Review 3.2 - European Pressure Ulcer Advisory Panel

epuap
EUROPEAN PRESSURE ULCER ADVISORY PANEL
Trustees of the European Pressure Ulcer Advisory Panel
Mission Statement
Executive Committee Members:
Trustees:
The European Pressure Ulcer Advisory Panel’s objective is to provide the
relief of persons suffering from, or at risk of pressure ulcers, in particular
through research and the education of the public.
Jeen Haalboom: President (Netherlands)
Gerry Bennett: Recorder (England)
Marco Romanelli: Vice President (Italy)
Keith Harding: (Past President) (Wales)
George Cherry: Secretary/Treasurer (England)
Christine Cherry: Business Administrator (England)
Michael Clark (Wales)
Denis Colin (France)
Christina Lindholm (Sweden)
Joan-Enric Torra i Bou (Spain)
Sue Bale (Wales)
Brigitte Barrois (France)
Andrea Bellingeri (Italy)
Carol Dealey (England)
Tom Defloor (Belgium)
Jacqui Fletcher (England)
Heinz Gerngross (Germany)
Finn Gottrup (Denmark)
Laszlo Gulacsi (Hungary)
Ruud Halfens (Netherlands)
Helvi Hietanen (Finland)
Deborah Hofman (England)
Agnes Jacquerye (Belgium)
Germain De Keyser (Belgium)
Maarten Lubbers (Netherlands)
Sylvie Meaume (France)
Zena Moore (Eire)
Terence Ryan (England)
Anne Witherow (Northern Ireland)
EPUAP Business Office:
Wound Healing Institute
Department of Dermatology
The Churchill Hospital, Old Road
Headington, Oxford, OX3 7LJ, UK
Tel: +44 (0)1865 228264
Fax: +44 (0)1865 228233
E-mail: EuropeanPressureUlcerAdvisPanel@compuserve.com
Volume 3, Number 2, 2001 33

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EUROPEAN PRESSURE ULCER ADVISORY PANEL
From the President
LETTER FROM THE PRESIDENT
Dr Jeen Haalboom
WITHIN two months the Fifth Conference of EPUAP will be in Le
Mans France and Marco Romanelli will take over as President. The
past two years were characterized by an ever increasing awareness
of the problem of pressure ulcers in most of the European countries and the
United States. The conferences we held in Amsterdam and Pisa were successful
and the number of participants increased steadily. In Le Mans we will
have a joint meeting with the French pressure ulcer organisation PERSE and
the number of participants of this joint meeting will exceed 1000. I am sure
that the results will be good, although such large numbers also bear the risk
that personal contacts become more difficult and personal contacts and respect
for each other are mainstays of the EPUAP. I think that especially the
installation of working groups or if you wish task forces was important. Within
relatively short periods of time difficult problems could be tackled and solved
as far as possible. We now have a minimum data set for new studies, the
criteria to which pressure relieving devices should perform have been extensively
dealt with, a European prevalence study was developed. In Le Mans
the first results of a group working on risk assessment will be presented and
if I am allowed to lift up a corner of the veils, the results will be at least
staggering. It could well be that the use of any risk assessment tool is not
without risk. Next year we will start a similar group working on wound dressings.
In summary, I think the EPUAP is healthy and bursting with energy and
can be handed over to Marco in good shape. This is due to the hard work of
the EPUAP Trustees and members. Thanks to you all.
Jeen Haalboom
President
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EUROPEAN PRESSURE ULCER ADVISORY PANEL
From the President Elect
LETTER FROM THE PRESIDENT ELECT
Dr Marco Romanelli
IN my first letter as the new President of the European Pressure Ulcer
Advisory Panel I would like to welcome all the members of the society
and also all the delegates attending the Fifth annual meeting of EPUAP
in Le Mans (France). The theme of this year’s meeting ‘Education – Experience
we can share’ is best giving the significance of confrontation in order
to improve our knowledge in managing pressure ulcers. The conference will
be held jointly with the PERSE (Prevention Education Recherche Soins
Escarres), a French wound healing society which is holding its annual meeting
in Le Mans. In the future I would like to encourage similar joint meetings
between European and National organizations to avoid multiple conferences
in the same year, and to enable our corporate members to collaborate
more in the society activities. The annual meeting continues to be the
most important event among the activities of EPUAP, but I would also like to
mention the EPUAP Review, edited by Michael Clark, and the new EPUAP
web site. These tools are real and attractive ways of communication and I
would like to encourage all members to be part of the contributions needed
to spread our mission on pressure ulcers.
Our society is growing rapidly to achieve the highest level of care standard
in the management of pressure ulcers. To date there has been a high
level of interest in all the activities running inside our group which we hope
will continue during the next few years. The countries represented inside
EPUAP has reached a total number of sixteen, and this is a true manifestation
of the global-European involvement of our group. There are many ongoing
activities at this time inside the panel, from the pressure ulcer prevalence
project to the various EPUAP working parties, which are going to update
their studies in Le Mans.
Finally I would like to thank the two past presidents of EPUAP – Prof
Keith Harding and Prof Jeen Haalboom – for the outstanding impetus they
gave to our panel, and to conclude with a statement which I think truly represents
the spirit of our society:
‘A well-conducted medical society may be of the greatest help in
stimulating the practitioner to keep up habits of scientific study.’
Sir William Osler (AEQUANIMITAS, 1903)
Marco Romanelli
President Elect
Volume 3, Number 2, 2001 35

