide the user with extensive overall knowledge<br />
of the subject area.<br />
This wound management package would provide a useful<br />
addition to both the Schools of Medicine/Nursing and<br />
to the individual student/learner. As adult learning moves<br />
more towards distance and computer-based learning perhaps<br />
future CD and web based developers of educational<br />
material should consider making applications for Continuing<br />
Education Points for Doctors who use the material, while<br />
nurses could be encouraged to record their outcomes of<br />
learning for the purposes of PREP.<br />
Samantha Holloway RGN, Cert Ed (FE)<br />
Education Assistant<br />
Wound Healing Research Unit<br />
University of Wales College of Medicine<br />
Cardiff, Wales<br />
May 2001<br />
LETTER TO THE EDITOR<br />
Dear Michael,<br />
I am pleased that several articles and abstracts address the<br />
issue of Quality of Life. However, Quality of Life in patients<br />
with ulcers does not depend on the ulcer alone. The new<br />
WHO classification disability uses the word dehabilitation<br />
to describe what happens to the whole person affected by<br />
disease. It is a process of decreasing attention to the whole<br />
person and loss of contact, rejection by friends and relatives.<br />
The quality of life for such a person may be impaired<br />
more by loss of such contacts than by the sickness itself.<br />
Loss of contact is determined by the ‘Good looks’ of the<br />
patient and the attractiveness of the patient to the carer. It<br />
is thus as important when managing pressure ulcers to improve<br />
the looks of the face and hair, the cleanliness and<br />
odour of the whole body, the brightness and odour of the<br />
environment and to have pictures on the walls which are<br />
attractive. All caretakers should speak to the patient when<br />
attending to their backside otherwise there is no reason for<br />
the patient to know that their existence is known to the<br />
carer other than as an ulcer.<br />
Terence Ryan<br />
Emeritus Professor in Dermatology<br />
Oxford Brookes University<br />
58<br />
Volume 3, Number 2, 2001
epuap Future<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Meetings<br />
SEPTEMBER 2001<br />
SEPTEMBER 2001 (continued)<br />
3 – 4 Narrative based medicine<br />
Conference supported by the British Academy<br />
Contact: Jane Lewis<br />
Conference Unit, BMA House<br />
PO Box 295<br />
London WC1 9TE<br />
Tel: +44 (0)20 7383 6663<br />
5 – 8 Joint ETRS / Wound Healing Society Meeting<br />
Cardiff International Arena, Wales<br />
Contact: Prof Keith Harding, ETRS2001,<br />
Wound Healing Research Unit, UWCM,<br />
Cardiff Medicentre, Heath Park,<br />
Cardiff, CF14 4UJ, Wales<br />
Fax: +44 (0)29 2075 4217<br />
Further information:<br />
Conference Office, Emap Healthcare<br />
Greater London House<br />
Hampstead Road,<br />
London, NW1 7EJ, UK<br />
Tel: +44 (0)20 7874 0294<br />
Fax: +44 (0)20 7874 0298<br />
E-mail: healthcare.conference@emap.com<br />
7 – 9 Diabetic Foot Study Group of the EASD<br />
2nd Scientific Meeting<br />
The Crieff Hydron<br />
Crieff, Scotland<br />
Contact: Ann Roscoe<br />
Department of Medicine<br />
Manchester Royal Infirmary<br />
Oxford Road<br />
Manchester M13 9WL<br />
Fax +44 (0)161 274 4740<br />
E-mail: ANNE.ROSCOE@MAN.AC.UK<br />
9 – 14 14th World Congess of Union Internationale<br />
de Phlebologie<br />
Rome, Italy<br />
Contact: GC Congressi<br />
Via P. Borsieri, 12 – 00185, Roma, Italy<br />
Tel: +39 06 370 0541<br />
Fax: +39 06 373 52337<br />
E-mail: angiolsg@pronet.it<br />
27 – 30 5th <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong><br />
Open Meeting<br />
Theme Education – Experiences we can share<br />
Palais des Congrès de la Culture du Mans<br />
Le Mans, France<br />
Contact: EPUAP Business Office:<br />
Wound Healing Institute, Dept of Dermatology,<br />
Churchill Hospital, Old Road, Headington,<br />
Oxford, OX3 7LJ, England<br />
Tel: +44 (0)1865 228264<br />
Fax: +44 (0)1865 228233<br />
E-mail: <strong>European</strong><strong>Pressure</strong><strong>Ulcer</strong>Advis<strong>Panel</strong><br />
@compuserve.com<br />
OCTOBER 2001<br />
6 – 7 Surgical Applications of Tissue Sealants<br />
and Adhesives<br />
Sheraton New Orleans<br />
New Orleans, Louisiana, USA<br />
Further information:<br />
http://www.healthtech.com<br />
9 – 10 Second transdisciplinary conference on the<br />
principles and perspectives in regenerative<br />
medicine<br />
Hannover, Germany<br />
Further information:<br />
http://www.regmed.de<br />
NOVEMBER 2001<br />
7 – 10 Ist Biennial Meeting of the <strong>European</strong> Tissue<br />
Engineering Society (ETES)<br />
Freiburg, Germany (EU)<br />
Contact: kongress & kommunikation GmbH<br />
Kongressorganisation<br />
Hugstetter Str. 55<br />
D–79106 Freiburg, Germany<br />
Tel: +49 (0)761 270 7316<br />
Fax: +49 (0)761 270 7317<br />
E-mail: kkkri@ukl.uni-freiburg.de<br />
Continued overleaf<br />
Volume 3, Number 2, 2001 59
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
NOVEMBER 2001 (continued)<br />
11 – 16 Global Holistic Health Summit; Holistic and<br />
Integrated Medicine for the 21st Century<br />
Bangalore, India<br />
Contact: Dr Isaac Mathai<br />
Secretary General,<br />
International Holistic Health Association<br />
202 Parvathi Plaza<br />
Richmond Circle<br />
Bangalore 560 025, India<br />
Tel: 91 80 221 4625, 227 9698<br />
Fax: 91 80 221 8252<br />
E-mail: holistic medicine@vsnl.com<br />
Website: www.holisticmedic.org<br />
14 Prevalence Survey in <strong>European</strong> Hospitals<br />
MAY 2002<br />
23 – 25 12th Conference of the <strong>European</strong> Wound<br />
Management Association<br />
‘Chronic wounds and quality of life’<br />
Contact: EWMA<br />
PO Box 864, London SE1 8TT<br />
and<br />
IV simposio Nacional sobre <strong>Ulcer</strong>as<br />
por Presion<br />
GNEAUPP<br />
Av. viana 1<br />
26001-Logrono (La Rioja), Espana<br />
Tel: +34 941 239 240<br />
Fax: +34 941 239 347<br />
E-mail: gneaupp@arrakis.es<br />
SEPTEMBER 2002<br />
18 – 21 6th <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong><br />
Open Meeting<br />
Budapest, Hungary<br />
Contact: EPUAP Business Office, Oxford.<br />
(Address above)<br />
60<br />
Volume 3, Number 2, 2001
epuap Membership<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
List<br />
Executive Trustees<br />
Mr David Gray, 15 Tarbothill Road, Aberdeen, Scotland, AB22 8RF<br />
Tel/Fax: 01224 703125, 01224 681818, Fax: 01224 685307<br />
Dr Jeen R E Haalboom, President<br />
Associate Professor of Internal Medicine, Dept of Internal Medicine,<br />
University Hospital, PO Box 85500, 3508 GA Utrecht, The<br />
Netherlands. Tel: 00 31 30 250 6214, Fax: 00 31 30 253 9060<br />
e-mail: Haalboom@med.ruu.ml<br />
Prof Gerry Bennett, Recorder<br />
Consultant Geriatrician, Department of Health Care of the Elderly,<br />
Academic Office, 1st Floor, Alderney Building, Mile End Hospital,<br />
Bancroft Road London, E1 4DG, England. Tel: 020 7377 7893,<br />
Fax: 020 7377 7844 bennettg@THHT.org<br />
Dr Marco Romanelli, Vice President<br />
Dept of Dermatology, University of Pisa, Via Roma 67, 56126 Pisa,<br />
Italy. Tel: 00 390 50 992 436 or 50 533 387, Fax: 00 390 50 551 124<br />
Professor Keith Harding, Past President<br />
Director of Wound Healing Research Unit, University Department of<br />
Surgery, Cardiff Medicentre, Heath Park, Cardiff, CF4 4XN, Wales.<br />
Tel: 02920 689703, Fax: 02920 745217, e-mail: wsrkgh@cf.ac.uk<br />
Dr George W Cherry, Secretary/Treasurer<br />
Chairman, Wound Healing Institute, Department of Dermatology,<br />
The Churchill Hospital, Headington, Oxford, OX3 7LJ, England.<br />
Tel: 01865 228269, Fax: 01865 228233<br />
Mrs Christine Cherry, Business Administrator<br />
EPUAP Business Administror, Wound Healiing Institute, Dept of<br />
Dermatology, The Churchill Hospital, Headington, Oxford, OX3<br />
7LJ, England. Tel: 01865 228264, Fax: 01865 228233<br />
Dr Michael Clark, Wound Healing Research Unit, Medicentre,<br />
University of Wales College of Medicine, Heath Park, Cardiff, CF4<br />
4XN, Wales. Tel: 02920 689703, Fax: 02920 754217<br />
Dr Denis Colin, Centre de l’Arche 72650, Saint Saturnin, France<br />
Dr Christina Lindholm, Nattarovagen 42, 13234 Saltsjo-Boo, Sweden<br />
Tel: 00 46 8 715 6263, Fax: 00 46 8 715 4442<br />
Mr Joan-Enric Torra i Bou, Consorci Sanitari de Terrassa, Hospital de<br />
Terrassa, Carretera de Terrassa s/n, 08227 Terrassa, Barcelona, Spain<br />
Tel: 00 34 93 731 00 07 (ext 2291), Fax: 00 34 93 731 44 51<br />
Trustees<br />
Mrs Sue Bale, Director of Nursing Research, Wound Healing Research Unit,<br />
University Department of Surgery, UWCM, Heath Park, Cardiff, CF4 4XN,<br />
UK. Tel: 02920 689703, Fax: 02920 745299<br />
Dr Brigitte Barrois, 32 Rue Roger Lemaire, Aulnay/s/Bois 93600 France<br />
Tel: +33 1 3453 2085 Fax: +33 1 3453 2481 bbarrois@ch-gonesse.fr<br />
Mrs Carol Dealey, 32 Serpentine Road, Harbourne, Birmingham,<br />
West Midlands, B17 9RE, UK. Tel/fax: 0121 426 5674<br />
Mr Tom Defloor, Nursing Sciences, Univ. of Gent, U.2. Block A 2 o V, De<br />
Pintelaan 185, 9000 Gent, Belgium. Tel/fax: 00 32 50 36 24 38<br />
Ms Jacqui Fletcher, Senior Lecturer, Univ of Hertfordshire, Hatfield Campus,<br />
Hatfield, AL10 9AB, England. Tel: 01707 284000, Fax: 01707 284954<br />
Prof Dr Heinz Gerngross, Bundeswehrkrankenhaus oberer Eselsberg 40,<br />
Ulm, D–89075, Germany Tel: 00 49 731 2020, Fax: 00 49 734 553100<br />
Professor Finn Gottrup, Bispebjerg Unit, Building 11a, Bispebjerg University<br />
Hospital, Bispebjerg Bakke 23, DK-2300, Copenhagen NV, Denmark.<br />
Tel: 00 45 3531 3721, Fax: 00 45 3531 3724<br />
Dr Laszlo Gulacsi, Bem ter 8, H-4026 Debrecen, Hungary Tel: +36 52 423 264<br />
Dr Ruud J G Halfens, Vakgroep Verplegingswetenschap, University of<br />
Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands.<br />
Tel: 00 31 43 388 2222, Fax: 00 31 43 367 1004<br />
Ms Helvi Hietanen, Head Nurse, HUCH, Toolo Hospital, Dept of Plastic<br />
Surgery, Box 266, 00029 HYKS, Finland<br />
Tel: +358 9 47 17 228, Fax: +358 9 47 17 260<br />
Mrs Deborah Hofman, Clinical Nurse Specialist, The Wound Healing<br />
Institute, Dept of Dermatology, Churchill Hospital, Headington, Oxford,<br />
OX3 7LJ, UK. Tel: 01865 228268, Fax: 01865 228233<br />
Ms Agnes Jacquerye, Hopital Erasme, 308 Route de Lenniik, Bruxelles 1070,<br />
Belgium. Tel: 00 32 2 555 36 65, Fax: 00 32 2 555 45 67<br />
Mr Germain de Keyser, WCS Belgium, Kapucijnenvoer 35, 3000 Leuven,<br />
Belgium. Fax: 00 32 16 22 8349 e-mail: germain.dekeyser@pandora.be<br />
Mr. Maarten Lubbers, Meibergdraas 9, 1100 A2, Amsterdam, The<br />
Netherlands. Tel: 00 31 20 56 69 111, Fax: 00 31 20 69 72 988<br />
Dr Sylvie Meaume, Hopital Charles Foix, 7 Avenue de la Republique, Ivry sur<br />
Seine, 94205, France Tel: 00 33 149 594 504, Fax: 00 33 149 594 524<br />
Zena Moore, The Adelaide & Meath Hospital, Dublin, Eire. Tel: 003531<br />
414200 (bleep 7190), Fax: 003531 4143576<br />
Dr Elaine Pina, Rua Prof Hernani Cidade, 2–2a Telheiras Sul, 1600 Lisboa,<br />
Portugal. Tel: 00 351 313 6390<br />
Prof Terence Ryan, Wound Healing Institute, Dept of Dermatology, The<br />
Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, England.<br />
Tel: 01865 228269, Fax: 01865 228233<br />
Anne Witherow, 36 Cappagh Grove, Portstewart, Derry, Northern Ireland.<br />
Tel: 02871 345171 (ext. 3602).<br />
Paying Members<br />
Ms Jolanda Alblas, Boveny Ziekenhuis, Statenjachtstraat 1, 1034 CS,<br />
Amsterdam, The Netherlands. Tel: +31 20 634 6346, Fax: +31 20 634 6730<br />
Mrs Patrizia Amione, Vulnera C50, Matteotti 35, Turin 10121, Italy.<br />
Tel: +39 011 544 747 +39 011 533 649 r.cassino@sicurdata.it<br />
Mrs Annika Andriessen, Zwenkgras 25, Malden 6581–RK, The Netherlands.<br />
Tel: 00 31 24 358 7086<br />
Dr Bauk Apotheker, James Stewart Straat 125, Almere-Stad, 1325–JC,<br />
The Netherlands.<br />
Mrs Leticia Arreytunandia, Lab Knoll SA, Av Burgos 91, Madrid 28050, Spain.<br />
Tel: 00 34 1 334 3900, Fax: 00 34 1 383 1676<br />
Associacao Portuguesa Tratamento de Feridas, Rua Alvares Cabral, 137–Sala<br />
14, 4050–041 Porto, Portugal. Tel: +351 222 026 725 Fax: +351 222 007 890<br />
Ms Stefania Astola, Vulnera C50, Matteotti 35, Turin, 10121 Italy.<br />
Tel: 00 39 011 544 747, Fax: 00 39 011 533 649 r.cassino@sicurdata.it<br />
Miss Sally Atkin, Smith & Nephew Medical, PO Box 81, Hessle Road, Hull,<br />
HU3 2BN, England<br />
Prof Elizabeth Ayello, New York University, Division of Nursing, 346 Green<br />
Street, New York, NY 10003, USA Tel: +212 998 5311 Fax: +212 995 4302<br />
elizabeth.ayello@nyu.edu<br />
Volume 3, Number 2, 2001 61