epuap Letter
EUROPEAN PRESSURE ULCER ADVISORY PANEL
from the Editor
EDITORIAL
Dr Michael Clark
WELCOME to the latest issue of the EPUAP Review. By the time you
read this, the 5th European Pressure Ulcer Advisory Panel Open
Meeting will be taking place in Le Mans, France. It hardly seems
like twelve months since the EPUAP last met in Pisa – perhaps this is because
the various working groups established over recent Open Meetings have been
keeping many of us busy! In this issue there is an update of some of the
activities of the various groups – perhaps you may be asking how can you get
involved with this work The lead person within each group is identified in
the progress report – contact them to discuss participation. EPUAP would
encourage all members to get involved with the engine of the organisation –
the working groups.
This issue also sees publication of the second part of Dr Gulacsi’s article
on Hungarian quality assurance activities related to pressure ulcers. This is a
timely article for in 2002 the 6th EPUAP Open Meeting will take place in
Budapest. We look forward to welcoming you to this historic city for what
promises to be another high quality conference upon pressure ulcers.
Pressure ulcer risk assessment continues to fascinate members of this organisation
– however, there seems to be strong, but divergent, views upon
how this is to be best performed and evaluated. Earlier this year a working
group, led by Tom Defloor (Belgium), began to compile a position statement
to identify just what was EPUAP’s stance upon risk assessment. The
latest version of this statement is published in this issue, while those attending
the Le Mans meeting will have the opportunity to discuss and vote upon
its contents. For those readers who were unable to attend the Le Mans meeting,
do not think that you have no opportunity to contribute to this position
statement. Please forward any comments upon the proposed EPUAP statement
on risk assessment direct to Tom Defloor.
E-mail to: < Tom.Defloor@rug.ac.be>
Please do not hesitate to write or call the Business Office at Oxford with
any comments or suggestions for this newsletter. I would also encourage all
members to consider contributing short or long pieces upon any topic related
to pressure ulcers, their prevention and management.
Looking forward to seeing you in Le Mans.
Michael Clark
Editor
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epuap Prevention
EUROPEAN PRESSURE ULCER ADVISORY PANEL
and Treatment of Pressure Ulcers
EPIDEMIOLOGY, PREVENTION AND TREATMENT OF PRESSURE
ULCERS IN HUNGARIAN HOSPITALS; 1992–1998. PART 2
Dr László Gulácsi, President, Hungarian Wound Healing Society
This article follows from Part 1 of Dr Gulacsi’s report published
in Vol 3 (1) of the EPUAP Review. For the convenience
of readers the abstract is reprinted to establish the
context of the article.
Abstract
Objectives: This project held three objectives: (1) Within
patients nursed in acute care hospitals and considered to be
at risk of pressure ulcer (PU) development, what was the baseline
prevalence and incidence of PU. (2) To establish the
current patterns of preventive and treatment interventions
and to investigate the economic burden imposed by the prevention
and treatment of PU within the hospital population.
(3) To improve the quality of both PU prevention and treatment
through the creation, dissemination and implementation
of quality assurance programmes in hospitals.
Design: Data were collected from several sources: (1) Retrospective
PU data gathered during the quality assurance
activities undertaken within 17 (COMAC/QA/HSR Programme)
and 20 (BIOMED/PECO Programme) general
public hospitals between 1992 and 1997 (*). (2) Retrospective
national data describing the prevalence of PU between
1993 and 1998. (3) Retrospective chart review to identify
PU management across 1,200 adult patient records drawn
from 7 hospitals in 1994. (4) Analysis of the national financial
reimbursement of the in-hospital PU cases in 1994. (5)
Prospective active surveillance of 705 adult patients in one
county hospital. (6) Prospective active surveillance of 2,702
adult patients along with the costing of 100 PU patients
(1,350 PU patient-days). (7) Changing PU prevention and
treatment practices through the use of clinical protocols
and guidelines.
Main results: (1) The actual prevalence of pressure ulcers
is estimated to be 16–27 fold higher (3.7%–5.7%) than the
officially published rate (0.18–0.21%) in Hungary. (2) On
average 1.0%–2.5% of the direct costs of PU treatment,
along with the estimated one to five days prolonged hospitalisation
are reimbursed under the current DRG financing
mechanism. (3) As a result of this four-year PU study
and quality assurance intervention, the Hungarian Wound
Healing Society was created in 1997 in order to improve
the quality of patient care through education, training, creating,
disseminating and implementing guidelines and conducting
surveillance in the field of prevention and treatment
of PU.
Conclusion: (1) In order to monitor the true incidence and
prevalence of PU active surveillance has to be established.
(2) Both the prevention and appropriate treatment of pressure
ulcers are in the economic interest of the hospitals
reimbursed under the current DRG mechanism, because
they are not reimbursed for any additional costs incurred
by the PU patients. (3) Appropriate PU surveillance and
documentation, including risk assessment, PU guidelines,
PU costing and disease forecast tools have to be implemented,
in addition disease-specific PU quality of life tools
have to be created, if health care professionals and managers
want opinion leaders, media and financing organisations
to be on their side. (4) Incidence and prevalence of
pressure ulcers can be decreased by appropriate prevention
and treatment.
This study was part of the ‘Concerted Action Programme on
Quality Assurance in European Hospitals (COMAC/HSR),
1992–1994, and part of its follow-up programme, the ‘Cooperation
in Science and Technology with Central and Eastern
European Countries and with the New Independent States of the
Former Soviet Union, Les Pays d’Europe Centrale et Orientale
(BIOMED/PECO)’ of the the European Union, DG XII, between
1994–1997, and This study was performed under the aegis of
the Hungarian Society for Quality Assurance in Health Care
and the Hungarian Wound Healing Society,
The author express special thanks to European Union, DG
XII., the Dutch Ministry of Health, Welfare and Sport, the
Hungarian Ministry of Health and Mölnlycke Health Care for
funding the study.
Section numbering follows from Part 1 of this article.
2. The epidemiology, prevention and treatment
of PU in Hungary (continued)
2.4 Phase 4: The reimbursement of hospitals for the care
of patients with PU, 1994
According to the Centre of Healthcare Information, Ministry
of Health, Hungary, 3,710 PU cases were recorded into
medical records and reported to the Centre in 1994. Overall
2.115 million patients episodes were reimbursed in 1994
giving a prevalence of PU cases of 0.18%.
Economic incentives can be important as levers to improve
the quality of care and to decrease unnecessary resource
utilisation. According to the economic analysis of
Phase 4, nationally in 1994, the extra payment approximated
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EUROPEAN PRESSURE ULCER ADVISORY PANEL
only between 1–2.5% of the cost of treating PU cases in
hospitals. This result shows that under the DRG system there
are explicit financial incentives for hospitals to perform effective
PU prevention given the high, and largely non-reimbursed
costs of their treatment.
2.5 Phase 5: Active prospective surveillance and risk
assessment of 705 adult patients in one county hospital
during 1995
In 1995, the fate of 705 consecutive patients newly-admitted
to four medical departments (3 active and 1 chronic)
in one large county hospital was followed. At admission their
current vulnerability to PU was documented using the
Norton Scale with one nurse performing all assessments.
The main aim of the study was to investigate any differences
in both the distribution of patient age and PU occurrence
between the acute and chronic care departments and secondarily
to explore the sensitivity and specificity of the
Norton Scale. The recruited subjects’ were largely elderly
with 454 (64.4%) over 60 years old. Only 17 (2.4%) were
under 30 years old with the remaining 234 (33.2%) falling
between 30 and 60 years. The prevalence of PU differed
between the acute (prevalence 2.9%) and chronic (prevalence
19.6%) departments. Overall, 40 patients (5.7%) were
found to present with PU. Subjects were divided into two
groups; Group A (at risk; Norton Score at admission 5–14,
n=189, 16.8%) and Group B (risk free Norton Score of at
least 15 at admission, n=516, 73.2%). In Group B 3 subjects
presented with PU (0.6%). Group A subjects were then
divided into two further groups; Group C (medium risk,
Norton Score at admission 13 or 14, n=52, 7.4%) and Group
D (high risk, Norton Score at admission 12 or less, n=137,
19.4%). Eight patients in Group C (15.4%) and 29 from
Group D (21.2%) presented with PU.
2.6 Phase 6: The cost of PU care based upon the fate of
100 adult in-patients with PU within one county hospital
In 1996, 100 consecutive patients with PU were recruited
across 15 departments of one county general hospital. These
patients either presented with PU at the time of admission
(n=49) or developed their ulcers during their stay (n=51).
The objective of the study was to define, and cost, the care
allocated to patients with, or at risk of, PU. The direct hospital
costs associated with PU prevention and treatment was
collected by micro-costing. Data collection was structured
using a standard instrument that recorded the location and
grade of PU, the patient’s diagnoses, progress and other
clinical circumstances, and finally any medical devices and
nursing procedures allocated to help prevent or treat PU.
All data was completed by a trained, specialist surveillance
nurse. Patients were eligible for recruitment if they had a
PU at the time of admission to hospital or developed a PU
during their stay. All eligible patients had to be aged eighteen
years or older, and admitted to one of the following
specialities – Medical I–III, Surgery, Traumatology, Neurology,
Urology, Oncology, Medical intensive, Surgical intensive,
Central admitting, Chronic medical, Acute Psychiatry,
Chronic Psychiatry and Rehabilitation.
The specialist nurse who completed all patient assessments
and who recorded all drug, device and medical investigation
related to PU prevention and treatment was
trained before the study began. On each participating ward,
the nurse who first identified the presence of a PU informed
the specialist nurse who then completed the resource utilisation
data collection form daily. Upon admission to the
study, a Norton Scale was completed and all body sites were
observed to record the distribution of PU. The Norton Score
was re-calculated upon any significant changes in the patient’s
health status and was also recorded at the time of
discharge from hospital. The specialist nurse was monitored
weekly by the hospital’s nursing director.
2.5.1 PU incidence and prevalence
During the six-month duration of the investigation 2,711
patients were admitted to the participating departments.
Of these, 100 (3.7%) patients had PU with 41 patients presenting
with PU at the time of admission. New PU developed
in 59 subjects admitted to hospital without PU. The
average age of the PU patients was 78.2 years with only 19
aged under seventy. The 100 PU patients presented with
308 co-morbidities (3.08 per patient). Of the 100 patients
with PU, 73 died during their stay in hospital (mean age
77.15 years, mean length of stay (LOS) 37.4 days), and these
patients had an average of 3.18 co-morbidities each. The
remaining 27 patients discharged alive (mean age 68.2 years,
mean LOS 27.5 days) from hospital had fewer co-morbidities
(2.77 per patient). Among the live discharges, 3 patients
experienced complete healing of their PU, the remainder
either showed some or no improvement in the status of
their PU. The average age of the patients who died during
the hospitalisation was 77.15 years, whereas the average age
of those discharged home was 68.2 years. The reduced age
of the patients discharged alive is consistent with other studies.
Michocki et al (1976) reported an approximate fourfold
increase in the probability of death following the development
of a PU among elderly patients. The advanced
age of the patients with PU has also been reported by others.
Walldorf (1986) reported an annual incidence of PU
in hospital of 3% with 96% of all affected patients being
over 65 years, with 36% over 85 years old.
The 100 patients with PU presented with 178 ulcers,
with wounds located at the left and right aspects of each
anatomical location treated as a single PU. The mean size
of the encountered PU was 425.5 square cm, and 74% of
PU classed as Grade 2 or more severe. The majority of PU
(89%) were located caudal to the apex of the iliac prominence.
Overall the total cost of PU treatment among the 100
patients (1,350 PU patient days) was 721,164 HUF, an average
of 534HUF per patient day. While the 100 subjects were
followed for 1,350 patient days, this period excluded a) time
spent in hospital prior to the start of the study and b) time
passed in medical departments other than the participating
specialities. Overall, the 100 PU patients remained in
hospital for 2,287 days at an estimated total cost of 1,072,934
HUF, an increase of 351,770 HUF above the study costing
(based on a total of 1,350 patient days). Table 8.15 illustrates
the size and cost of treatment of the encountered PU
by their severity. Both the mean size and cost per day of
treatment increased as PU became more severe.
The presented costs related only to those directly incurred
in PU prevention and treatment. Additional costs
that may be incurred through any prolongation of the stay
in hospital due to having a PU were not included. Such
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THE PREVENTION AND TREATMENT OF PRESSURE ULCERS
hidden costs include hotel services and overheads. The estimated
total hospital cost incurred by the 100 PU patients
was 9,703,868 HUF. Presently the extent to which (if any) a
PU extends LOS is unknown. However any extension of
LOS due to pressure ulcers will be costly; for example in
medical department I., a 1% increase in LOS would cost
7,155 HUF.
2.5.2 Estimating the burden and cost of PU at the
national level
In 1996, 2,250,000 people were admitted to hospital in
Hungary. From the results of the current study, the estimated
national prevalence of PU in 1996 was 3.7% (78,000
PU patients). This should be contrasted with the information
available through the Centre for Healthcare Information,
Ministry of Welfare, which reported 4,139 PU patients
in 1996 (national prevalence 0.18%). It is suggested that,
based on the current investigation, a 3% (n=66,700 PU patients)
to 5% (n=113,000 PU patients) can be expected
within Hungarian hospitals.
During 1996 the total reimbursement for PU patients
was 24,844,514 HUF with a PU related DRG creep of only
12,499 HUF. If hospitals had adopted excellent disease classification
coding practices then PU reimbursement would
have only increased by 0.05%. However, the reimbursement
was based upon the data reported to the Centre for Healthcare
Information, an estimated under-reporting of 78,020
cases of PU patients! If hospitals had reported the likely
true number of PU patients the estimated national reimbursement
would have been 522,491,500 HUF. This calculation
assumes that the distribution of PU by main nursing
diagnosis, complication and co-morbidity was constant in
both the reported and estimated populations. When calculating
the cost of PU, the cost elements can be grouped
into two categories: a) Direct costs of PU treatment amounting
to 837,135,650 HUF in 1994 (cost estimated from sample
population data), and b) Indirect costs of hospitalisation
among patients who have PU among other diagnoses.
This estimation clearly depends upon the daily cost of hospital
care within different medical specialities. A one-day
prolongation of LOS due to PU would cost 330,708,150 HUF
(national level, 1996 costs). While there is no information
upon the effect of PU on LOS in Hungary, it is more widely
speculated that PU may extend LOS by five days.
Assume that the prolonged LOS represents:
• One day per PU patient: In this scenario the additional
cost due to the prolonged hospital stay would
be 330,708,150 HUF, and the total costs of all PU
patients would reach 1,167,843,800 HUF. In 1996
the total PU patient reimbursement to hospitals was
24.844.514 HUF suggesting that only 2.5% of the
total cost of caring for PU patients in hospital was
reimbursed by the Health Insurance Fund.
• Five day per PU patient: In this perhaps worst-case
scenario the additional cost due to the prolonged
hospital stay would be 1,653,540,700 HUF, and the
total costs of all PU patients would reach
2,490,676,300 HUF. If this extension of LOS was
accepted then in 1996, only 1% of the total costs of
caring for patients with PU in Hungarian hospitals
was reimbursed by the Health Insurance Fund.
These scenarios both assume that the costs of
hospital care increase in a linear relationship with
the extended LOS.
2.7 Phase 7: Changing PU prevention and treatment
practices through the use of clinical protocols and
guidelines, 1997–1998
One central effect of the overall study was to make health
professionals aware that guidelines and local protocols on
PU prevention and treatment were required to reduce local
practice variations and so improve the quality of care.
Consensus building conferences were organised with the
participation of the hospitals involved in earlier stages of
the study. These events resulted in the creation of Hungarian
guidelines for PU prevention and treatment, based upon
several published international PU guidelines (The Dutch
Consensus Prevention of Bedulcers CBO, 1985; National
Pressure Ulcer Advisory Panel, 1995; European Pressure
Ulcer Advisory Panel, 1998). Draft versions of the PU prevention
and treatment guidelines were provided for comment
through various multidisciplinary meetings involving
nurses, physicians (surgeons, dermatologists, orthopaedists,
intensive care specialists, etc) and the medical and nursing
directors of Hungarian hospitals. The final versions were
published in medical and nursing journals under the aegis
of the Hungarian Wound Healing Society, and the Hungarian
Society for Quality Assurance in Health Care. These
guidelines were generally accepted and widely implemented
across Hungarian hospitals. The Hungarian PU prevention
and treatment guidelines are slightly modified versions of
the European Pressure Ulcer Advisory Panel’s PU prevention
(1998) and treatment (1999) guidelines.
3. Discussion and conclusion
The relatively high number of study participants, patients,
professionals and organisations, the high level of willingness
of participation and the high completion rate suggest
that we have now sufficient experience in this area to make
some general conclusions about the current situation and
possible future development of quality assurance in Hungary.
Various quality measures were used in the presented
study associated with structure, process and outcome. Results
show that both structure and process quality improved.
‘intermediate’ outcome was assessed.
This project hold three main goals: a) to develop the
baseline prevalence and incidence of PU in Hungarian hospitals;
b) to establish the current patterns of preventive and
treatment interventions and to investigate the economic
burden imposed by the prevention and treatment of PU;
and c) to improve the quality of both PU prevention and
treatment through the creation, dissemination and implementation
of quality assurance programmes in hospitals.
a) Prevalence and incidence of PU in Hungarian hospitals
The actual prevalence of pressure ulcers according to the
Hungarian study presented in this chapter, is estimated to
be 16–27 fold higher (3.7%–5.7%) than the officially published
rate (0.18–0.21%) by the Centre for Healthcare Information
Ministry of Health in Hungary. Compared with
the international literature on PU prevalence the number
of officially reported PU cases is very low, due to various
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EUROPEAN PRESSURE ULCER ADVISORY PANEL
methodological problems including misclassification, incompleteness
and inaccuracy of data collection, unchecked
and mainly self-reported data.
Baseline PU prevalence and incidence data is needed
to properly evaluate the effect of any PU quality assurance
initiative. This requires the availability of trained staff and
a standardised approach to data collection.
b) Current patterns of preventive and treatment
interventions and the economic burden of PU
The second aim of the study was to establish the current
patterns of preventive and treatment interventions and to
investigate the economic burden imposed by the prevention
and treatment of PU. The study showed that there was
a widespread local variation in the current patterns of preventive
and treatment interventions among hospitals and
hospital departments. One consequence of the wide practice
variations was that it was practically impossible to identify
either the results (outcomes) or the costs of different interventions.
It is likely that these differences in nursing practice
may result in differences in the recorded incidence of PU.
The level of knowledge about PU was meagre and pressure
ulcers were seldom viewed as a major problem in the
hospitals. It was frequently unclear who is responsible for
the prevention and treatment of pressure PU in the hospitals,
the quality of PU care was depending in a large extent
on personal initiatives. Practice guidelines and protocols
were not created, disseminated and implemented in the
hospitals. When PU quality assurance programmes began
in Hungary it was widely accepted that PU were almost nonexistent
and that this disease and its economic burden were
not important. In contrast, according to the study presented
in this chapter, the total cost of all PU patients would reach
the level of 1,167–2,490 million HUF annually, which is 0.4–
0.8% of the total health care budget in Hungary. Reliable
PU prevention and treatment cost information can be obtained
through micro-costing. On average 1.0%–2.5% of this
direct costs of PU treatment are reimbursed under the current
DRG financing mechanism. Economic incentives for
creating better quality nursing care are required, while at
present the cost of ‘poor quality care’ are not identifiable.
c) To improve the quality of PU prevention and treatment
Another aim of the study was to improve the quality of both
PU prevention and treatment through the creation, dissemination
and implementation of quality assurance programmes
in hospitals. PU prevention and treatment technologies
were often used inappropriately due to the lack of
practice guidelines. Practice guidelines were required to
decrease the use of ineffective interventions or those with
low cost-effectiveness. One important result of the overall
study was to make health professionals aware that guidelines
and local protocols on PU prevention and treatment
are required to reduce local practice variations and improve
the quality of care. The study resulted in the creation of
Hungarian guideline for PU prevention and treatment,
based upon several published international PU guidelines
such as: The Dutch Consensus Prevention of Bedulcers CBO
(1985), National Pressure Ulcer Advisory Panel (1995) and
the European Pressure Ulcer Advisory Panel (1998). This
guideline was widely disseminated and implemented among
Hungarian hospitals. The importance of the continuous
education for all staff involved in PU prevention and treatment
was recognised as well. Training for ‘Pressure Ulcer
Nurses’ was provided and a 350 member large professional
society on PU prevention and treatment was created (Hungarian
Wound Healing Society).
This study provided evidences that the structure and
process quality were improved as a result of this project.
International literature shows that there is a direct link between
structure and process quality and outcome in the field
of PU prevention and treatment. Based on this conclusion
from the literature and some indirect evidences from this
study it seems to be fair to conclude that the outcome of
the PU prevention and treatment was also improved. The
project probably had a Hawthorn effect as well, where the
quality of nursing care was improved purely by the fact the
study was being performed.
3.1 General conclusions and recommendations
Based upon the officially available data by the Centre for
Healthcare Information Ministry of Health in Hungary, on
PU epidemiology in Hungarian hospitals policy and decision
makers might fail to prioritise PU initiatives due to the
apparently low prevalence of the condition. It would appear
that some form of quality assurance activity has to be
in place in order to identify the extent of the burden of any
particular problem area. Overall, this seven-phase study has
demonstrated that effective quality assurance programmes
can be established to tackle PU prevention and treatment.
PU quality assurance programmes along with practice guidelines
can be created through consensus of the relevant
health care professions. The implementation of such programmes
can improve the quality of nursing care even during
a time of transition within the Hungarian health care
system.
This programme provided direct evidence that quality
assurance in the field of prevention and treatment of pressure
ulcers can be implemented and used and the effectiveness
of health care services can be improved in a group
of Hungarian hospitals. In contrast, no empirical data of
good quality have been yielded by the quality assurance studies
presented in this thesis, concerning the question: ‘Do
quality assurance initiatives in Hungary contribute to cost
containment’ Cost containment is a very difficult issue to
be discussed in the Hungarian health care system, due to
the lack of agreement on the meaning of quality and cost,
and because no standardised costing mechanisms are implemented
in the Hungarian hospitals in general, and as
part of quality assurance programmes in particular.
Full References to Parts 1 and 2
Clark M, Watts S (1994) The incidence of pressure ulcers
within a National Health Service Trust hospital during
1991, J.Adv.Nurs. 20,1, 33–6.
Gulácsi L, Jakab Zs, Szloboda I (1993) Pressure Scores; A
quality circle investigation, Health Management Review
31,5, 425–449
Haalboom JRE, van Everdingen JEE, Cullum N (1997)
Incidence, prevalence and classification, in: Parish
LC, Witkowski JA, Crissey JT (1997) The decubitus ulcer
in clinical practice, Springer: 12–23
Jakab Zs, Gulácsi L (1993a) Prevention and Treatment of
Bedulcers, Nursing Care 2,6, 20–28.
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THE PREVENTION AND TREATMENT OF PRESSURE ULCERS
Jakab Zs, Gulácsi L (1993b) Prevention and Treatment of
Bedulcers in a Group of Hungarian Hospitals, The
Nurse 5,6, 33–59.
Klazinga N (1994) Concerted Action Programme on
Quality Assurance in Hospitals 1990–1993 (COMAC/
HSR/QA), Global Results of the Evaluation, International
Journal in Health Care 6,3, 219–230.
Michocki RJ (1976) The problem of pressure ulcers in a
nursing home population: statistical data, Journal of the
American Geriatric Society 24, 323–326.
National Pressure Ulcer Advisory Panel, (1995), Pressure
Ulcer Healing: Controversy to Consensus, Assessment
methods and Outcomes, Springhouse Corporation.
Pressure Ulcer Treatment Guidelines (1999) European
Pressure Ulcer Advisory Panel, Oxford.
Pressure Ulcer Prevention Guidelines (1998) European
Pressure Ulcer Advisory Panel, Oxford.
The Dutch Consensus Prevention of Bedulcers (1985)
CBO, Utrecht.
Treatment of Pressure Ulcers Guideline Panel, (1994)
Treatment of pressure ulcers, Rockville: Department of
Health and Human Services, Agency for Health Care
Policy and Research. Clinical Practice Guideline No
15. Publication No. 95–0653.
Visit the new EPUAP website . . .
Volume 3, Number 2, 2001 41