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Ms Eve Baker, Smith & Nephew Medical Ltd, PO Box 81, Hessle Road, Hull,<br />
HU3 2BN, England<br />
Mrs Sue Bale, Dir of Nursing Research, Wound Healing Research Unit,<br />
UWCM, The Medi Centre, Heath Park, Cardiff, CF14 4UJ, Wales<br />
Tel: 02920 682 187, 02920 754 217<br />
Mr Graham Ball, Jacksons, 8 Mill Field, Barnston, Essex, CM6 1LH, England<br />
Tel: 01371 872 097 g.j.ball@herts.ac.uk<br />
Ms Maria Barbierato, via ca’ Brazzo, no. 44, Arre (Padua), Padova 35020, Italy.<br />
Tel: +39 049 538 4324<br />
Dr Richard Barnett, Hill–Rom, 4349 Corporate Road, Charleston, South<br />
Carolina, 29405, USA<br />
Ms Sharon Baranoski, 24724 W Park River LN, Shorewood, IL 60431 U.S.A.<br />
Tel: 001 815 740 1078, sbaranoski@silvercross.org<br />
Dr Brigitte Barrois, 32 Rue Roger Lemaire, Aulnay/s/Bois, 93600 France<br />
Tel: +33 1 3453 2085 Fax: +33 1 3453 2481 bbarrois@ch-gonesse.fr<br />
Dr Andrea Bellingeri, Via Marongoni 15, Pavia 27100, Italy.<br />
Tel: +39 038 252 9975, Fax: +39 038 252 3203 ebellingeri@venus.it<br />
Mrs Maureen Benbow, 20 Cloverfields, Haslington, Cheshire, CW1 5AL,<br />
England. Tel: 01270 251833, Fax: 01270 612041<br />
Prof Gerry Bennett, Consultant Geriatrician, Department of Health Care of<br />
the Elderly, Academic Office, 1st Floor, Alderney Building, Mile End Hospital,<br />
Bancroft Road, London, E1 4DG, England. Tel: 020 7377 7893,<br />
Fax: 020 7377 7844 bennettg@THHT.org<br />
Mrs Susan Bennett, c/o Ward Five, North Tyneside General Hospital, Rake<br />
Lane, North Shields, England<br />
Mr Paul Bennis, Training Manager & Nursing Specialist, Redactron<br />
International b.v., Lange Voren 18, 5521 DD Eersel, The Netherlands.<br />
Tel: +31 497 516895 Fax: +31 497 516833 r.bennis@redactron.com<br />
Mrs S Benton-Jones, The Nuffield Orthopaedic Centre, Windmill Road,<br />
Headington, Oxford, OX3 7LD, UK.<br />
Mr Joseph Berman, Dept of Physical Therapy, 346 WSC Marqhette University,<br />
PO Box 1881, Milwaukee, Wisconsin, 53201-1881, USA<br />
Tel: 001 414 288 3363, Fax: 001 414 288 5987<br />
Dr Laurent Bernier, Le Green, rue des Granges, Dommartin, 69380 France.<br />
Tel: 00 33 478 435 127, Fax: 00 33 478 435 172 lbernier@plaies.com<br />
Mrs Elaine Bethell, c/o Michelle Morris, Secretary, City Hospital NHS Trust,<br />
Dudley Road, Birmingham, B18 7QM, UK. Tel: 0121 554 3801<br />
Fax: 0121 507 5610 elaine.bethell@cityhospbham.wmids.nhs.uk<br />
Mr Bert Billen, The ROHO Group, Peter Valentinuslaan 4, B–3500 Hasselt,<br />
Belgium Tel: 00 31 1128 4359, Fax: 00 31 1128 1517, bbillen@attglobal.net<br />
Mr Eric Binder, TUV Product Service, Basis Institute, Ridler Str. 31,<br />
D–80339 Munich, Germany<br />
Mr Itzak Binderman, School of Dental Medicine, Tel-Aviv University, Ramat<br />
Aviv, 69978 Tel Aviv, Israel Tel: +972 3 695 1835, Fax: +972 3 640 9250<br />
binderma@post.tau.ac.il<br />
Miss Lynne Birchall, Dept of Nursing, Metchley Lane, Edgbaston, Birmingham,<br />
B15 4TH, England Tel: 0121 472 1311<br />
Dr Mary Bliss, 49 Groombridge Road, London, E9 7DP, England<br />
Tel: 020 8985 2007<br />
Mr Giovanni Bollini, Via Palestrina 6, 20014 Nerviano (MI), Italy<br />
Tel: 00 39 2 6444 2526, Fax: 00 39 2 6444 2618<br />
Mr Johe Bominaar, ConvaTec, Ujzelmolenlaan 9, AM Woerden, 3440 gx,<br />
The Netherlands. Tel: +31 348 436950, Fax: +31 348 423084<br />
johe.bominaar@BMS.com<br />
Helen Boon, Wallsend Health Centre, The Green, Wallsend, Tyne and Wear,<br />
NE28 7PD, England Tel: 0191 220 5916, 0191 220 5943<br />
Mrs Th CM Bots, Silversteyn 64, 3621 PD Breukelen, The Netherlands.<br />
Tel: +31 346 264 208, Fax: +31 346 264 163 postbus@thbots.demon.nl<br />
Dr R T Boumans, TNO Prevention & Health, PO Box 2215, Leiden 2301 CE,<br />
The Netherlands.<br />
Dr Gerrie Bours, Maastricht Univ, Dept Nursing Science, PO Box 616,<br />
Maastricht 6200 MD, The Netherlands. Tel: +31 43 388 1279,<br />
Fax: +31 43 388 4162 G.Bours@zw.unimaas.nl<br />
Dr Carlijn Bouten, Eindhoven University of Technology, Div. Continuum and<br />
Biomechanics, MATE, PO Box 513, 5600 MB, Eindhoven, The Netherlands.<br />
Tel: 00 31 40 247 3006 Fax: 00 31 40 244 7355 c.v.c.Bouten@tue.nl<br />
Mr Hendrika Bouwman, Wilsonstr. 90, Hoofdorp, 2313 PV, The Netherlands.<br />
Tel: 00 31 23 561 1850<br />
Mr Jon Bredal, Semsveien 150, 1384 Asker, Norway. Tel: +47 661 05610,<br />
Fax: +47 669 05611 bred@online.no<br />
Ms Gail Broadbent, 44 Warley Road, Blackpool, FY1 2LL England<br />
Tel: 01253 303238<br />
Joost L. Broerse, Postbus 167, Weesp, 1380 AD, The Netherlands.<br />
Tel: 00 33 294 415001, Fax: 00 33 294 430475<br />
Miss Jill Brooks, Abingdon Hospital, Marcham Road, Abindon, Oxford,<br />
OX14 1AG, England. Tel: 01993 774126, Fax: 01992 706947<br />
jill.brooks@oxch-tr.anglox.nhs.uk<br />
Mr Harry Brouwer, c/o Sterreboslaan 2, Bloemendaal, 2061 VV, The<br />
Netherlands. Tel: +31 6 53 66 3583<br />
Dr Roel Brull, Huntleigh Healthcare, Flevolaan 8, 1382 JZ Weesp, The<br />
Netherlands<br />
Ms Mariantonietta Brunengo, Hill-Rom Spa, Via Ambrosoli 6, 20090 Rodana<br />
(MI) Italy<br />
Dr Enrica Buonagurio, via A. Manzoni 6, Vimodrone, Milan 20090, Italy.<br />
Tel: +39 022 650 062, Fax: +39 022 502 546 ebuonagurio@libero.it<br />
Ms Annette Buschka, Mölnlycke Health Care AB, PO Box 13080, SE 40252,<br />
Sweden. Tel: 00 46 31 722 8121, 00 46 31 722 3409<br />
Mr Cesar Calderon, Beiersdorf Portugesa, Rus Soeiro Pereira Gomes, 59 –<br />
Queluz de Baixo, 2746–952, Portugal.<br />
Tel: 00 351 21 436 8500, Fax: 00 351 21 436 2874<br />
Dr Gianna Rita Carella, ‘C Golgi’ Geriatric Institute, Piazza Golgi 11, Abbiategrasso<br />
(Milan) 20081, Italy. Tel: +39 029 466 771 Fax: +39 029 496 808<br />
Mrs Antonietta Carusone, ‘C Golgi’ Geriatric Institute, Piazza Golgi 11, Abbiategrasso<br />
(Milan) 20081, Italy. Tel: +39 029 466 771 Fax: +39 029 496 809<br />
Ms Andrea Cavicchioli, Via Siligardi 14, 41100 Modena, Italy<br />
Tel: +39 059 4401 24, Fax: +39 059 3992 10 cavicchioliandrea@hotmail.com<br />
Mrs Tina Chambers, 11 Adison Square, Ringwood, Hants BN24 1NV, England.<br />
Tel: 01425 471291<br />
Dr Michael Clark, Wound Healing Research Unit, UWCM, The Medi Centre,<br />
Heath Park, Cardiff, CF14 4UJ, Wales. Tel: 02920 682 191, 02920 754 217<br />
Dr Denis Colin, Medical Director, Centre de l’Arche, 72650 Saint Saturnin, Le<br />
Mans, France. Tel: +33 243 51 72 57, Fax: +33 243 51 72 67<br />
Denis.Colin2@wanadoo.fr<br />
Mr Mark Collier, 61 Sparrowhawk Way, Hartford, Huntingdon, Cambridgeshire,<br />
PE18 7XE, England. Tel: 020 8280 5020, Fax: 01480 434100<br />
Mrs Fiona Collins, 25 Hyde Gardens, Eastbourne, East Sussex, BN21 4PX,<br />
England. Tel: 01323 735588, Fax: 01323 737132 fiona@trcs.cc<br />
Miss Pamela Cooper, Clinical Nurse Specialist, Dept of Tissue Viability,<br />
Foresthill, Grampion University Hospital, AB25 2ZN, Scotland.<br />
Tel: 01224 554621, Fax: 01224 849139<br />
Mrs Barbara Craven, Disability Services, Walton Hospital, Chesterfield,<br />
Derbyshire, S40 3HW, England. Tel: 01246 552875 (ext 5707)<br />
Fax: 01246 552910<br />
Ms Jean Cregg, 9 Goddards Lane, Aldbourne, Marlborough, Wilts, SN8 2DZ,<br />
England. Tel: 01282 432072, Fax: 01282 421597<br />
Ms Ann Daenekindt, Stapelplein 70, Gent 9000, Belgium. Tel: +32 9 265 8770<br />
Fax: +32 9 265 8771 ann.daenekindt@huntleigh-healthcare.be<br />
Dr Cynthia Dale, Johnson & Johnson Medical Ltd, New Product Development,<br />
Gargrave, North Yorks, BD23 3RX, England.<br />
Tel: 01756 747455 Fax: 01756 748158<br />
62<br />
Volume 3, Number 2, 2001
EPUAP MEMBERS<br />
Dr Sarah Daniels, Harrington House, Milton Road, Ickenham, Uxbridge,<br />
Middlesex, UB10 8PU, England. Tel: 01895 628395 Fax: 01895 628338<br />
Mrs Carol Dealey, 32 Serpentine Road, Harborne, Birmingham, B17 9RE,<br />
England. Tel: (and Fax:) 0121 426 5674<br />
Nathalie de Dieulveult, Smith & Nephew SA, Espace Novaxis, 25 Bld<br />
Alexandre Oyon, 72019 Le Mans Cedex, France<br />
Dr Tom Defloor, Kerklaan 58, Brugge 8310, Belgium<br />
Tel: 00 32 50 36 24 38, Fax: 00 32 50 36 24 38<br />
Mr Germain de Keyser, Kapucijnenvoer 35, 3000 Leuven, Belgium<br />
Tel: 00 32 1633 2211, 00 32 1922 8349 germain.dekeyser@pandora.be<br />
Dr Bart Derre, Aartstraat 210, Ronse, B-9600, Belgium. Tel: 00 32 55 20 6948<br />
Ms Ingrid Devries, Smith & Nephew BV, Kruisweg 659, 2132 HG Hoofdorp,<br />
The Netherlands<br />
Dr Andy Dobrzeniecki, Torsana A/S, Skosborg Strandvej 156, DK-2942<br />
Skodsborg, Denmark<br />
Dr Sonia Dumit-Minkel, 1231 E. Donges Crt, Bayside, Wisconsin 53217, USA<br />
Mrs Cheryl Dunford, Medical Equipment Centre, Salisbury District Hospital,<br />
Salisbury, Wilts, SP2 8BJ<br />
Dr Ana Durao, R Replia Horsensia de Castro, No 2 – 8oD to, Colina do Sol,<br />
2700 Amadora, Portugal. Tel: +351 21 474 8559 anadurao@net.sapo.pt<br />
Mrs Sandra Ellis, 14 Pinewood Road, Eaglescliffe, Cleveland, TS16 0AH,<br />
England Tel: 01642 791558 Fax: 01642 624165<br />
Mrs Wendy Eve, Saiyang, 30 Torton Hill Road, Arundel, West Sussex, BN18<br />
9HL, England Tel: 01903 882212, Fax: 01243 623664<br />
wendyeve@u.genie.co.uk<br />
Carlos Ferrer, Smith & Nephew SA, Fructuos Gelabert 2 y 4, 08970 Sant Juan<br />
Despi, Barcelona, Spain<br />
Ms Cynthia Fleck, The ROHO Group, 100 North Florida Avenue, Belleville,<br />
Illinois, 62221, USA Tel: +618 277 9173, Fax: +618 277 9561<br />
cynthiaf@therohogroup.com<br />
Mrs Jacqui Fletcher, University of Hertfordshire, Hatfield Campus, College<br />
Lane, Hatfield, Herts, AL10 9AB, England<br />
Tel: 01707 284000, Fax: 01707 284954 j.fletcher@herts.ac.uk<br />
Mr Håkan Freijd, Convatec/Bristol-Myers Squibb, Box 15200, S–16715<br />
Bromma, Sweden. Tel: 00 46 8 7047250<br />
Mr Gerd-Wenche Frilseth, Smith & Nephew A/S, PO Box 224, Nye Vakaas vei<br />
64, 1360 Newbru, Norway<br />
MsKatia Furtado, Rua Viturino Nemesio, No.2–7 Esquerdo, 1750-307 Lisbon,<br />
Portugal. Tel: +351 21 758 8288 kfurtado@ip.pt<br />
Mr Lucas Garabet, GerroMed GmbH, Fangdieckstra 75B, Hamburg 22547,<br />
Germany Tel: +49 40 547 3030, Fax: +49 40 547 30331<br />
GarabetL@Gerromed.de<br />
Mr K. G. Gebhardt, 2 Manchuria Villas, Wix’s Lane, London, SW4 0AG,<br />
England. Tel: 020 7228 8545, Fax: 020 8725 1621<br />
Prof Dr Heinz Gerngross, Bundeswehrkrankenhaus, Oberer Eselberg 40, D–<br />
89070, Ulm, Germany. Tel: 00 49 931 171 2020, Fax: 00 49 937 553100<br />
Dr Carella Gianna Rita, ‘C Golgi’ Geriatric Institute, Piazza Golgi 11, Abbiategrasso<br />
(Milan) 20081, Italy. Tel: 00 39 029 466 771 Fax: 00 39 029 496 808<br />
Dr Walter Gianni, via Appennini 38, Rome 00198, Italy<br />
Tel: +39 06 3034 2690, wgianni@tiscalinet.it<br />
Franco Giraudi, Smith & Nephew Srl, Centro Direzionale Colleoni, Viale<br />
Colleoni 13, Palazzo Orione Ingresso 1, 20041 Agrate Brianza, Milan, Italy.<br />
Me Anabela Gomes, Rua Teofilo Braga, 154–1o, 4435–461 Rio Tinto, Portugal.<br />
Tel: +351 224 889 791<br />
Mrs Ann Goodhead, Derbyshire Royal Infirmary, London Road, Derby, DE1<br />
2QY, England. Tel: 01332 347141, Fax: 01332 254958<br />
Dr Allison Graham, 75 Mellstock Road, Aylesbury, Bucks, HP21 7NX, England<br />
Tel: 01296 315851, Fax: 01296 315867<br />
Dr Jeffrey Graham, Dept of Health, Room LG24, Wellington House, Walterloo<br />
Road, London, SE1 8UG, England Tel: 020 7972 4710 Fax: 020 7972 4405<br />
Mr David Gray, 15 Tarbothill Rd, Aberdeen, AB22 8RF, Scotland.<br />
Tel: 01224 681818 (703125), Fax: 01224 708665 (703125)<br />
Mr Mark Green, 1 Greenwood Avenue, Horwich, BL6 6FA, UK.<br />
Dr Laszlo Gulacsi, Bem ter 8, H–4026 Debrecent, Hungary.<br />
Mrs Lena Gunningberg, Department of Nursing Research and Development,<br />
University Hospital, 75185 Uppsala, Sweden. Tel: +46 18 611 3194,<br />
Fax: +46 18 611 3025 lena.gunningberg@adm.uas.lul.se<br />
M Susan Gwynne, C.I. Adulti, Ospedale G Pasquinucci, via Aurelia Sud 1,<br />
Massa 54100, Italy.<br />
Dr Jeen RE Haalboom, Dept. of Internal Medicine, University Hospital,<br />
Heidelberglaan 100, Utrecht 3508, The Netherlands.<br />
Tel: 00 31 30 250 6214, Fax: 00 31 30 253 9060<br />
Dr Satsue Hagisawa, Qita Medical University, School of Nursing, Hasama, Qita<br />
879-5593, Japan.<br />
Mr Kurt Halbwachs, Smith & Nephew GmbH, Concorde Business Park D2/<br />
Top 11, 2320 Schwechat, Austria.<br />
Dr Ruud Halfens, Praaglaan 123, 6229 HR Maastricht, The Netherlands.<br />
Ms Samantha Hall, Acordis Speciality Fibre Ltd. Lockhurst Lane, Coventry,<br />
CV6 5RS, England.<br />
Ms Tracey Hamlyn, 61 Lydford Park Road, Peverell, Plymouth, PL3 4LQ,<br />
England Tel: 01752 670601<br />
Mr Mark Hammonds, Coronary Care Unit, James Cook University Hospital,<br />
Marton Road, Middlesborough, TS4 3BW, England<br />
Tel: 01642 854801, Tel: 01642 854196<br />