epuap Fifth
EUROPEAN PRESSURE ULCER ADVISORY PANEL
Oxford European Wound Healing Summer School, 2000
MEDICAL MANAGEMENT OF PRESSURE ULCERS. PART 2
Dr Mary Bliss, London, adapted from a talk given at the Fifth Oxford European
Wound Healing Summer School held at St Anne’s College, Oxford, 28 June – 1 July 2000
P RESSURE RELIEF
Grab bars and bed cradles
Two simple measures which help pressure relief and make
patients more comfortable which have largely been forgotten
are the grab bar (or monkey pole) and the bed cradle.
Providing it is carefully positioned above the patient with
the arms at full stretch, the grab bar [Figure 5] is an invaluable
aid to assisting a weak patient to lift himself and relieve
his own pressure areas. Posture in bed, particularly
assisting patients to sit upright when they experience discomfort,
is vitally important. A bed cradle over the legs and
feet removes the weight of the covers from these vulnerable
areas and makes it easier for the patient to move to
relieve pressure pain in the heels.
Figure 1: A grab bar
Repositioning
If no part of the body remains in contact with a resistant
surface for long enough, pressure necrosis will not occur.
But it is important to realise that the length of time which
the tissues can withstand ischaemia and recover may be
much less in an acutely ill patient than in a healthy person.
In a patient with a new spinal cord injury, less than half an
hour of unrelieved pressure may be sufficient to cause a
sore. 24 Thus, if a patient is found to have a red heel (a Grade
1 pressure sore), it should immediately be propped off the
bed surface, e.g., by means of a pillow under the calf.
However, except in intensive care wards or private nursing
homes with 1:1 nurse patient ratios, reliance on regular
repositioning alone as a method of pressure relief is unlikely
to be successful. Individual care should be the aim of
every nurse, but it is impracticable for preventing sores in
the very large number of patients at risk in geriatric and
orthopaedic wards and in the long stay units and nursing
homes. It is labour intensive and is often difficult or impossible
for patients who have to sit up, or who have numerous
catheters or monitoring lines, or unstable fractures. Elderly
patients dislike being turned (or tilted) and usually beg
to be returned to lie on their backs, or move out of position.
The lateral position also causes high pressures over
the greater trochanter. This can cause severe pressure injuries
in sick patients if maintained for an hour or more.
Longer periods may be safe if the patient is also nursed on
an effective pressure relieving mattress. 25
If it is practicable and the patient can tolerate it, repositioning
should be carried out as often as possible whether
he has a pressure relieving support or not. Changes of posture
have many benefits besides relieving pressure, e.g.,
improving lymph flow, 26 helping to prevent joint pain and
contractures, and reducing stasis in the lungs 27 and bladder
28 as well as providing an opportunity for personal care.
Pressure relieving supports.
An effective support which prevents prolonged pressure on
the body is an invaluable aid for nursing a sick patient but
it must be able to prevent tissue breakdown very ill as well
as less ill patients. As we have seen, a patient’s condition
can deteriorate rapidly so that there is no place for partially
effective or ‘first line’ supports on which he is at risk of
developing a tissue injury before he can be transferred to a
more effective machine. This approach is like treating a
patient with pneumonia with a cough linctus until he becomes
sufficiently ill to be given an antibiotic.
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MEDICAL MANAGEMENT OF PRESSURE ULCERS
Although the idea of giving a powerful support to all
vulnerable patients in the first instance may seem expensive,
the money saved by their more rapid recovery if they
do not develop sores, and the reduced nurse time and cost
of expensive dressings, to say nothing of the patient’s comfort
and the risk of litigation, is likely to outweigh the initial
cost. (The Touch Ross Report in 1993 29 which concluded
that it was cheaper to treat than to prevent sores was based
on calculation of the nurse time required for regular repositioning
of at-risk patients assuming that there were no effective
pressure relieving supports, which was and is untrue.
25,30 Furthermore, pressure relieving machines do not
need to be particularly costly or sophisticated to be effective.
Simple alternating pressure overlays are not much more
expensive than less efficient soft static supports if the latter
are cared for and replaced in accordance with manufactures’
instructions. 30 Finally, a pressure relieving support is
usually only necessary for the first week of a patient’s illness
whist he is most at risk. It can safely be removed once he
has regained his normal level of mobility. Of course, if he
has been allowed to develop a sore during this time, pressure
relief and continued bed rest may be needed for much
longer. Some chronically ill or dying patients may need supports
indefinitely.
If we exclude turning bed which are mainly only useful
for spinal injury patients, pressure relieving supports fall into
two categories: low pressure (soft) supports and alternating
pressure supports. It is important to understand the distinction
because they work on entirely different principles.
Low pressure supports.
Figure 6 shows a diagram of a low pressure support. These
aim to adapt to the body contours so as to distribute the
weight as widely as possible thus preventing high pressures
over bony prominences. The oldest, and one of the most
effective, was the waterbed. 31 Providing the bath was sufficiently
deep and the cover protecting the patient from the
water was sufficiently loose, so that patients were able to
sink into it as if they were floating, pressures were equalised
over the whole of the under surface of the body and they
did not get sores. However, the water bed’s instability made
it very difficult for nursing patients and it has since be superseded
by the low air loss and air fluidised bead bed. 32
These achieve a similar floating action by means of automatically
inflated air sacs of air fluidised beads respectively.
Their advantage over the waterbed is that their floating
action can be controlled or stopped when necessary to
permit nursing procedures. Their main disadvantages are:
the enforced immobility of the patient which reduces reactive
hyperaemia and lymph flow and their size and cost
which prohibit their use for preventing sores in the very
large number of patients at risk in hospitals and the community.
They are mainly used for healing. Low air loss mattress
replacements and overlays which are easier to manage
than flotation beds are available but their effectiveness
has not yet been tested in a clinical trial.
Efforts have been made to find cheaper, more portable
low pressure alternatives to flotation beds, e.g., slit foam,
static air, fibre, gel, but none have shown to be able to prevent
sores in very ill patients. 25,30,34 Although many appear
to provide low interface pressure profiles in healthy volunteers,
35 they are apparently unable to modify pressure over
internal bony prominences sufficiently to prevent deep tissue
distortion and ischaemia in illness. They should therefore
be avoided unless they can be used in conjunction with
regular repositioning.
Alternating pressure mattresses
Alternating pressure mattresses [Figure 7] work on a different
principle to soft supports. They have more in common
with the method of repositioning than that of reducing
of pressure over bony prominences. Instead of preventing
pressure, they aim to continually change the supporting
areas of high pressure on the body so that no part remains
ischaemic long enough to cause cell death. Alternate
air cells inflate and deflate about every 5–10 minutes, thus
constantly changing the points of support, and therefore
pressure [Figure 8] on the body. The mattresses are not
designed to be particularly soft: indeed they must have sufficient
air pressure to lift the patient off the surface of the
underlying bed or mattress so that areas overlying deflated
cells are effectively relieved of pressure. The continual
movement on the body also helps to stimulate reactive hyperaemia
and lymph flow. 5 Simple large celled alternating
pressure overlays (cells 10 cm or more in diameter) have
been shown in randomised controlled trials to prevent pressure
injuries in intensive care patients 3 and in deteriorating
long term elderly patients. 25
Alternating pressure overlays are light and portable and
easy to install for patients at risk in hospital or in the community.
They have a reputation for being uncomfortable,
but this is largely because they are often used inappropriately.
Most patients who are sufficiently alert to complain
about the discomfort of alternating pressure are well enough
not to be at risk of developing a pressure injury. Comfort is
not important in an unconscious patient, and most geriatric
patients, the largest group at risk, have so much sensory
inattention that they are unaware that they are lying on
special supports.
However, some patients with non neurological diseases,
such as cancer or rheumatoid arthritis cannot tolerate the
continual movement of an alternating pressure mattress and
for these a low pressure support such as a low air loss overlay
may be more appropriate. As with other life support
equipment, pressure relieving mattresses can safely be removed
in the majority of patients when they have recov-
Figure 6: Diagram of a low
pressure support.
Volume 3, Number 2, 2001 43