Miss Jane Hampton, 25 Trentham St, Southfields, London, SW18 5AS<br />
England. Tel: 020 8846 6544 Fax: 020 8846 6543<br />
Dr Carita Hansson, Dept of Dermatology, Wound Healing Centre,<br />
Sahlgrenska University Hospital, 41345 Göteborg, Sweden<br />
Tel: +46 31 342 1000 Fax: +46 31 821 871<br />
Prof Keith Harding, Director, Wound Healing Research Unit, UWCM, Cardiff<br />
Medicentre, Heath Park, Cardiff, CF14 4UJ, Wales, UK<br />
Tel: 02920 682 176, Fax: 02920 754 217 HardingKG@cf.ac.uk<br />
Ms Elizabeth Hardy, Northumbria Healthcare NHS Trust, Wallsend Health<br />
Centre, The Green, Wallsend, Tyne and Wear NE28 7PD England. Tel: 0191<br />
220 5928, Fax: 0191 220 5943<br />
Ms Diane Hargrove, Seton Healthcare, Tubiton House, Medlock Street,<br />
Oldham, OL1 3HS, England. Tel: 0161 652 2222, Fax: 0161 621 2627<br />
Ms Judy Harker, Room 15 Chalmers Keddie Building, Royal Oldham Hospital,<br />
Rochdale Road, Oldham, OL1 2JH, England Tel: 0161 627 8701<br />
Fax: 0161 627 8554, judy.harker@oldham-tr.nwest.nhs.uk<br />
Mrs Lucy Harper, 50 Somersall Street, Mansfield, Notts., NG19 6EP, England.<br />
Tel: 01623 456063 lucy@ntlworld,com<br />
Ms Joy Harris, Smith & Nephew Medical Ltd, PO Box 81, Hessle Rd, Hull,<br />
HU3 2BN, UK. Tel: 01482 225181 (x 2645), 01482 673106<br />
Mr Kenny Harris, Davenant, 18a Lordsgate Lane, Burscough, Ormskirk, L40<br />
7ST, UK<br />
Mr William Haughton, 211 Spital Road, Bromborough, Wirral, Merseyside,<br />
CH62 2AF, England. Tel: 0151 334 8461<br />
Mrs Linda Haywood, 25 Avalanche Road, Southwell, Portland, Dorset, DT5<br />
2DT, England. Tel: 01305 252812<br />
Ms Arja Heikinheimo, Kuntokatu 8, 15900 Lahti, Finland Tel: +358 3 819<br />
4857, Fax: +358 3 819 7850 arja.heikinheimo@phks.fi<br />
Ms Jussi Heikkila, Kuoppatie 4, PO Box 25, Helsinki, 00731 Finland<br />
Tel: +358 9 346 2574, Fax: +358 9 346 2576 jussi.heikila@icfgroup.fi<br />
Dr Eva-Lisa Heinrichs, ConvaTec Ltd, Swakeleys House, Milton Rd, Ickenham,<br />
Uxbridge, Middlesex, UB10 8NS, England.<br />
Tel: 01895 628330, Fax: 01895 628332<br />
Volume 3, Number 2, 2001 63
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Ms Taina Hemmila, Kuoppatie 4, PO Box 25, Helsinki, 00731 Finland<br />
Tel: +358 9 346 2574, Fax: +358 9 346 2576 taina.hemmila@icfgroup.fi<br />
Mr Jan Hermkens, Weymar Straat 8, Maasbree, 5993 CT, The Netherlands.<br />
Tel: +31 77 465 2676, Fax: +31 77 465 1599 jan.hermkens@wxs.nl<br />
Ms Hilde Heyman, Karel VD, Woestynelaan 40, 2630 Aartselaar, Belgium<br />
Tel: +31 3 289 4087<br />
Ms Helvi Hietanen, Tonttumuorinkija 1, 02200 Espoo, Finland.<br />
Tel: +35 85 001 02947, Fax: +35 89 412 5074 hetu.hietanen@magabaud.fi<br />
Mrs Deborah Hofman, Wound Healing Institute, Dept of Derm., Churchill<br />
Hospital, Headington, Oxford, OX3 7LJ, England<br />
Tel: 01865 228268, Fax: 01865 228233<br />
Mrs Monica Hofmann-Rosener, HNE Healthcare, Im Hulsenfeld 19, 40721<br />
Hilden, Germany. Tel: +49 2013 97110<br />
Fax: +49 2013 971146 hne.hofrose@t-online.de<br />
Mrs Helen Hollinworth, 10 Cages Way, Melton, Woodbridge, Suffolk,<br />
IP121TE, England Tel: 01473 296557<br />
Ms Alison Hopkins, Primary Care, Mile End Hospital, Bancroft Rd, London<br />
E1 4DG, England. Tel: 020 7377 7000 (ext 4331) Fax: 020 7377 7802<br />
Ms Hovannouhi Houniet, Nutricia Netherlands, Postbus 1, Zoetermeer, 2700<br />
MZ, Netherlands. Tel: 00 31 353 9370<br />
Ms Ansa Iivanainen, Potnolankatu 5, Mikkeli, 50120 Finland.<br />
Tel: +358 15 150 632, Fax: +358 15 355 6686 ansa.iivanainen@mikkeliamk.fi<br />
Prof Agnes Jacquerye, Clinique Universitaires de Brusselles, Route de Lemik<br />
808, 1070 Brusselles, Belgium.<br />
Tel: +32 2 555 4567, Fax: +32 2 555 3665<br />
Sister Sian James, Wound Healing Office, East 5, Whitchurch Hospital, Park<br />
Road, Whitchurch, Cardiff CF4 7XB, UK<br />
Mr Torsten Johansen, Smith & Nephew A/S, Naerum Hovedgade 2, 2850<br />
Haerum, Denmark<br />
Ms Elisabeth Jolink, Rijnstate Hospital, PO Box 9555, 6800 TA Arnhem,<br />
The Netherlands. Tel: +31 26 378 6973<br />
Dr Wilhelm Jung, Wound Manage. Division, Smith & Nephew Medical Ltd,<br />
PO Box 81, Hessle Rd, Hull, HU3 2BN, England.<br />
Tel: 01482 673030 Fax: 01482 673106<br />
T Kaldijk, Academisch Ziekenhuis Maastricht, Postbus 5800, 6202 AZ,<br />
Maastricht, The Netherlands. Tel: 00 31 43 387 5912, Fax: 00 31 43 387 5142<br />
Mr Raija Kannininen, Perkionkuja 5B, 01670 Vantaa 67, Finland.<br />
Tel: 00 358 9 270 92790, Fax: 00 358 9 270 92798<br />
Greger Karlsson, Smith & Nephew AB, Textilvagen 7, 3tr, S–120 30 Stockholm,<br />
Sweden.<br />
Mrs Anne Keogh, 8 Glenavon Road, Kings Heath, Birmingham, B14 5BL,<br />
England. Tel: 0121 604 2287, Fax: 0121 697 8377<br />
Dr Morris Kerstein, 1214 Valley Road, Villanova, PA 19085, USA<br />
Tel: 001 215 762 8402 Fax: 001 215 762 8389<br />
Mrs Penny Keynton-Hook, Department of Professional Studies, Sussex Weald<br />
and Downs NHS Trust, 9 College Lane, Chichester, PO19 4FX, England.<br />
Tel: 01203 815336 (0402 891835) Fax: 01203 815413<br />
Mrs Brenda King, 12 Beckton Ave, Waterthorpe, Sheffield, S20 7NA, England.<br />
Tel: 0114 271 6416, Fax: 0114 271 6417, brenda.king@virgin.net<br />
Prof Luther Kloth, Dept of Physical Therapy, Marquette University, PO Box<br />
1881, Milwaukee, WI 53201-1881 USA<br />
Tel: 001 414 288 3381 Fax: 001 414 288 5987<br />
Mrs Cathy Knowles, Tissue Viability Specialist, Royal Devon and Exeter<br />
Hospital (Wonford), Barrack Road, Exeter, EX2 5DW, England.<br />
Tel: 01392 402846 Fax: 01392 402774<br />
Mr E. Koopman, Deventer Ziekenh Stg, Fesevurstraat 7, 7415 CM Deventer,<br />
The Netherlands. Tel: +31 (0)570 646 078<br />
Prof. Andrzej Kubler, Chalublinskiego 1A, Wroclan, 50368 Poland.<br />
Tel: +48 71 328 1534, Fax: +48 71 328 5087<br />
andrzej.kubler@anest.am.wroc.pl<br />
Mr Erik Küppers, HNE Healthcare, Im Hulsenfeld 19, 40721 Hilden,<br />
Germany. Tel: +49 2013 97110 Fax: +49 2013 971146<br />
hne.kueppers@t-online.de<br />
Mr Jan van Laere, Smith & Nephew SA, Avenue du Four a Briques 3B, 1140<br />
Bruxelles, Belgium.<br />
Ms J Leenman, Albert Cuyplaan 17, Woudenberg LD 3931, The<br />
Netherlands. Tel: 00 31 33 286 2303 Fax: 00 31 33 693 2740<br />
Mr Derek Lemon, 13 Victoria Road, Northampton, NN1 5ED, England.<br />
Tel: 01604 604763 Fax: 01604 604763<br />
Miss Ruth Lester, 64 Wellington Road, Edgbaston, Birmingham, B15 2ET,<br />