EUROPEAN PRESSURE ULCER ADVISORY PANEL
Figure 7 (left): Diagram of an alternating
pressure air mattress overlay.
Figure 8 (below):
Changes in interface pressure on the sacrum,
hips and heels of a volunteer lying on a large
celled alternating pressure air overlay.
ered from their acute illness. This prevents unnecessary
discomfort and facilitates rehabilitation as well as freeing
the supports for use for other patients.
Deep and double layered alternating pressure mattress
replacements are available and are widely used for intensive
care patients and for healing sores. However, they are
less portable, and except for heavy or bony patients who
are liable to ‘bottom through’ single layer supports, there
is no evidence that they are move effective than good quality
overlays to justify their considerable extra cost.
Policy and education
It is not sufficient simply to have pressure relieving supports
which work. They must be immediately available, in
hospital or in the community, whenever a patient is found
to be at risk, and removed when they are no longer needed.
Like all medical equipment, they must be correctly installed
and continually checked to ensure that they are working
properly. They must be robust enough to withstand constant
use, have warning indicators in the event of failure
and be regularly serviced.
The National Health Service continues to fail on nearly
all of these counts. Training in pressure care is still almost
non existent for doctors and is deteriorating generally for
nurses. In 1989, a British Standard for Alternating Pressure
Air Mattresses was published which resulted in stronger machines
than had been previously available, but at the same
time servicing was mainly relegated to manufactures. This
has not only put up costs but has had the effect of putting
pressure care largely into the hands of industry.
As the use of support surfaces for preventing and treating
pressure sores has become widespread, competition between
manufactures has intensified. Marketing methods
have become more subtle. Unfortunately, because doctors
and nurses have a poor understanding of pressure injuries,
manufacturers are able to make recommendations which
are seldom challenged. Indeed, many health authorities and
nursing schools have come to rely on manufacturers to provide,
not only the supports, but a complete package of education
and in-service training to go with them. Some firms
have even had the temerity to offer to indemnify users if
patients get patient sores. This means that they hope to
prevent – and heal – sores, but at their own price.
44
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MEDICAL MANAGEMENT OF PRESSURE ULCERS
Healthcare dynamics are complicated. Although we like
to think that doctors and nurses and manufacturers are primarily
interested in preventing pressure sores, this is not
necessarily so. The challenges and status of healing sores
may be more rewarding. Industry exploits this. It wants to
help nurses and patients but also to make money. The latter
is essential because otherwise businesses will fail. Thus
manufacturers are not greatly interested in preventing sores.
If patients develop sores on a ‘first line’ low pressure supports
they can then sell the service more profitable low air
loss or alternating pressure mattresses to heal them. They
can also recommend that all very ill patients are nursed on
‘second line’ mattress replacements or even on flotation
beds from the start. As rental in the UK of an air fluidised
bed is about £70 per day, compared with a purchase price
of about £700 for an alternating pressure overlay which is
likely to last for about five years, this can make a big difference
to hospital budgets. Rental and purchase of pressure
relieving equipment is now one of the three top items on
the NHS purchasing bill, along with pacemakers and equipment
for diabetics. The presence of sores also gives industry
the opportunity for developing and marketing a ‘bewildering
array of complex wound interventions’. 36
Sadly, the NHS Centre for Reviews and Dissemination
did not help this situation when it published its Effective
Healthcare Bulletin in 1996 37 in which it concluded that
none of the clinical trials which had been carried out up
until that time had been sufficiently rigorously controlled
to prove that any system of pressure relief was better than
another. This has not only discouraged further research but
has given manufacturers carte blanche to say what they like
about their products because there is no accepted evidence
to the contrary. Worst of all, it has prevented nurses who
have found particular supports useful in practice, from incorporating
this knowledge into training schemes because
‘there is no evidence’. As a result, despite a plethora of
‘guidelines’, training in pressure care in the nursing profession
is more confused than it has ever been. Few manuals
contain any practical instructions about how to relieve
pressure in a vulnerable patient, and least of all about the
continually changing equipment which all nurses are expected
to use.
Both the medical and nursing professions need to return
to the patient. For patients, the primary need is to prevent
illness, or, if they are ill, to recover as quickly and safely
as possible. Every clinical observation and every strategy
must be harnessed to achieve this. Effective antibiotics are
prescribed by doctors as first line treatment for sick patients
(has penicillin ever been tested in a randomised controlled
trial) so why not effective pressure relieving supports
References
1–23 can be found with the first part of this essay, on page
21 of the EPUAP Review, Volume 3/1.
24. Gunnewicht BR. Management of pressure sores in a
spinal injuries unit. Journal of Wound Care 1996; 5(1):
36–39.
25. Bliss MR. Preventing pressure sores in elderly patients:
a comparison of seven mattress overlays. Age
and Ageing 1995; 24: 297–302.
26. Ryan TJ. Cellular responses to tissue distortion. In:
Bader DL (ed). Pressure sores. Clinical practice and
scientific approach. Basingstoke: Macmillan Press 1990:
141–152.
27. Summer WR, Curry P, Haponik EF, Nelson S, Elston
R. Continuous mechanical turning of intensive care
patients shortens length of stay in diagnostic related
groups. Journal of Critical Care 1989; 4: 45–53.
28. Guttman L. The prevention and treatment of pressure
sores. In: Kenedi RM, Cowden JM, Scales JT
(eds). Bedsore biomechanics. London: Macmillan Press
1976: 153–159.
29. Touch Ross and Company: The costs of pressure sores.
Report to the Department of Health December 1993.
30. Gebhardt KS, Bliss MR, Winwright PL, Thomas JM.
Pressure relieving supports in an ICU. Journal of
Wound Care 1996; 5(3) :116–121.
31. Editorial: Hydrostatic beds for invalids. London
Medical Gazette 1832: 10: 712–714.
32. Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical
utility and cost effectiveness of an air suspension bed
in the prevention of pressure sores. Journal of the
American Medical Association 1993; 269: 1139–1143.
33. Allman RM, Walker JM, Hart MK et al. Air fluidised
beds or conventional therapy for pressure sores – a
randomised controlled trial. Annals of Internal Medicine
1987; 107: 641– 648.
34. Hofman A, Greelkerken RH, Hamming JJ et al.
Pressure sores and pressure decreasing mattresses:
controlled clinical trial. Lancet 1994; 343: 568–571.
35. Rondorf-Klym LA M, Langemo D. Relationship
between body weight, body position, support surface
and tissue interface pressure at the sacrum. Decubitus
1993; 6(1): 22–30.
36. Harding K. Challenges for skin and wound care in the
New Century. Advances in Skin and Wound Care 2000;
13(5): 212–215.
37. Cullum N, Deeks L, Fletcher A, Long A, Mouneimne
H, Sheldon T, Song F. The prevention and treatment
of pressure sores. Effective Health Care 1995; 2(1)
(Churchill Livingstone).
Volume 3, Number 2, 2001 45

epuap Pressure
EUROPEAN PRESSURE ULCER ADVISORY PANEL
Ulcer Risk Assessment
A DRAFT EPUAP POSITION STATEMENT
On Risk Assessment in Pressure Ulcer Prevention and Management
THE following text outlines a draft EPUAP position
statement upon pressure ulcer risk assessment. This
document will be discussed in depth during the Le
Mans Open Meeting of the EPUAP. However, we would urge
all members to consider this document and to e-mail suggestions
or amendments to Tom Defloor at:
Tom.Defloor@rug.ac.be
The position statement is intended to reflect the stateof-the-art
in risk assessment based upon the best available
evidence. The text is accompanied by a supporting reference
list outlining the breadth of material considered by
the Working Group when developing the draft statement.
European Pressure Ulcer Advisory Panel
Draft Position Statement on Risk Assessment in
Pressure Ulcer Prevention and Management
Authors:
Defloor T, Schoonhoven L, Clark M, Halfens R, Nixon J.
Comments received from:
Dealey C, Jacquerye A, MacLeod A, Scott E, Torra i Bou
JE, Weststrate J.
THIS document sets out a draft statement and rationale
for the European Pressure Ulcer Advisory
Panel upon the issue of risk assessment in pressure
ulcer prevention and management. This draft will change
upon receipt of comments from EPUAP members, and
should not be considered as the definitive document. The
purpose of this statement is to guide clinicians towards the
most appropriate course of action when considering the
implementation of risk assessment. The statement is set out
in two sections; firstly a series of propositions are offered,
while in the second section the evidence base supporting
each proposition is explored.
Actual risk
PROPOSITION 1
The purpose of risk assessment is to identify those patients
who are in need of measures to prevent pressure ulcers.
PROPOSITION 2
Patients with an actual risk of developing pressure ulcers
and/or with existing non-blanchable erythema or pressure
ulcer lesions (grade 2 and higher) should receive appropriate
preventive measures.
Risk assessment scales
PROPOSITION 3
Current risk assessment scales often over and under represent
the risk of pressure ulcer development.
PROPOSITION 4
It is not possible to recommend a specific risk assessment
scale.
Elements of Risk Analysis
PROPOSITION 5
While the origin of pressure ulcers is undoubtedly multifactorial,
reductions in activity and/or mobility are observable
factors that have been consistently shown to increase
the risk of pressure ulcer development. Patients with existing
pressure ulcers (non-blanchable erythema or grade 2
and higher) have a higher risk of developing new pressure
ulcers on other anatomical sites. The importance of other
potential risk factors is less clear.
PROPOSITION 6
Acknowledging the limitations in both the reliability and
validity of risk assessment scales there are indications that
the risk of pressure ulcer development may be best assessed
by means of a risk assessment scale in combination with
assessment of skin and the clinical judgement of the nursing
staff.
PROPOSITION 7
Assessment of risk should be a continuous process where
changes in patient condition and/or skin appearance
prompt formal re-assessment using a risk assessment tool
and clinical judgement. In addition a formal risk assessment
should take place on a regular basis, the frequency depending
on the patient population.
Background to the Propositions
Pressure ulcer prevention is typically considered to begin
with the formal, or informal, assessment that an individual
client may be vulnerable to developing these wounds, these
processes are described as ‘Risk assessment’. The presumed
value of risk assessment lies in reducing the probability that
the client will develop a pressure ulcer following the implementation
of preventive measures upon the perception that
a ‘risk’ exists.
Preventive measures should (at least) be taken immediately
if an non-blanchable erythema (grade 1 pressure ulcer)
and/or pressure ulcers develop. Non-blanchable erythema
is reversible in the majority of cases if preventive
46
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PRESSURE ULCER RISK ASSESSMENT
measures are implemented in good time (135). If these
measures are not taken, non-blanchable erythema may develop
into a more serious injury in many cases (7, 74).
Patients with existing pressure ulcers have a higher risk of
developing new pressure ulcers on other sites (65; 189).
Therefore, when a pressure ulcer has developed, immediate
preventive measures should be taken to prevent pressure
ulcers on other sites of the body.
A variety of risk assessment scales are used (1, 13, 17,
21, 28, 36, 51, 53, 55, 61, 75, 112, 184, 80, 99, 124, 132, 206,
217). Frequently used scales are the Norton scale (155),
the Braden scale (155) and the Waterlow scale (206). Most
scales have not been scientifically studied for reliability and
validity (65, 147). The research available is aimed at sensitivity
and specificity of the risk assessment scales. However,
sensitivity and specificity are influenced by the preventive
measures taken, the length of the observation period and
the nature of the group of people studied. Therefore, the
sensitivity and specificity figures are not straightforward
measures that can be used to judge the performance of the
risk assessment scales (65, 111, 69, 70).
Use of preventive measures in patients at risk has the
effect of lowering the risk of the individual. Vice versa, stopping
preventive measures in patients at risk has the effect
of increasing the risk of the individual.
The risk assessment scales include some items for which
the link to pressure ulcers has not been established in longitudinal
research. The individual numeric value, which is
given to these items, has also not been validated (183). In
addition the items in many risk assessment scales are not or
only vaguely described and to be completed by the nursing
staff subjectively.
Despite the limitations the use of risk assessment scales
may lead to the systematic assessment of the risk of pressure
ulcers (98, 202). However, it is not possible to recommend
any one risk assessment tool over its alternatives (180,
181).
Informal assessment of risk also occurs in clinical practice;
this reflects the clinical judgement, primarily of nursing
staff. There is a lack of evidence to show whether the
exercise of clinical judgement or use of a risk assessment
tool provides the most accurate prediction of vulnerability
to pressure ulcer development. (202, 118).
There is limited evidence to suggest that the use of a
risk assessment scale may help develop the clinical decisionmaking
skills in the nursing staff (98, 202). The use of a
risk assessment scale may not be the only criterion used
when making a decision on taking preventive measures. It
is recommended to use the risk assessment scale as an aid
in combination with the clinical judgement of the nursing
staff. The total score cannot be a criterion for taking preventive
measures, if the nursing staff judges differently. The
score is only indicative for the degree of risk and not for
the preventive methods to be used.
Pressure ulcers are caused by an oxygen deficit due to
tissue-deformation. The tissue-deformation is caused by
pressure and shearing forces. Immobility and reduced activity
are observable parameters of pressure and shearing
forces (155, 65). For this reason preventive measures must
be taken to prevent pressure ulcers in patients for whom it
is difficult to change position independently and are bed
or chairbound (155, 65).
Primarily these interventions are likely to be directed
towards the management of tissue deformation resulting
from localised applied forces.
The frequency of risk assessment requires consideration.
A clientís condition will not remain static and the frequency
of assessment (both formal and informal) will be driven by
the nature of the client population. For this reason it is
necessary to assess the changes in health status of the patient
daily. The frequency for formal risk analysis (i.e. using
a risk assessment scale in combination with clinical judgement)
depends on the population. Times when a formal
risk analysis should definitely take place: if a patient becomes
bed or chairbound, if the patientís condition seriously
deteriorates or improves, if there is a sudden change
in punctuations.
Risk assessment may be inappropriate where specific circumstances
exist. For example in Intensive Care preventive
measures are probably a universal requirement given the
nature of the client population. Other specific circumstances
can be identified where preventive measures may
not require formal risk assessment – where a client presents
with non-blanchable erythema (grade 1 pressure ulcer) or
any other grade of pressure ulcers then preventive measures
are required. Non-blanchable erythema is likely to be
reversible if preventive measures are implemented in a
timely manner. Furthermore clients with existing pressure
ulcers have a higher risk of developing new pressure ulcers
at other body locations. Therefore, where a pressure ulcer
has developed, immediate preventive measures should be
taken to prevent further pressure ulcer developing upon
other parts of the body.
Bibliography
1. Abruzzese, R. S. (1985). Early assessment and prevention
of pressure sores. In B. Y. Lee (Ed.), Chronic ulcers of the skin
(pp. 1–17). New York: McGraw-Hill.
2. Adams, M. (1986). Aging: gerontological nursing
research. Annual Review of Nursing Research, 4, 77–103.
3. Ahlbom, A. & Norell, S. (1990). Introduction to modern
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4. Allman, R. M., Walker, J. M., Hart, M. K., Laprade, C. A.,
Noel, L. B., & Smith, C. R. (1987). Air-fluidized beds or
conventional therapy for pressure sores. A randomized trial.
Annals of Internal Medicine, 107, 641–648.
5. Allman, R. M., Laprade, C. A., Noel, L. B., Walker, J. M.,
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6. Allman, R. M. (1989). Epidemiology of pressure sores in
different populations. Decubitus, 2, 30–33.
7. Allman, R. M., Goode, P. S., Patrick, M. M., Burst, N. and
Bartolucci, A. A. (1995). Pressure ulcer risk factors among
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865–870.
8. Allman, R. M., Damiano, A. M. and Strauss, M. J. (1996).
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9. Allman, R. M. (1997). Pressure ulcer prevalence, incidence,
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10. Allman, R. M., Goode, P. S., Burst, N., Bartolucci, A. A., &
Thomas, D. R. (1999). Pressure ulcers, hospital complica-
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EUROPEAN PRESSURE ULCER ADVISORY PANEL
tions, and disease severity: impact on hospital costs and
length of stay. Adv. Wound Care, 12, 22–30.
11. Altman, D. G. & Bland, J. M. (1994a). Diagnostic tests 2:
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12. Altman, D. G. & Bland, J. M. (1994b). Diagnostic tests 3:
receiver operating characteristic plots. B.M.J., 309, 188.
13. Arnold, N. (1994). Clinical study : the relationship
between patient perceived risk and actual risk for the
development of pressure ulcers. Ostomy/Wound Management,
40(3), 36–52.
14. Arnout, E., Deconinck, K., Desaver, M., Ghekiere, C.,
Vereecke, V., & Werbrouck, E. (1990). Vergelijking tussen
de Norton- en de Douglasschaal in het opsporen van
risicopatiönten. Ligament, 21, 182–186.
15. Aronovitch, S. A. (1993). The use of an assessment tool in
managing placement on pressure relief surfaces. Ostomy/
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16. Aronovitch, S. A., Millenbach, L., Kelman, G. B., & Wing,
P. (1992). Investigation of the Knoll Assessment Scale in a
tertiary care facility. Decubitus, 5, 70–2, 74.
17. Aronovitch, S. A. (1999). Intraoperatively acquired
pressure ulcer prevalence: a national study. J. Wound.
Ostomy. Continence. Nurs., 26, 130–136.
18. Bale, S., Finlay, I., & Harding, K. G. (1995). Pressure sore
prevention in a hospice. J. of Wound Care 1995, Nov.; 4.(10.):
465.8 (9 ref.), 4, 465.
19. Banks, V. (1998). Pressure sore risk assessment. J. of Wound
Care, 7, 91–92.
20. Barbenel, J. C., Ferguson, P. M., & Kennedy, R. (1986).
Mobility of elderly patients in bed. Measurement and
association with patient condition. J. Am. Geriatr. Soc., 34,
633–636.
21. Bedi, A. (1993). A tool to fill the gap. Developing a wound
risk assessment chart for children. Prof. Nurse, 9, 112–120.
22. Beekman, E. P. (1995). Het risico op decubitus : hoe
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een populatie. II Onderzoek naar gevoeligheid voor decubitus.
Amsterdam: VU Uitgeverij.
166. Richardson, G. M., Gardner, S. and Frantz, R. A. (1998).
Nursing assessment: impact on type and cost of interventions
to prevent pressure ulcers. J. Wound. Ostomy Continence
Nurs., 25, 273–280.
167. Rodriguez, G. P. and Garber, S. L. (1994). Prospective
study of pressure ulcer risk in spinal cord injury patients.
Paraplegia., 32, 150–158.
168. Ryan, N. (1996). A study of the contribution of effective
pressure care on elderly female patients attending accident
and emergency who have a suspected fractured neck of
femur. Accid. Emerg. Nurs., 4, 21–24.
169. Salvadalena, G. D., Snyder, M. L., & Brogdon, K. E.
(1992). Clinical trial of the Braden Scale on an acute care
medical unit. J. of ET Nursing, 19, 160–150.
170. Salzberg, C. A., Byrne, D. W., Cayten, C. G., van-Niewerburgh,
P., Murphy, J. G. and Viehbeck, M. (1996). A new
pressure ulcer risk assessment scale for individuals with
spinal cord injury. Am. J. Phys. Med. Rehabil., 75, 96–104.
171. Salzberg, C. A., Byrne, D. W., Cayten, C. G., Kabir, R., van–
Niewerburgh, P., Viehbeck, M., Long, H. and Jones, E. C.
(1998). Predicting and preventing pressure ulcers in adults
with paralysis. Advances in Wound Care: The J. for Prevention
and Healing, 1998.Sep.; 11.(5.): 237.46 (24 ref.), 11, 237.
172. Salzberg, C. A., Byrne, D. W., Kabir, R., van-Niewerburg, P.,
& Cayten, C. G. (1999). Predicting pressure ulcers during
initial hospitalization for acute spinal cord injury. Wounds: A
Compendium of Clinical Research and Practice, 1999. Mar. Apr.;
11.(2): 45.57.(18 ref.), 11, 45.
173. Schoonhoven, L. (1997). Niet Wegdrukbare Roodheid als
indicator voor preventie van decubitus. Utrecht University.
174. Schoonhoven, L. (1998). Incidentie van decubitus op de
operatietafel. MSc Utrecht University.
175. Schoonhoven, L. (2000). Decubitus op de operatietafel.
[Pressure ulcers on the OR table]. met VerVe, 6, 10–12.
176. Schoonhoven, L. and Grypdonck, M. H. Decubitus bij
chirurgische patienten. [Pressure ulcers in surgical
patients]. Verpleegkunde 14[4], 277–278. 1999.
177. Schoonhoven, L. and Grypdonck, M. H. (2000). Incidentie
van decubitus op de operatietafel [Incidence of pressure
ulcers on the OR table]. In Handboek verpleegkundige diagnostiek,
interventies en resultaten (juli 2000 ed., pp. C2850–1–
C2850–7). Houten: Bohn Stafleu Van Loghem.
178. Schoonhoven, L. and Grypdonck, M. H. (2000). Decubitus
tijdens de operatie: een onderschat probleem. WCS nieuws,
16, 71–73.
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EUROPEAN PRESSURE ULCER ADVISORY PANEL
179. Schoonhoven, L., Haalboom, J. R., and Buskens, E.
Development of a pressure ulcer risk assessment tool; a
study design. 82, 18–21 June 2000, the Hague, 16th annual
meeting of the international society of technology assessment
in health care.
180. Schoonhoven, L., Haalboom, J. R., Bousema, M. T., and
Buskens, E. Incidentie en preventie van decubitus in het
ziekenhuis. 6–7 juni 2001. Amsterdam, WEON 2001.
181. Schoonhoven, L., Haalboom, J. R., Bousema, M. T., and
Buskens, E. Risicoscores bij decubituspreventie. 6–7 juni
2001. Amsterdam, WEON 2001.
182. Schubert, V. (1991). Hypotension as a risk factor for the
development of pressure sores in elderly subjects. Age
Ageing, 20, 255–261.
183. Scott EM. The prevention of pressure ulcers through risk
assessment. J. of Wound Care, 2000; 9 (2):69–70.
184. Smith, L. N., Booth, N., Douglas, D., Robertson, W. R.,
Walker, A., Durie, M., Fraser, A., Hillan, E. H., & Swaffield, J.
(1995). A critique of ‘at risk’ pressure sore assessment tools.
J. of Clinical Nursing, 4, 153–159.
185. Sparks, S. M. (1993). Clinical validation of pressure ulcer
risk factors. Ostomy/Wound Management, 39, 40–1, 43.
186. Sparks, S. M. (1992). Nurse validation of pressure ulcer
risk factors for a nursing diagnosis. Decubitus, 5, 26–5.
187. Spieker, P. (1999). Risicoscores decubitus achterhaald
Verpleegkunde Nieuws 16–17.
188. Spoelhof, G. D. and Ide, K. (1993). Pressure ulcers in
nursing home patients. American Family Physician, 47, 1207–
1215.
189. Stordeur S, Laurent S, D’Hoore W. (1998) The importance
of repeated risk assessment for pressure sores in
cardiovascular surgery. J. of Cardiovascular Surgery; 39: 343–9.
190. Stotts, N. (1985). Nutritional parameters of pressure sores
in surgical patients. Nursing Research, 34, 383–383.
191. Stotts, N. A. (1988). Predicting pressure ulcer development
in surgical patients. Heart and Lung, 17, 641–647.
192. Stotts, N. A. (1989). Risk factors associated with pressure
ulcer development in surgical patients. Decubitus, 2, 59.
193. Stotts, N. A. (1998). Risk and assessment of pressure ulcer
development in surgical patients. Adv. Wound Care, 11, 7.
194. Stotts, N. A. (1999). Risk of pressure ulcer development in
surgical patients: a review of the literature. Adv. Wound Care,
12, 127–136.
195. Taylor, K. J., Bryant, R. and Boarini, J. (1988). Assessment
tools for the identification of patients at risk for the
development of pressure sores: a review. J. of Enterostomal
Therapy, 15, 201–205.
196. Theaker, C., Mannan, M., Ives, N. and Soni, N. (2000).
Risk factors for pressure sores in the critically ill. Anaesthesia,
55, 221–224.
197. Towey, A. P. and Erland, S. M. (1988). Validity and
reliability of an assessment tool for pressure ulcer risk.
Decubitus, 1, 40–48.
198. Van Marum, R. J., Germs, P., & Ribbe, M. W. (1992). De
risicoscoring voor decubitus volgens Norton in een verpleeghuis.
Tijdschrift voor Gerontologie en Geriatrie, 23, 48–53.
199. Van Marum, R. J., Germs, P. H., Ribbe, M. W. and Meyer, J.
H. (1990). Analyse van de decubitus-risicoscoring volgens
Norton. In C. Knipscheer, J. Michels and M. Ribbe (Eds.),
Ouder worden nu ’90 (pp. 410–415). Almere: Versluys.
200. Van Marum, R. J. (1998). The risk of developing decubitus
ulcers. Risk factors and risk scores in a nursing home population.
Vrije Universiteit te Amsterdam.
201. Van Marum, R. J., Ooms, M. E., Ribbe, M. W. and Van Eijk,
J. T. (2000). The Dutch pressure sore assessment score or
the Norton scale for identifying at-risk nursing home
patients Age Ageing, 29, 63–68.
202. VandenBosch, T., Montoye, C., Satwicz, M., Durkee, L. K.
and Boylan, L. B. (1996). Predictive validity of the Braden
Scale and nurse perception in identifying pressure ulcer
risk. Applied Nursing Research, 9, 80–86.
203. Vernon, M. J. (1996). The Norton score and pressure
prevention. Critique II. J. of Wound Care, 5, 96–97.
204. Wai-Han, C., Kit-Wai, C., French, P., Yim-Cheung, L. and
Lai-Kwan, T. (1997). Which pressure sore risk calculator A
study of the effectiveness of the Norton scale in Hong Kong.
Int. J. Nursing Studies, 34, 165–169.
205. Wardman, C. (1991). Norton v. Waterlow. Nursing Times,
87(13), 74, 76, 78–74, 76, 78.
206. Waterlow, J. (1985). Pressure sores: a risk assessment card.
Nursing Times, 81, 49–55.
207. Waterlow, J. (1996b). Pressure sore assessments. Nursing
Times, 92, 53–6,58.
208. Waterlow, J. (1996a). The Norton score and pressure
prevention. Critique I. J. of Wound Care, 5, 93–96.
209. Waterlow, J. (1987). Calculating the risk… preventing
pressure sores. Nursing Times, 1987. Sep.30 Oct.6; 83.(39.):
Tissue Viability: 58., 60.(14.ref.), 83, Tissue.
210. Waterlow, J. (1996). Operating table. The root cause of
many pressure sores Br. J. Theatre Nurs, 6, 19–21.
211. Waterlow, J. (1998). Wound care. The history and use of
the Waterlow card. Nursing Times, 1998. Feb 18 24; 94.(7.):
61., 63 4., 66.7.(11.ref.), 94, 61,63.
212. Watkinson, C. (1996). Inter-rater reliability of riskassessment
scales. Prof. Nurse, 11, 751–2,755–6.
213. Watkinson, C. (1997). Risk assessment tools [letter]. Prof.
Nurse, 12, 600.
214. West, B. J., Brockman, S. J. and Scott, A. (1991). Action
research and standards of care. The prevention and
treatment of pressure sores in elderly patients. Health Bull.
(Edin.), 49, 356–361.
215. Weststrate, J. T. and Bruining, H. A. (1996). Pressure sores
in an intensive care unit and related variables: a descriptive
study. Intensive Crit. Care Nurs., 12, 280–284.
216. Weststrate, J. T., Hop, W. C., Aalbers, A. G., Vreeling, A. W.
and Bruining, H. A. (1998). The clinical relevance of the
Waterlow pressure sore risk scale in the ICU. Intensive Care
Med., 24, 815–820.
217. Williams, C. (1991). Journal of wound care nursing.
Comparing Norton and Medley. Nursing Times, 87, 66, 68.
218. Willson, D., Ashton, C., Wingate, N., Goff, C., Horn, S.,
Davies, M. and Buxton, R. (1995). Computerized support of
pressure ulcer prevention and treatment protocols. Proc.
Annu. Symp. Comput. Appl. Med. Care 646–650.
219. Wolfswinkel-de Jong, C. J. A. & Halfens, R. J. G. (1995).
Decubituspreventie : het effect van een scorelijst.
Verpleegkunde, 10, 29–36.
220. Xakellis, G. C., Frantz, R. A., Arteaga, M., Nguyen, M., &
Lewis, A. (1992). A comparison of patient risk for pressure
ulcer development with nursing use of preventive interventions.
J. Am. Geriatr. Soc., 40, 1250–1254.
221. Zulkowski, K. (1998). Construct validity of Minimum Data
Set items within the context of the Braden Conceptual
Schema. Ostomy Wound Manage, 44, 36–4, 46.
52
Volume 3, Number 2, 2001

epuap News
EUROPEAN PRESSURE ULCER ADVISORY PANEL
from the Working Groups
EPUAP WORKING GROUPS AND PEPUS STUDY
Progress Reports
OVER the past few months, three EPUAP Working
Groups have been particularly active. In April,
members met in the Netherlands to progress discussions
upon contact pressure measurements upon beds
and mattresses. This group, led by Dr Alastair McLeod (England,
e-mail: alastair.mcleod@ hunhcare.co.uk), will report
their progress during the Le Mans Open Meeting with a
position paper published in the EPUAP Review next year.
The last meeting of the working group (Photograph 1) was
attended by Dr Steve Reger (USA) reinforcing that the activities
of the EPUAP are well respected world-wide.
One major action for the EPUAP in 2001 has been the
implementation of a European-wide pressure ulcer prevalence
survey. In May 2001, National Co-ordinators from the
participating countries met in the Netherlands (Photograph
2) to receive their training for the study. At this time the
survey date has been set for 8 November 2001 when a minimum
of 700 adult hospital in-patients per country will be
surveyed. This pilot study is intended to explore the robustness
of the data collection instrument and the training
materials across different countries. Full details of the survey
methodology will be presented at Le Mans with the survey
results issued in the EPUAP Review early in 2002. To
participate in this exciting venture please contact the Working
Group chair (Gerrie Bours) at the following e-mail address:
G.Bours@ZW.UNIMAAS.NL.
As reported elsewhere in this issue, the most recently
formed Working Group has prepared a position statement
on pressure ulcer risk assessment on behalf of the EPUAP.
This group, led by Tom Defloor (Belgium, e-mail:
Tom.Defloor@rug.ac.be), met in Belgium in June (Photograph
3) to agree word-by-word upon the text of the draft
position statement! This document will be presented, and
voted upon, during the Le Mans Open Meeting.
While not constituted as an EPUAP Working Group, the
Pan-European Pressure Ulcer Study (PEPUS) has been hard
at work arranging ethical approval for the project within
the participating countries.
The primary objective of the PEPUS study is to record
the care currently received by patients across 12 European
Photograph 1
Volume 3, Number 2, 2001 53