England. Tel: 0121440 4937, Fax: 0121 440 7708<br />
ruthlester@compuserve.com<br />
Mr Nigel Lewis, Smith & Nephew Healthcare Ltd, Healthcare House, Goulton<br />
Street, Hull, HU3 4DJ, England.<br />
Ms Sarah Lewis, 14 Lancaster Road, Walthamstow, London, E17 6AJ, England.<br />
Tel: 020 8503 3921 sarah.lewis@uclh.org<br />
Mr Wouter Lioen, Sampli NV, Schamperij 9, B–9667 Horebeue, Belgium.<br />
Tel: 00 32 55 45 5867, Fax: 00 32 55 45 6986<br />
Dr Christina Lindholm, Uppsala University Hospital, Uppsala, 75185, Sweden.<br />
Tel: 00 46 18 66 3087. Fax: 00 46 87 15 44 42<br />
Dr Maarten Lubbers, Surgeon AMC, Meibergdreef 9 1105 AZ, Amsterdam,<br />
The Netherlands. Tel: 00 31 20 566 9111, Fax: 00 31 20 697 2988<br />
Ms Yvonne Lutgens, Nieuwe Uilenburgerstraat 10B, 10011 LP Amsterdam,<br />
The Netherlands. Tel: +31 20 566 9111 Fax: +31 20 566 9221<br />
y.h.lutgens@amc.uva.nl<br />
Ms Gysesl Machteld, De Domk 4, Mortsel, B–2640, Belgium<br />
Tel: 00 32 3455 2660 Fax: 00 32 3457 3419<br />
Mrs Helga Magnusson, Mölnlycke Health Care, PO Box 13080, 40503<br />
Göteborg, Sweden<br />
Mrs Peta Matthews, Southern Cottage, Jenkins Lane, St Leonards, Tring,<br />
Herts, HP23 6NW, England. Tel: 01494 758751<br />
Mr Andrew Cox Martin, Dept of Medical Engineering, Salisbury District<br />
Hospital, Salisbury, Wilts, SP2 8BJ, England.<br />
Tel: 01722 425138 Fax: 01722 416227 bill@medengsdh.demon.co.uk<br />
Dr Stella Maurizio, Burn Unit/CTO, via Zuretti 29, Torino, 10137 Italy. Tel:<br />
+39 11 693 3423/5, Fax: +39 11 693 3425<br />
Mr Anton Mayrhauser, Ketzergasse 39 (FA Sunmed), 1232 Vienna, Austria<br />
Tel: +43 1699 2299 Fax: +43 1699 2299-1 mayrhauser@ sunmed.at<br />
Mr Ray McDermott, Smith & Nephew Ltd, Pottery Road, Kill O’the Grange,<br />
Dun Laoghaire, Co. Dublin, Ireland.<br />
Dr Alistair McLeod, Huntleigh Technology PLC, 310-312 Dallow Road, Luton,<br />
LU1 1TD, England. Tel: 01582 745768, Fax: 01582 745862<br />
Ms Mary McMahon, St Joseph’s Ward, Cappagh National Orthopaedic<br />
Hospital, Finglas, Dublin 11, Ireland.<br />
Dr Sylvie Meaume, Hopital Charles Foix, 7 Avenue de la Republique, Ivry sur<br />
Seine, 94205, France Tel: 00 33 149 594 504,<br />
Fax: 00 33 149 594 524 sylvie.meaume@cfx.ap-hop-paris.fr<br />
Dr Julian Minns, Dept of Medical Physics, Dryburn Hosp, Durham, DH1 5TW,<br />
England. Tel: 0191 333 2220, Fax: 0191 386 5695 jminns@compuserve.com<br />
Mr Peter Mitchell, 40-60 West Thebarton Road, Thebarton, South Australia<br />
5031, Australia.<br />
Ulla Moe, Product Manager, Huntleigh Healthcare, Hejreskouvej 18a, 3490<br />
Kvistgard, Denmark. Tel: 00 45 49 138 486, Fax: 00 45 49 138 487<br />
Prof Fabrizio Moffa, Vulnera C50, Matteotti 35, Turin 10121, Italy.<br />
Tel: +39 011 544 747, Fax: +39 011 533 649 r.cassino@sicurdata.it<br />
Ms Sue Moody, Smith & Nephew Medical Ltd, PO Box 81, Hessle Rd, Hull,<br />
HU3 2BN, England.<br />
Ms Louise Morris, 3 Bowood Lane, St Peters, Worcester, WR5 3UT, England.<br />
Tel: 01905 769337 garethandlouise@talk21.com<br />
64<br />
Volume 3, Number 2, 2001
EPUAP MEMBERS<br />
Ms Libby Morrison, Worldwide Clinical Research Group, Johnson & Johnson<br />
Medical, Gargrave, North Yorkshire, BD23 3RX, England.<br />
Mr Olavi Murros, Kuoppatie 4, PO Box 25, 00731, Finland.<br />
Tel: +358 9 346 2574, Fax: +358 9 346 2576 olavi.murros@kolumbus.fi<br />
Mrs Jeanette Nelson, Vibro-Pulse Ltd, Colomendy Industrial Estate, Denbigh,<br />
N Wales, LL16 5TS, UK Tel: 01745 811200, Fax: 01745 817142<br />
epetern@aol.com<br />
Mr Peter Nelson, Vibro-Pulse Ltd, Colomendy Ind. Estate, Denbigh, N Wales,<br />
LL16 5TS, UK Tel: 01745 811206, Fax: 01745 817142 epetern@aol.com<br />
Ms Kaoru Nishide, Smith & Nephew KK, Shiba-Nikkei-Yuraku Bld, 1-10-13<br />
Shiba, Minato-ku, Tokyo 105-0014, Japan. Tel: 00 81 3544 35721,<br />
Fax: 00 81 3544 35722 kaoru.nishide@smith-nephew.com<br />
Mrs Jane Nixon, Park View House, Parkside, Bingley, BD16 3DG, England.<br />
Tel: 01904 434114, Fax: 01904 434101 jen@york.ac.uk<br />
Mrs Pia Obank, Lane End Surgery, Finings Road, Lane End, Bucks, HP14 3ES,<br />
England Tel: 01494 883364<br />
Miss Louise O’Connor, 37 Clough House Drive, Leigh, Lancashire, WN7 2GD,<br />
England. Tel: 0161 291 3227 louise.oconnor@smunt.nwest.nhs.uk<br />
Dr Cathy O’Neill, Huntleigh Healthcare, 312 Dallow Road, Luton, LU1 1TD,<br />
England. Tel: 01582 745736, Fax: 01582 459100 cathy.oneill@hunhcare.co.uk<br />
Sabine Onillon, Smith & Nephew AG, Hans-Huber Strasse 38, Postfach CH–<br />
Soluthurn, Switzerland.<br />
Mrs Nwando Onugha, 3 Wood Close, Salfords, Redhill, Surrey, RH1 5EE,<br />
England. Tel: 01293 823176<br />
Dr Cees Oomens, Eindhoven Univ of Technology, Mech Eng Dept, PO Box<br />
513, 5600 MB, Eindhoven, The Netherlands. Tel: +31 40 247 2818,<br />
Fax: +31 40 244 7355 oomens@wfw.wtb.tue.nl<br />
Ms Sarah Pankhurst, Wollaton Vale Health Centre, Wollaton, Nottingham,<br />
NG8 2GR, England. Tel: 0115 928 8861, 0590<br />
Mrs Anne-Marie Perrin, 13 Pettitts Lane, Dry Drayton, Cambs, CB3 8BT,<br />
England. Tel: 01954 780467 Fax: 01954 789729<br />
Dr Carla Pezzuto, Torino via Garibaldi 6, 10121, Italy. Tel: 00 39 011 521 5909<br />
Dr Maria Pietropaolo, via val Trompia 56, Rome 00141, Italy<br />
Tel: +39 06 871 92 983, Fax: +39 06 494 0594<br />
Dr Elaine Pina, Comissao de Controlo de Infeccao, Hopital sto Antonio dos<br />
Capuchos, Alameda sto Antonio, Dos Capuchos, 1150 Lisbon, Portugal.<br />
Mrs Monica Pittarello, Vulnera-Corso, Matteotti 35, Torino, 10121 Italy.<br />
Tel: +39 011 544 747, Fax: +39 011 533 649 r.cassino@sicurdata.it<br />
Dr Chryssanthi Plati, Univ of Athens, Fragokklissias 12 Str, 15125 Marousi,<br />
Athens, Greece. Tel/Fax: +301 61 98 619<br />
Mrs Fiona Preece, Staff Development Education Centre, Worcester Royal<br />
Infirmary NHS Trust, Ronkswood Branch, Newtown Rd, Worcester, WR5 1HN,<br />
England. Tel: 01905 760604, Fax: 01905 760580<br />
Mrs Maria Priami, Univ of Athens, Fragokklissias 12 Str, Marousi, 15125<br />
Athens, Greece. Tel/Fax: +301 61 98 619<br />
Dr Patricia Price, Wound Healing Research Unit, Cardiff Medi Centre, Heath<br />
Park, Cardiff, CF14 4UJ, Wales. Tel: 02920 682 179, Fax: 02920 754 217<br />
pricepe@cf.ac.uk<br />
Mr Terence Price, Seers Bough, Wilton Lane, Jordans, Beaconsfield, HP9<br />
2RG, England. Tel: 01494 874 589<br />
Mr Marcus Raphael, B Braun Medical Ltd, Thorncliffe Park, Sheffield, S35<br />