EUROPEAN PRESSURE ULCER ADVISORY PANEL
Photograph 2
Photograph 3
countries where these individuals have been admitted to
hospital for surgery following sustaining a hip fracture. The
secondary goal is to seek to identify consistent risk factors
for pressure ulcer development within this patient population.
If common risk factors can be identified then a future
development of the project may be to test a pressure ulcer
risk assessment instrument specific to patients with fractured
hips. The project is co-ordinated by Christina Lindholm
(Sweden) with national co-ordinators within each of the
participating countries.
54
Volume 3, Number 2, 2001

epuap Pressure
EUROPEAN PRESSURE ULCER ADVISORY PANEL
Mattress Overlays
NATIONAL SPECIFICATION FOR ALTERNATING PRESSURE
MATTRESS OVERLAYS
NHS Purchasing and Supply Agency
OVER the life of the EPUAP to date, there has often
been debate regarding the need for formal
specifications of pressure redistributing beds, mattresses
and cushions. Within the UK the National Health
Service Purchasing and Supply Agency recently released
such a draft specification covering alternating pressure
mattress overlays. This draft specification is printed in full
in this issue of the EPUAP by kind permission of the NHS
Purchasing and Supply Agency. We hope that the publication
of this specification will generate debate among EPUAP
members – are there other specifications currently in development
(or indeed been finalised!) within other countries
If other specifications exist, we would be delighted to
reprint them in the EPUAP Review to allow members to
see the current state of play of specification development
across Europe. Members may wish to consider whether we
as a European organisation should be seeking to work with
public bodies to develop such specifications Please send
any specific comments upon the UK draft specification direct
to Nikki Aylward (nikki.aylward@doh.gsi.gov.uk).
SPECIFICATION FOR ALTERNATING
PRESSURE AIR MATTRESS OVERLAY FOR
ADULTS
1. Construction
a) Mattress overlay
(i)
Constructed in one layer of either replaceable cells
individually attached to manifold or of two or more
sheets welded together, whichever more economical
overall. 16–19 cells, all alternating. All connections
to be secured (e.g., glued over barbed connector or
clipped over groove, not push-fit) to resist pull force
of 25kg.
(ii) Construction will allow profiling, without any loss of
function.
(iii) Fully enclosed within waterproof cover zipped at
least on two short and one long sides. Zip protected
with skirt. Cover will not hammock between alternating
cells.
(iv) Dimensions inflated: length and width to comply
with specifications for hospital bed dimensions as
specified by National and International regulations
(v)
when supplied for hospital use; otherwise a range of
sizes suitable for domestic use should be provided;
depth 13–15cm.
Rapid deflation for CPR by disconnection of air
tubes from the mattress at the normal point of
attachment deflation for the thorax should be
achieved within 15 seconds for an individual of 70kg
and normal BMI.
(vi) Attached to underlying mattress by head and foot
end flaps which are secured in place by continuous
elasticised bands miming from the long edges of the
mattress under the underlying mattress.
(see Figure 1)
(vii) Maximum weight not to exceed 15kg
b) Connecting tubes
(i)
Tubing of a durable, kink resistant material (e.g.,
EPDM rubber), at least 60cm and not more than
100cm long.
(ii) Attached to motor with high quality positive mechanical
latch connectors (e.g., plastic Colder
connector at least 1.9cm external diameter or
equivalent). Plastic to plastic or metal to metal but
not mixture. Connectors on the pump unit to be
attached and secured (e.g., glued over barbed
connector, clipped over groove or screwed in, not
push-fit) to resist pull force of 25kg. Attached to
pump unit with adequate separation between
connectors to allow easy connection and disconnection
of mattress.
(iii) Tubing permanently attached to mattress and
secured (e.g., glued over barbed connector or
clipped over groove, not push-fit) to resist pull force
of 25kg.
c) Pump unit
(i)
Dimensions: not more than 13cm deep, 33cm wide.
Height should not impede use of bed stripper when
pump unit is suspended from foot board of bed.
(ii) Box constructed of impact resistant, smooth, easily
decontaminated material. Recessed control panel to
protect from accidental damage. Rounded internal
corners to facilitate cleaning.
(iii) Attachment to foot end of bed by hook built into
Volume 3, Number 2, 2001 55

EUROPEAN PRESSURE ULCER ADVISORY PANEL
Figure 1 (left):
Attachment of mattress overlay to
underlying mattress.
Figure 2 (below):
Side view of pump unit to show
hook for hanging from bed end.
box top (see figure 2). Alternative option of placing
on the floor in an upright position.
(iv) Controls:
on/off switch back lit to show when power is on,
override for ‘power off alarm.
(v)
Alarms audible and visual. Different lights for each
alarm preferred:
power off,
‘patient grounding (mattress not supporting
patient above base)’,
Automatic reset of alarms in event of power failure
or power surge.
(vi) Electrical connection: wire at least 510cm long,
permanently attached to motor, with live ends
insulated with plastic jackets (which insulate the wire
ends if pulled out of the motor casing).
(vii) Maximum noise output not to exceed 40 dB (A)
when measured 100cm from pump unit. (viii)
Maximum weight not to exceed 8kg.
2. Performance
a) Mode of action
The overlay will operate by cyclically changing the
air pressure in individual cells from a minimum
between 0–5 mmHg and a maximum between 80–
120 mmHg. The time for individual cells to complete
one inflation and deflation cycle should be 8–
15 minutes.
b) Lifting capacity
The overlay will lift a 100kg patient of normal BMI
at least 2 cm above an underlying solid surface and
maintain function.
c) Mechanical reliability
Not more than one breakdown caused by manufacturing/design
faults per year per mattress is permitted
in the first year of usage (excludes user error/
accidental damage).
d) Transport mode
Activated by disconnection from power supply.
Overlay will continue to alternate or pressure will be
equalised between the two cell sets and be maintained.
In transport mode, the overlay will lift a
100kg patient of normal BMI at least 2 cm above an
underlying solid surface for at least 4 hours.
3. Instructions
a) Essential installation, user, cleaning and safety
instructions printed on mattress cover and pump
unit. Manufacturer contact number on mattress and
pump unit.
b) Detailed maintenance manual available on request.
c) CPR instruction to be attached to connecting tubes
and pump unit so that they are visible when bed
made up.
4. Warranties
a) The product will comply with Medical Devices
Directive 93/42/EEC June 14 1993 and any subsequent
amendments.
b) Product will be manufactured for at least 5 years in
identical external form unless mandated for or
required to by an adverse incident report. Spare
parts will be available for at least 5 years after
termination of product manufacture.
56
Volume 3, Number 2, 2001

PRESSURE MATTRESS OVERLAYS
5. Additional items, which must be available on request
a) Carrying bags (not zip fastened).
b) Spare parts available individually from a part’s list.
c) Extension tube set of 2–3m.
6. Additional features
The above specification is for a baseline model.
Before agreeing to any additional features the
purchaser should consider whether they are necessary
and whether any additional cost is justified by
the benefits. They should also be aware that additional
features may in some circumstances render
the alternating overlay less clinically effective, less
mechanically reliable or more prone to misuse and/
or mismanagement.
Additional features not included in specification
– Listed for discussion
1a) Construction of mattress
(i) Mattress to have non-alternating head set
Potential benefits:
more comfortable for patients nursed without
pillow.
Potential disadvantages:
increased risk of pressure ulcers on the head
and also on heels if mattress accidentally used
head to foot reversed.
(ii) Specify vapour permeable, two way stretch cover
Potential benefits:
thought to increase patient comfort.
Potential disadvantages:
no clinical evidence of benefit or improved
comfort.
(iii) Construct mattress in a fashion which allows the mattress
to be its own ‘carrying case’ when rolled up (i.e., provide
straps etc., to hold it rolled together, plus carrying handles)
so that a need for carrying cases is eliminated.
Potential benefits:
no need for separate carrying cases which are
frequently lost in some areas. Reduced costs.
Potential disadvantages:
not required in many areas – additional expense.
Infection control issues if soiled mattresses are
carried around without being first placed in
another container.
(iv) Provide ventilation holes in mattress
Potential benefits:
improves patient comfort by increasing air at the
patient/mattress interface.
Potential disadvantages:
requires battery back-up for transport mode.
(v) Bottom of mattress clearly printed with message “Turn
mattress over. It must be used other side up”.
Potential benefits:
reduced chance of incorrect positioning of
mattress
Potential disadvantages:
increased cost
2a) Mode of action:
Maximum operating pressure pertinent to a given, set either
by the user or by internal mechanisms (i.e. have either a
manually set or automatically adjusted ‘comfort control’).
Potential benefits:
Mattress can be made softer and therefore more
comfortable for some lighter patients.
Potential disadvantages:
In practice, rarely set correctly if manual. Thus
usually no benefit for lighter patients but risk of
pressure sores for heavier patients as they can
bottom through mattress. Automatic systems
expensive to date. More potential for mechanical
failure with both systems, more complicated
maintenance.
2 b) Lifting capacity:
Maximum lifting capacity of 150kg.
Potential benefits:
Can carry heavier patients. Average patient mass
is increasing year on year.
Potential disadvantages:
Inflation pressures would need to be higher,
increasing discomfort problems for lighter
patients. Shorter working life for mattress and
pump unit.
Alternative solutions:
Nurse patients >150 kg in weight on mattress
replacement systems
Volume 3, Number 2, 2001 57

epuap CD
EUROPEAN PRESSURE ULCER ADVISORY PANEL
Review and Letter to the Editor
WOUND MANAGEMENT CD ROM REVIEW
THE East London Wound Healing Centre has produced
a very comprehensive study guide to the assessment
and management of Leg Ulcers and Pressure
Ulcers. This educational package has very clear objectives
and is divided into two levels, level one is designed as a
core text and is aimed at undergraduate students. It includes
literature guides, case studies and questions. Level two is at
a more advanced level and is aimed at qualified nurses and
doctors.
Within Level 2 there are links to the Tower Hamlets
own Wound Care Manual and Leg Ulcer/Pressure Ulcer
Programmes which provides the user with valuable information
to enable them to expand their knowledge base.
There are also hyperlinks included to vitual websites and
company web-sites for further product/equipment data.
Further sections address related areas such as, nutrition,
radiological investigations, wound infection and microbiology
and patient information. These sections complement
the text and provide the user with extensive overall knowledge
of the subject area.
This wound management package would provide a useful
addition to both the Schools of Medicine/Nursing and
to the individual student/learner. As adult learning moves
more towards distance and computer-based learning perhaps
future CD and web based developers of educational
material should consider making applications for Continuing
Education Points for Doctors who use the material, while
nurses could be encouraged to record their outcomes of
learning for the purposes of PREP.
Samantha Holloway RGN, Cert Ed (FE)
Education Assistant
Wound Healing Research Unit
University of Wales College of Medicine
Cardiff, Wales
May 2001
LETTER TO THE EDITOR
Dear Michael,
I am pleased that several articles and abstracts address the
issue of Quality of Life. However, Quality of Life in patients
with ulcers does not depend on the ulcer alone. The new
WHO classification disability uses the word dehabilitation
to describe what happens to the whole person affected by
disease. It is a process of decreasing attention to the whole
person and loss of contact, rejection by friends and relatives.
The quality of life for such a person may be impaired
more by loss of such contacts than by the sickness itself.
Loss of contact is determined by the ‘Good looks’ of the
patient and the attractiveness of the patient to the carer. It
is thus as important when managing pressure ulcers to improve
the looks of the face and hair, the cleanliness and
odour of the whole body, the brightness and odour of the
environment and to have pictures on the walls which are
attractive. All caretakers should speak to the patient when
attending to their backside otherwise there is no reason for
the patient to know that their existence is known to the
carer other than as an ulcer.
Terence Ryan
Emeritus Professor in Dermatology
Oxford Brookes University
58
Volume 3, Number 2, 2001