2PW, England. Tel: 0114 225 9127<br />
Fax: 0114 225 9123 marcus.raphael@bbraun.com<br />
Mr Claude Regnier, B. Braun Biotrol SA, 69 Rue de la Grange Aux Belles,<br />
75010 Paris, France.<br />
Brukhard Reis, Smith & Nephew GmbH, Medical Division, Max-Planck-Strasse<br />
1–3, D–34253 Lohfelden, Germany<br />
Prof Elia Ricci, Vulnera-Corso, Matteotti 35, Turino 10121, Italy<br />
Tel: +39 011 544 747 Fax: +39 011 533 649 r.cassino@sicurdata.it<br />
Dr Marina Ritter, Polyheal Ltd, 44 Bar Jehuda Str, Nesher, 20300 Israel<br />
Tel: +972 4 820 7917, Fax: +972 4 820 7919 marina@polyheal.co.il<br />
Dr Vladimire Ritter, Polyheal Ltd, 44 Bar Jehuda Str, Nesher, 20300 Israel<br />
Tel: +972 4 820 7917, Fax: +972 4 820 7919<br />
Dr Cassino Roberto, Vulnera-Corso, Matteotti 35, Torino 10121, Italy.<br />
+39 011 544 747 Fax: +39 011 533 649 r.cassino@sicurdata.it<br />
Dr Marco Romanelli, Department of Dermatology, University of Pisa, Via<br />
Roma 67, 56126 Pisa, Italy. Tel: 00 39 050 992 436 Fax: 00 39 050 551 124<br />
Prof Lior Rosenberg, 13 Harduf Street, Omer 84965, Israel<br />
Tel: +972 764 00880, Fax: +972 764 03033 proflior@netvision.net.il<br />
Voula Rossetto, Smith & Nephew Medical Ltd, PO Box 81, Hessle Rd, Hull,<br />
HU3 2BN, England.<br />
Dr Vincenzo Ruggiero, Clinica villa Bianca Martina, Franca Taranto Italie,<br />
74100 Taranto, Italy Tel: +39 080 449 0234<br />
Mrs Linda Russell, Queens Hospital, Burton Hospitals NHS Trust, Belvedere<br />
Rd, Burton on Trent, Staffs, DE13 0RB, England.<br />
Tel: 01283 511511 (x 2272)<br />
Dr David Ryan, General 1W, Freeman Hospital, Newcastle upon Tyne, NE7<br />
7DN, England. Tel: 0191 284311 (x 26423) Fax: 0191 223401<br />
David.Ryan@nuth.northg.nhs.uk<br />
Prof Terence Ryan, Wound Healing Institute, Department of Dermatology,<br />
Churchill Hospital, Headington, Oxford, OX3 7LJ, England.<br />
Tel: 01865 228269, Fax: 01865 228233<br />
Dr Paini Salminen-Peltola, Kuusaankuja 2, Jarvenpaa, 04430 Finland<br />
paivi.salminen-peltola@hus.fi<br />
Ms Margarita Sanchez, CI Cacandvas 27/31 SN, Corbera de Llobregat, 08757<br />
Barcelona, Spain. msanchez@icnpharm.com<br />
Mr Bob Sandham, Smith & Nephew Medical Ltd, PO Box 81, Hessle Rd, Hull,<br />
HU3 2BN, England.<br />
Andre Santos, Smith & Nephew Lda, Galerias do Alto da Barra, Av. Das<br />
Descobertas, Piso 3 No 59, Alto da Barra – 2780 Oeiras, Portugal.<br />
Dr Wayne Schroeder, 8023 Vantage Drive, PO Box 659508, San Antonio,<br />
78265-9508 Texas, USA. Tel: 001 210 554 5396<br />
Fax: 001 210 255 6988 schroedw@kci1.com<br />
Mrs Eileen Scott, Professorial Unit of Surgery, North Tees & Hartlepool NHS<br />
Trust, Stockton on Tees, TS19 8PE, England.<br />
Tel: 01642 624087 Fax: 01642 624165<br />
Mr Tony Seaney, Niaraga Holdings plc, 88a High Street, Shoreham-by-Sea,<br />
West Sussex, BN43 5DB, England.<br />
Dr Joseph Selkon, 4 Ethelred Court, Oxford, OX3 9DA, England.<br />
Tel: 01865 764098, Fax: 01865 764098<br />
Dr Zina Serafim, R.D. Estefania 5–3° D, Lisboa, Portugal. 1150–120.<br />
Tel: +351 1 354 9154<br />
Mrs Catherine Sharp, 3 Salisbury Street, South Hurstville, Sydney 2221,<br />
Australia Tel. & Fax: +61 2 958 50393 Tel: +61 2 938 53588<br />
Fax: +61 2 938 51086 catherine 410@hotmail.com<br />
Miss Helen Shearer, 164 Scalby Road, Scarborough, North Yorkshire, TO12<br />
6TB, England Tel: 01723 3754525 hcs164@hotmail.com<br />
Mr Andy Smallwood, NHS Purchasing & Supply Agency, 80 Lightfoot Street,<br />
Chester, CH2 3AD, England. Tel: 01244 586807 Fax: 01244 586828<br />
andy.smallwood@doh.gsi.gov.uk<br />
Ms Helen Smyth, Anglia Polytechnic University, School of Healthcare Practice,<br />
24 Park Road, Chelmsford, Essex CM1 1LL, England<br />
Tel: 01245 493131 (x 4142), Fax: 01245 250368 h.smyth@apu.ac.uk<br />
Mr Javier Soldevilla, Agreda Avda de Navarra, 8-10, 4-D, Logrono, 26001,<br />
Spain. Tel: +34 41 251 392, Fax: +34 41 22 03 44<br />
Mr Steve Spurgin, Smith & Nephew Medical Ltd, PO Box 81, Hessle Road,<br />
Hull, HU3 2BN, England. Tel: 01482-673742 Fax: 01482-673106<br />
Mrs Julie Stevens, 11 Portland Road, Ashford, Middlesex, TW15 3BU,<br />
England. Tel: 01784 242312 Work: 020 8321 2435 Fax: 020 8321 2272<br />
Tel:<br />
Volume 3, Number 2, 2001 65
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Mrs Fiona Stephens, 16 Strangford Rd, Tankerton, Whitstable, Kent, CT5 2EP,<br />
England. Tel: 01227 459371 Fax: 01227 812268<br />
r.f.stephens@btinternet.com<br />
Dr Thomas Stewart, Gaymar Industries Inc, 10 Center Drive, Orchard Park,<br />
NY-14127, USA<br />
Mrs Lesley Stockton, Department of Psychology, Manchester University,<br />
Oxford Road, Manchester, England Tel: 01942 682217,<br />
Fax: 01942 681995 otlesely@yahoo.co.uk<br />
Mrs Varda Swager, Hoshav Serufa Doan Nah, Hof Ha Carmel, 30850, Israel.<br />
Tel: +972 4984 2928 Fax: +972 4854 2750<br />
Dr Ian Swain, Dept of Medical Physics and Bio. Engineering, Salisbury District<br />
Hospital, Salisbury, SP2 8BJ, England. Tel: 01722 336262 (x 4065), 425263<br />
Ms Anna-Britta Tallberg, Vaksala Svia, 75594 Uppsala, Sweden<br />
Tel: +46 18 31 7412, Fax: +46 18 611 2460<br />
Mrs Adrienne Taylor, Salford Community Health Care NHS Trust, The<br />
Willows Centre for Health Care, Lords Avenue, Salford M5 2JR England.<br />
Tel: 0161 737 0330 Fax: 0161 745 8042<br />
Mrs Ann Withington, 10 Barnfield Crescent, Wellington, Telford, Shropshire<br />
TF1 2ES, England. Tel: 01952 641222<br />
Dr Helene Wolff, Fyra Dalersgatan 32, 41319, Sweden Tel: 00 46 342 1000<br />
Mrs Frances Worboys, 2 The Poplars, Cheshunt, Herts, EN7 6AR, England.<br />
Tel: 01992 626100<br />
Ms Trudie Young, School of Nursing, Glan Clwyd Hospital, Bodelwyddan,<br />
Denbighshire, LL18 5UJ, UK Tel: 01745 583910 Fax: 01745 534960<br />
Mr Arkadiusz Zbronski, ul Kasztanowa 27, Olsztyn, 10–156 Poland.<br />
real@cso.com.pl<br />
Mr Ireneusz Zbronski, ul Kasztanowa 27, Olsztyn, 10–156 Poland.<br />
real@cso.com.pl<br />
Mr Jintiene Zeilstra, Academisch Zienhuis Groningen, Postbus 30001<br />
Groningen, Secretarial Dermatologie TI 250, 97008 B, The Netherlands.<br />
Tel: 00 31 50 361 2520 Fax: 00 31 50 361 2624 j.t.zeilstra@derm.az.nl<br />
Dr M Barend ter Haar, BES Rehab Ltd, 9 Cow Lane, Fulbourn, Cambridge,<br />
CB1 5HB, England. Tel: 01223 882105, Fax: 01223 882105<br />
b.e.s.rehab@btconnect.com<br />