epuap Future
EUROPEAN PRESSURE ULCER ADVISORY PANEL
Meetings
SEPTEMBER 2001
SEPTEMBER 2001 (continued)
3 – 4 Narrative based medicine
Conference supported by the British Academy
Contact: Jane Lewis
Conference Unit, BMA House
PO Box 295
London WC1 9TE
Tel: +44 (0)20 7383 6663
5 – 8 Joint ETRS / Wound Healing Society Meeting
Cardiff International Arena, Wales
Contact: Prof Keith Harding, ETRS2001,
Wound Healing Research Unit, UWCM,
Cardiff Medicentre, Heath Park,
Cardiff, CF14 4UJ, Wales
Fax: +44 (0)29 2075 4217
Further information:
Conference Office, Emap Healthcare
Greater London House
Hampstead Road,
London, NW1 7EJ, UK
Tel: +44 (0)20 7874 0294
Fax: +44 (0)20 7874 0298
E-mail: healthcare.conference@emap.com
7 – 9 Diabetic Foot Study Group of the EASD
2nd Scientific Meeting
The Crieff Hydron
Crieff, Scotland
Contact: Ann Roscoe
Department of Medicine
Manchester Royal Infirmary
Oxford Road
Manchester M13 9WL
Fax +44 (0)161 274 4740
E-mail: ANNE.ROSCOE@MAN.AC.UK
9 – 14 14th World Congess of Union Internationale
de Phlebologie
Rome, Italy
Contact: GC Congressi
Via P. Borsieri, 12 – 00185, Roma, Italy
Tel: +39 06 370 0541
Fax: +39 06 373 52337
E-mail: angiolsg@pronet.it
27 – 30 5th European Pressure Ulcer Advisory Panel
Open Meeting
Theme Education – Experiences we can share
Palais des Congrès de la Culture du Mans
Le Mans, France
Contact: EPUAP Business Office:
Wound Healing Institute, Dept of Dermatology,
Churchill Hospital, Old Road, Headington,
Oxford, OX3 7LJ, England
Tel: +44 (0)1865 228264
Fax: +44 (0)1865 228233
E-mail: EuropeanPressureUlcerAdvisPanel
@compuserve.com
OCTOBER 2001
6 – 7 Surgical Applications of Tissue Sealants
and Adhesives
Sheraton New Orleans
New Orleans, Louisiana, USA
Further information:
http://www.healthtech.com
9 – 10 Second transdisciplinary conference on the
principles and perspectives in regenerative
medicine
Hannover, Germany
Further information:
http://www.regmed.de
NOVEMBER 2001
7 – 10 Ist Biennial Meeting of the European Tissue
Engineering Society (ETES)
Freiburg, Germany (EU)
Contact: kongress & kommunikation GmbH
Kongressorganisation
Hugstetter Str. 55
D–79106 Freiburg, Germany
Tel: +49 (0)761 270 7316
Fax: +49 (0)761 270 7317
E-mail: kkkri@ukl.uni-freiburg.de
Continued overleaf
Volume 3, Number 2, 2001 59

EUROPEAN PRESSURE ULCER ADVISORY PANEL
NOVEMBER 2001 (continued)
11 – 16 Global Holistic Health Summit; Holistic and
Integrated Medicine for the 21st Century
Bangalore, India
Contact: Dr Isaac Mathai
Secretary General,
International Holistic Health Association
202 Parvathi Plaza
Richmond Circle
Bangalore 560 025, India
Tel: 91 80 221 4625, 227 9698
Fax: 91 80 221 8252
E-mail: holistic medicine@vsnl.com
Website: www.holisticmedic.org
14 Prevalence Survey in European Hospitals
MAY 2002
23 – 25 12th Conference of the European Wound
Management Association
‘Chronic wounds and quality of life’
Contact: EWMA
PO Box 864, London SE1 8TT
and
IV simposio Nacional sobre Ulceras
por Presion
GNEAUPP
Av. viana 1
26001-Logrono (La Rioja), Espana
Tel: +34 941 239 240
Fax: +34 941 239 347
E-mail: gneaupp@arrakis.es
SEPTEMBER 2002
18 – 21 6th European Pressure Ulcer Advisory Panel
Open Meeting
Budapest, Hungary
Contact: EPUAP Business Office, Oxford.
(Address above)
60
Volume 3, Number 2, 2001

epuap Membership
EUROPEAN PRESSURE ULCER ADVISORY PANEL
List
Executive Trustees
Mr David Gray, 15 Tarbothill Road, Aberdeen, Scotland, AB22 8RF
Tel/Fax: 01224 703125, 01224 681818, Fax: 01224 685307
Dr Jeen R E Haalboom, President
Associate Professor of Internal Medicine, Dept of Internal Medicine,
University Hospital, PO Box 85500, 3508 GA Utrecht, The
Netherlands. Tel: 00 31 30 250 6214, Fax: 00 31 30 253 9060
e-mail: Haalboom@med.ruu.ml
Prof Gerry Bennett, Recorder
Consultant Geriatrician, Department of Health Care of the Elderly,
Academic Office, 1st Floor, Alderney Building, Mile End Hospital,
Bancroft Road London, E1 4DG, England. Tel: 020 7377 7893,
Fax: 020 7377 7844 bennettg@THHT.org
Dr Marco Romanelli, Vice President
Dept of Dermatology, University of Pisa, Via Roma 67, 56126 Pisa,
Italy. Tel: 00 390 50 992 436 or 50 533 387, Fax: 00 390 50 551 124
Professor Keith Harding, Past President
Director of Wound Healing Research Unit, University Department of
Surgery, Cardiff Medicentre, Heath Park, Cardiff, CF4 4XN, Wales.
Tel: 02920 689703, Fax: 02920 745217, e-mail: wsrkgh@cf.ac.uk
Dr George W Cherry, Secretary/Treasurer
Chairman, Wound Healing Institute, Department of Dermatology,
The Churchill Hospital, Headington, Oxford, OX3 7LJ, England.
Tel: 01865 228269, Fax: 01865 228233
Mrs Christine Cherry, Business Administrator
EPUAP Business Administror, Wound Healiing Institute, Dept of
Dermatology, The Churchill Hospital, Headington, Oxford, OX3
7LJ, England. Tel: 01865 228264, Fax: 01865 228233
Dr Michael Clark, Wound Healing Research Unit, Medicentre,
University of Wales College of Medicine, Heath Park, Cardiff, CF4
4XN, Wales. Tel: 02920 689703, Fax: 02920 754217
Dr Denis Colin, Centre de l’Arche 72650, Saint Saturnin, France
Dr Christina Lindholm, Nattarovagen 42, 13234 Saltsjo-Boo, Sweden
Tel: 00 46 8 715 6263, Fax: 00 46 8 715 4442
Mr Joan-Enric Torra i Bou, Consorci Sanitari de Terrassa, Hospital de
Terrassa, Carretera de Terrassa s/n, 08227 Terrassa, Barcelona, Spain
Tel: 00 34 93 731 00 07 (ext 2291), Fax: 00 34 93 731 44 51
Trustees
Mrs Sue Bale, Director of Nursing Research, Wound Healing Research Unit,
University Department of Surgery, UWCM, Heath Park, Cardiff, CF4 4XN,
UK. Tel: 02920 689703, Fax: 02920 745299
Dr Brigitte Barrois, 32 Rue Roger Lemaire, Aulnay/s/Bois 93600 France
Tel: +33 1 3453 2085 Fax: +33 1 3453 2481 bbarrois@ch-gonesse.fr
Mrs Carol Dealey, 32 Serpentine Road, Harbourne, Birmingham,
West Midlands, B17 9RE, UK. Tel/fax: 0121 426 5674
Mr Tom Defloor, Nursing Sciences, Univ. of Gent, U.2. Block A 2 o V, De
Pintelaan 185, 9000 Gent, Belgium. Tel/fax: 00 32 50 36 24 38
Ms Jacqui Fletcher, Senior Lecturer, Univ of Hertfordshire, Hatfield Campus,
Hatfield, AL10 9AB, England. Tel: 01707 284000, Fax: 01707 284954
Prof Dr Heinz Gerngross, Bundeswehrkrankenhaus oberer Eselsberg 40,
Ulm, D–89075, Germany Tel: 00 49 731 2020, Fax: 00 49 734 553100
Professor Finn Gottrup, Bispebjerg Unit, Building 11a, Bispebjerg University
Hospital, Bispebjerg Bakke 23, DK-2300, Copenhagen NV, Denmark.
Tel: 00 45 3531 3721, Fax: 00 45 3531 3724
Dr Laszlo Gulacsi, Bem ter 8, H-4026 Debrecen, Hungary Tel: +36 52 423 264
Dr Ruud J G Halfens, Vakgroep Verplegingswetenschap, University of
Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands.
Tel: 00 31 43 388 2222, Fax: 00 31 43 367 1004
Ms Helvi Hietanen, Head Nurse, HUCH, Toolo Hospital, Dept of Plastic
Surgery, Box 266, 00029 HYKS, Finland
Tel: +358 9 47 17 228, Fax: +358 9 47 17 260
Mrs Deborah Hofman, Clinical Nurse Specialist, The Wound Healing
Institute, Dept of Dermatology, Churchill Hospital, Headington, Oxford,
OX3 7LJ, UK. Tel: 01865 228268, Fax: 01865 228233
Ms Agnes Jacquerye, Hopital Erasme, 308 Route de Lenniik, Bruxelles 1070,
Belgium. Tel: 00 32 2 555 36 65, Fax: 00 32 2 555 45 67
Mr Germain de Keyser, WCS Belgium, Kapucijnenvoer 35, 3000 Leuven,
Belgium. Fax: 00 32 16 22 8349 e-mail: germain.dekeyser@pandora.be
Mr. Maarten Lubbers, Meibergdraas 9, 1100 A2, Amsterdam, The
Netherlands. Tel: 00 31 20 56 69 111, Fax: 00 31 20 69 72 988
Dr Sylvie Meaume, Hopital Charles Foix, 7 Avenue de la Republique, Ivry sur
Seine, 94205, France Tel: 00 33 149 594 504, Fax: 00 33 149 594 524
Zena Moore, The Adelaide & Meath Hospital, Dublin, Eire. Tel: 003531
414200 (bleep 7190), Fax: 003531 4143576
Dr Elaine Pina, Rua Prof Hernani Cidade, 2–2a Telheiras Sul, 1600 Lisboa,
Portugal. Tel: 00 351 313 6390
Prof Terence Ryan, Wound Healing Institute, Dept of Dermatology, The
Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ, England.
Tel: 01865 228269, Fax: 01865 228233
Anne Witherow, 36 Cappagh Grove, Portstewart, Derry, Northern Ireland.
Tel: 02871 345171 (ext. 3602).
Paying Members
Ms Jolanda Alblas, Boveny Ziekenhuis, Statenjachtstraat 1, 1034 CS,
Amsterdam, The Netherlands. Tel: +31 20 634 6346, Fax: +31 20 634 6730
Mrs Patrizia Amione, Vulnera C50, Matteotti 35, Turin 10121, Italy.
Tel: +39 011 544 747 +39 011 533 649 r.cassino@sicurdata.it
Mrs Annika Andriessen, Zwenkgras 25, Malden 6581–RK, The Netherlands.
Tel: 00 31 24 358 7086
Dr Bauk Apotheker, James Stewart Straat 125, Almere-Stad, 1325–JC,
The Netherlands.
Mrs Leticia Arreytunandia, Lab Knoll SA, Av Burgos 91, Madrid 28050, Spain.
Tel: 00 34 1 334 3900, Fax: 00 34 1 383 1676
Associacao Portuguesa Tratamento de Feridas, Rua Alvares Cabral, 137–Sala
14, 4050–041 Porto, Portugal. Tel: +351 222 026 725 Fax: +351 222 007 890
Ms Stefania Astola, Vulnera C50, Matteotti 35, Turin, 10121 Italy.
Tel: 00 39 011 544 747, Fax: 00 39 011 533 649 r.cassino@sicurdata.it
Miss Sally Atkin, Smith & Nephew Medical, PO Box 81, Hessle Road, Hull,
HU3 2BN, England
Prof Elizabeth Ayello, New York University, Division of Nursing, 346 Green
Street, New York, NY 10003, USA Tel: +212 998 5311 Fax: +212 995 4302
elizabeth.ayello@nyu.edu
Volume 3, Number 2, 2001 61