Mrs Susan Thomas, 3 Tylston Meadow, Liphook, Hants, GU30 7YB, England.<br />
Tel: 01420 488999, Fax: 01420 489009 clinical@crownmed.co.uk<br />
Ms Jean Thomson, 9 Goddards Lane, Aldbourne, Marlborough, Wilts, SN8<br />
2DZ, England.<br />
Mr Tore Tomter, Tordivelen 20, Hamar, N-2316 Norway.<br />
Tel: +47 625 26272, Fax: +47 625 21211 tore@togemo.no<br />
Mrs Hazel Tonge, Clinical Department, Beiersdorf UK Ltd, Yeoman’s Drive,<br />
Blakelands, Milton Keynes, Bucks. MK14 5LS, England. Tel: 01908 211333,<br />
Tel: 01908 211555<br />
Dr Joan Enric Torra i Bou, Galle 5. Bis, Barcelona, 08021, Spain.<br />
Tel: +34 3 731 0474<br />
Mr Bart Van der Heyden, Slagmanstraat 48, 9080 Lochristi, Belgium.<br />
Tel: +32 (0)9356 72 22 Fax: +32 (0)9356 69 15<br />
bvanderheyden@attglobal.net<br />
Mr Edwin Van der Zee, Krommekamp 232, Harderwijk, 3848 DT, The<br />
Netherlands Tel: +31 341 4189214, Fax: +31 341 422957<br />
vanderzee@globalxs.nl<br />
Mrs Tracy Vernon, Doncaster Royal Infirmary, Armthorpe Road, Doncaster,<br />
Yorks, DN2 5LT, England. Tel: 01302 366666 (ext. 3359) Fax: 01302 320098<br />
Dr Senen Vilaro Coma, Facultat de Biologia, Department de Biologia Celular,<br />
AVDA Diagonal 1645 1o Planta, 08028 Barcelona, Spain. Tel: 00 34 93 402<br />
1550, Fax: 00 34 93 411 2967<br />
Ms Heidi Vrijdagh, Huntleigh Healthcare, Stapelplein 70, 9000 Gent, Belgium<br />
Tel: +32 9 265 8770, Fax: +32 9 265 8771<br />
heidi.vrijdagh@huntleigh-healthcare.be<br />
Ms Ann-Brigitte Vugelsang, Bogfinhevg 8, Hinnerup, 8382 Denmark.<br />
Tel: +45 86 91 2811 anne-brig@hotmail.tele.dk<br />
Ms Anna Watson, 72 The Paddocks, Hybreasal, South Circular Raod,<br />
Kilmainham, Dublin 8, Ireland. Tel: +353 1 473 1605<br />
Dr K-G. Werner, Compliance Network Physicians/Health Force Initiative, P.O.<br />
Box 02 12 45, Berlin, D–10123, Germany.<br />
Tel: +49 30 2472 1772, Fax: +49 30 2472 1773<br />
Jan Weststrate, University Hospital Rotterdam, Room Z–646, P.O. Box 2040,<br />
Rotterdam, 3000 CA, The Netherlands.<br />
Tel: +31 10 463 4237, Fax: +31 10 463 4234<br />
Miss Emma Wheat, 89 Llanishen Street, Heath, Cardiff, CF14 3QD, Wales, UK<br />
Tel: 02920 404729 ewheat@uwic.ac.uk<br />
Mr Arthur Wheeler, 1 Samsworth Close, Castor, Peterborough, Cambs. PE5<br />
7BQ, England. Tel: 01733 380774<br />
Ms Ada Wimmers, Boveny Ziekenhuis, Statenjachtstraat 1, 1034 CS,<br />
Amsterdam, The Netherlands. Tel: +31 20 634 6346, Fax: +31 20 634 6730<br />
66<br />
Volume 3, Number 2, 2001
epuap Membership<br />
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Application Form, 2001–2002<br />
MISSION STATEMENT<br />
The <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong>’s objective is to provide the<br />
relief of persons suffering from, or at risk of pressure ulcers, in particular<br />
through research and the education of the public. The <strong>European</strong> <strong>Pressure</strong><br />
<strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong> is a registered charity, number 1066856.<br />
MEMBERSHIP APPLICATION<br />
PLEASE PRINT CLEARLY<br />
Name: _________________ _______________________ __________________________ ______________________<br />
Title (Prof, Dr, etc) First name Last Name Degrees<br />
Full Postal Address: ___________________________________________________________________________________<br />
_____________________________________________________________________________________________________<br />
______________________________ Postcode: ______________________ Country: ___________________________<br />
Tel: ___________________________________________________________<br />
Fax: _______________________________<br />
E-mail: ______________________________________________________________________________________________<br />
Main fields of interest: _________________________________________________________________________________<br />
_____________________________________________________________________________________________________<br />
_____________________________________________________________________________________________________<br />
Membership fee: £30 per year (September 2001 – September 2002)<br />
Which includes Certificate of Membership plus the EPUAP <strong>Review</strong><br />
Cheques should be made payable, in British Pounds drawn on a UK Bank, to:<br />
EPUAP Registered Charity 1066856<br />
And application forms should be returned to:<br />
EPUAP Office, Wound Healing Unit<br />
Department of Dermatology, Churchill Hospital<br />
Old Road, Headington, Oxford<br />
OX3 7LJ, UK<br />
Fax: +44 (0)1865 228233<br />
Arrangements can be made for payment by Access/Mastercard/Visa credit cards<br />
(There is a £2 service charge added for this facility)<br />
a) Credit card type: Access/Mastercard/Visa (Please delete as appropriate) b) Amount to be debited: £32<br />
c) Credit card number: ______________________________________ d) Expiry date of credit card: ______ /______<br />
e) Exact name and initials on credit card: _______________________________________________________________<br />
f) Address to which credit card statements are sent: _______________________________________________________<br />
_____________________________________________________________________________________________________<br />
_____________________________________________________________________________________________________<br />
g) Signature to authorise debit of annual subscription: ____________________________________________________<br />
Volume 3, Number 2, 2001 67
C O R P O R A T E M E M B E R S<br />
A N D S P O N S O R S O F T H E<br />
F O U R T H O P E N M E E T I N G<br />
O F T H E E P U A P<br />
3M<br />
Augustine Medical<br />
B. Braun Medical S.A.<br />
ConvaTec<br />
Cook<br />
Frontier Therapeutics<br />
Gaymar Industries Inc<br />
Hill-Rom Europe<br />
Huntleigh Healthcare<br />
Paul Hartmann AB<br />
KAYMED<br />
Mölnlycke Healthcare AB<br />
Nutricia Healthcare<br />
Pegasus Ltd<br />
Smith & Nephew<br />
Tempur U.K. Ltd<br />
URGO<br />
Designed and produced by John Brennan at the Positif Press, Oxford<br />
Tel: +44 (0)1865 243220 Fax: +44 (0)1865 243272<br />
Printed by Oxuniprint at Oxford University Press<br />
© <strong>European</strong> <strong>Pressure</strong> <strong>Ulcer</strong> <strong>Advisory</strong> <strong>Panel</strong>, 2001<br />
ISSN 1464–7796<br />
68<br />
Volume 3, Number 2, 2001