EUROPEAN PRESSURE ULCER ADVISORY PANEL
Ms Eve Baker, Smith & Nephew Medical Ltd, PO Box 81, Hessle Road, Hull,
HU3 2BN, England
Mrs Sue Bale, Dir of Nursing Research, Wound Healing Research Unit,
UWCM, The Medi Centre, Heath Park, Cardiff, CF14 4UJ, Wales
Tel: 02920 682 187, 02920 754 217
Mr Graham Ball, Jacksons, 8 Mill Field, Barnston, Essex, CM6 1LH, England
Tel: 01371 872 097 g.j.ball@herts.ac.uk
Ms Maria Barbierato, via ca’ Brazzo, no. 44, Arre (Padua), Padova 35020, Italy.
Tel: +39 049 538 4324
Dr Richard Barnett, Hill–Rom, 4349 Corporate Road, Charleston, South
Carolina, 29405, USA
Ms Sharon Baranoski, 24724 W Park River LN, Shorewood, IL 60431 U.S.A.
Tel: 001 815 740 1078, sbaranoski@silvercross.org
Dr Brigitte Barrois, 32 Rue Roger Lemaire, Aulnay/s/Bois, 93600 France
Tel: +33 1 3453 2085 Fax: +33 1 3453 2481 bbarrois@ch-gonesse.fr
Dr Andrea Bellingeri, Via Marongoni 15, Pavia 27100, Italy.
Tel: +39 038 252 9975, Fax: +39 038 252 3203 ebellingeri@venus.it
Mrs Maureen Benbow, 20 Cloverfields, Haslington, Cheshire, CW1 5AL,
England. Tel: 01270 251833, Fax: 01270 612041
Prof Gerry Bennett, Consultant Geriatrician, Department of Health Care of
the Elderly, Academic Office, 1st Floor, Alderney Building, Mile End Hospital,
Bancroft Road, London, E1 4DG, England. Tel: 020 7377 7893,
Fax: 020 7377 7844 bennettg@THHT.org
Mrs Susan Bennett, c/o Ward Five, North Tyneside General Hospital, Rake
Lane, North Shields, England
Mr Paul Bennis, Training Manager & Nursing Specialist, Redactron
International b.v., Lange Voren 18, 5521 DD Eersel, The Netherlands.
Tel: +31 497 516895 Fax: +31 497 516833 r.bennis@redactron.com
Mrs S Benton-Jones, The Nuffield Orthopaedic Centre, Windmill Road,
Headington, Oxford, OX3 7LD, UK.
Mr Joseph Berman, Dept of Physical Therapy, 346 WSC Marqhette University,
PO Box 1881, Milwaukee, Wisconsin, 53201-1881, USA
Tel: 001 414 288 3363, Fax: 001 414 288 5987
Dr Laurent Bernier, Le Green, rue des Granges, Dommartin, 69380 France.
Tel: 00 33 478 435 127, Fax: 00 33 478 435 172 lbernier@plaies.com
Mrs Elaine Bethell, c/o Michelle Morris, Secretary, City Hospital NHS Trust,
Dudley Road, Birmingham, B18 7QM, UK. Tel: 0121 554 3801
Fax: 0121 507 5610 elaine.bethell@cityhospbham.wmids.nhs.uk
Mr Bert Billen, The ROHO Group, Peter Valentinuslaan 4, B–3500 Hasselt,
Belgium Tel: 00 31 1128 4359, Fax: 00 31 1128 1517, bbillen@attglobal.net
Mr Eric Binder, TUV Product Service, Basis Institute, Ridler Str. 31,
D–80339 Munich, Germany
Mr Itzak Binderman, School of Dental Medicine, Tel-Aviv University, Ramat
Aviv, 69978 Tel Aviv, Israel Tel: +972 3 695 1835, Fax: +972 3 640 9250
binderma@post.tau.ac.il
Miss Lynne Birchall, Dept of Nursing, Metchley Lane, Edgbaston, Birmingham,
B15 4TH, England Tel: 0121 472 1311
Dr Mary Bliss, 49 Groombridge Road, London, E9 7DP, England
Tel: 020 8985 2007
Mr Giovanni Bollini, Via Palestrina 6, 20014 Nerviano (MI), Italy
Tel: 00 39 2 6444 2526, Fax: 00 39 2 6444 2618
Mr Johe Bominaar, ConvaTec, Ujzelmolenlaan 9, AM Woerden, 3440 gx,
The Netherlands. Tel: +31 348 436950, Fax: +31 348 423084
johe.bominaar@BMS.com
Helen Boon, Wallsend Health Centre, The Green, Wallsend, Tyne and Wear,
NE28 7PD, England Tel: 0191 220 5916, 0191 220 5943
Mrs Th CM Bots, Silversteyn 64, 3621 PD Breukelen, The Netherlands.
Tel: +31 346 264 208, Fax: +31 346 264 163 postbus@thbots.demon.nl
Dr R T Boumans, TNO Prevention & Health, PO Box 2215, Leiden 2301 CE,
The Netherlands.
Dr Gerrie Bours, Maastricht Univ, Dept Nursing Science, PO Box 616,
Maastricht 6200 MD, The Netherlands. Tel: +31 43 388 1279,
Fax: +31 43 388 4162 G.Bours@zw.unimaas.nl
Dr Carlijn Bouten, Eindhoven University of Technology, Div. Continuum and
Biomechanics, MATE, PO Box 513, 5600 MB, Eindhoven, The Netherlands.
Tel: 00 31 40 247 3006 Fax: 00 31 40 244 7355 c.v.c.Bouten@tue.nl
Mr Hendrika Bouwman, Wilsonstr. 90, Hoofdorp, 2313 PV, The Netherlands.
Tel: 00 31 23 561 1850
Mr Jon Bredal, Semsveien 150, 1384 Asker, Norway. Tel: +47 661 05610,
Fax: +47 669 05611 bred@online.no
Ms Gail Broadbent, 44 Warley Road, Blackpool, FY1 2LL England
Tel: 01253 303238
Joost L. Broerse, Postbus 167, Weesp, 1380 AD, The Netherlands.
Tel: 00 33 294 415001, Fax: 00 33 294 430475
Miss Jill Brooks, Abingdon Hospital, Marcham Road, Abindon, Oxford,
OX14 1AG, England. Tel: 01993 774126, Fax: 01992 706947
jill.brooks@oxch-tr.anglox.nhs.uk
Mr Harry Brouwer, c/o Sterreboslaan 2, Bloemendaal, 2061 VV, The
Netherlands. Tel: +31 6 53 66 3583
Dr Roel Brull, Huntleigh Healthcare, Flevolaan 8, 1382 JZ Weesp, The
Netherlands
Ms Mariantonietta Brunengo, Hill-Rom Spa, Via Ambrosoli 6, 20090 Rodana
(MI) Italy
Dr Enrica Buonagurio, via A. Manzoni 6, Vimodrone, Milan 20090, Italy.
Tel: +39 022 650 062, Fax: +39 022 502 546 ebuonagurio@libero.it
Ms Annette Buschka, Mölnlycke Health Care AB, PO Box 13080, SE 40252,
Sweden. Tel: 00 46 31 722 8121, 00 46 31 722 3409
Mr Cesar Calderon, Beiersdorf Portugesa, Rus Soeiro Pereira Gomes, 59 –
Queluz de Baixo, 2746–952, Portugal.
Tel: 00 351 21 436 8500, Fax: 00 351 21 436 2874
Dr Gianna Rita Carella, ‘C Golgi’ Geriatric Institute, Piazza Golgi 11, Abbiategrasso
(Milan) 20081, Italy. Tel: +39 029 466 771 Fax: +39 029 496 808
Mrs Antonietta Carusone, ‘C Golgi’ Geriatric Institute, Piazza Golgi 11, Abbiategrasso
(Milan) 20081, Italy. Tel: +39 029 466 771 Fax: +39 029 496 809
Ms Andrea Cavicchioli, Via Siligardi 14, 41100 Modena, Italy
Tel: +39 059 4401 24, Fax: +39 059 3992 10 cavicchioliandrea@hotmail.com
Mrs Tina Chambers, 11 Adison Square, Ringwood, Hants BN24 1NV, England.
Tel: 01425 471291
Dr Michael Clark, Wound Healing Research Unit, UWCM, The Medi Centre,
Heath Park, Cardiff, CF14 4UJ, Wales. Tel: 02920 682 191, 02920 754 217
Dr Denis Colin, Medical Director, Centre de l’Arche, 72650 Saint Saturnin, Le
Mans, France. Tel: +33 243 51 72 57, Fax: +33 243 51 72 67
Denis.Colin2@wanadoo.fr
Mr Mark Collier, 61 Sparrowhawk Way, Hartford, Huntingdon, Cambridgeshire,
PE18 7XE, England. Tel: 020 8280 5020, Fax: 01480 434100
Mrs Fiona Collins, 25 Hyde Gardens, Eastbourne, East Sussex, BN21 4PX,
England. Tel: 01323 735588, Fax: 01323 737132 fiona@trcs.cc
Miss Pamela Cooper, Clinical Nurse Specialist, Dept of Tissue Viability,
Foresthill, Grampion University Hospital, AB25 2ZN, Scotland.
Tel: 01224 554621, Fax: 01224 849139
Mrs Barbara Craven, Disability Services, Walton Hospital, Chesterfield,
Derbyshire, S40 3HW, England. Tel: 01246 552875 (ext 5707)
Fax: 01246 552910
Ms Jean Cregg, 9 Goddards Lane, Aldbourne, Marlborough, Wilts, SN8 2DZ,
England. Tel: 01282 432072, Fax: 01282 421597
Ms Ann Daenekindt, Stapelplein 70, Gent 9000, Belgium. Tel: +32 9 265 8770
Fax: +32 9 265 8771 ann.daenekindt@huntleigh-healthcare.be
Dr Cynthia Dale, Johnson & Johnson Medical Ltd, New Product Development,
Gargrave, North Yorks, BD23 3RX, England.
Tel: 01756 747455 Fax: 01756 748158
62
Volume 3, Number 2, 2001

EPUAP MEMBERS
Dr Sarah Daniels, Harrington House, Milton Road, Ickenham, Uxbridge,
Middlesex, UB10 8PU, England. Tel: 01895 628395 Fax: 01895 628338
Mrs Carol Dealey, 32 Serpentine Road, Harborne, Birmingham, B17 9RE,
England. Tel: (and Fax:) 0121 426 5674
Nathalie de Dieulveult, Smith & Nephew SA, Espace Novaxis, 25 Bld
Alexandre Oyon, 72019 Le Mans Cedex, France
Dr Tom Defloor, Kerklaan 58, Brugge 8310, Belgium
Tel: 00 32 50 36 24 38, Fax: 00 32 50 36 24 38
Mr Germain de Keyser, Kapucijnenvoer 35, 3000 Leuven, Belgium
Tel: 00 32 1633 2211, 00 32 1922 8349 germain.dekeyser@pandora.be
Dr Bart Derre, Aartstraat 210, Ronse, B-9600, Belgium. Tel: 00 32 55 20 6948
Ms Ingrid Devries, Smith & Nephew BV, Kruisweg 659, 2132 HG Hoofdorp,
The Netherlands
Dr Andy Dobrzeniecki, Torsana A/S, Skosborg Strandvej 156, DK-2942
Skodsborg, Denmark
Dr Sonia Dumit-Minkel, 1231 E. Donges Crt, Bayside, Wisconsin 53217, USA
Mrs Cheryl Dunford, Medical Equipment Centre, Salisbury District Hospital,
Salisbury, Wilts, SP2 8BJ
Dr Ana Durao, R Replia Horsensia de Castro, No 2 – 8oD to, Colina do Sol,
2700 Amadora, Portugal. Tel: +351 21 474 8559 anadurao@net.sapo.pt
Mrs Sandra Ellis, 14 Pinewood Road, Eaglescliffe, Cleveland, TS16 0AH,
England Tel: 01642 791558 Fax: 01642 624165
Mrs Wendy Eve, Saiyang, 30 Torton Hill Road, Arundel, West Sussex, BN18
9HL, England Tel: 01903 882212, Fax: 01243 623664
wendyeve@u.genie.co.uk
Carlos Ferrer, Smith & Nephew SA, Fructuos Gelabert 2 y 4, 08970 Sant Juan
Despi, Barcelona, Spain
Ms Cynthia Fleck, The ROHO Group, 100 North Florida Avenue, Belleville,
Illinois, 62221, USA Tel: +618 277 9173, Fax: +618 277 9561
cynthiaf@therohogroup.com
Mrs Jacqui Fletcher, University of Hertfordshire, Hatfield Campus, College
Lane, Hatfield, Herts, AL10 9AB, England
Tel: 01707 284000, Fax: 01707 284954 j.fletcher@herts.ac.uk
Mr Håkan Freijd, Convatec/Bristol-Myers Squibb, Box 15200, S–16715
Bromma, Sweden. Tel: 00 46 8 7047250
Mr Gerd-Wenche Frilseth, Smith & Nephew A/S, PO Box 224, Nye Vakaas vei
64, 1360 Newbru, Norway
MsKatia Furtado, Rua Viturino Nemesio, No.2–7 Esquerdo, 1750-307 Lisbon,
Portugal. Tel: +351 21 758 8288 kfurtado@ip.pt
Mr Lucas Garabet, GerroMed GmbH, Fangdieckstra 75B, Hamburg 22547,
Germany Tel: +49 40 547 3030, Fax: +49 40 547 30331
GarabetL@Gerromed.de
Mr K. G. Gebhardt, 2 Manchuria Villas, Wix’s Lane, London, SW4 0AG,
England. Tel: 020 7228 8545, Fax: 020 8725 1621
Prof Dr Heinz Gerngross, Bundeswehrkrankenhaus, Oberer Eselberg 40, D–
89070, Ulm, Germany. Tel: 00 49 931 171 2020, Fax: 00 49 937 553100
Dr Carella Gianna Rita, ‘C Golgi’ Geriatric Institute, Piazza Golgi 11, Abbiategrasso
(Milan) 20081, Italy. Tel: 00 39 029 466 771 Fax: 00 39 029 496 808
Dr Walter Gianni, via Appennini 38, Rome 00198, Italy
Tel: +39 06 3034 2690, wgianni@tiscalinet.it
Franco Giraudi, Smith & Nephew Srl, Centro Direzionale Colleoni, Viale
Colleoni 13, Palazzo Orione Ingresso 1, 20041 Agrate Brianza, Milan, Italy.
Me Anabela Gomes, Rua Teofilo Braga, 154–1o, 4435–461 Rio Tinto, Portugal.
Tel: +351 224 889 791
Mrs Ann Goodhead, Derbyshire Royal Infirmary, London Road, Derby, DE1
2QY, England. Tel: 01332 347141, Fax: 01332 254958
Dr Allison Graham, 75 Mellstock Road, Aylesbury, Bucks, HP21 7NX, England
Tel: 01296 315851, Fax: 01296 315867
Dr Jeffrey Graham, Dept of Health, Room LG24, Wellington House, Walterloo
Road, London, SE1 8UG, England Tel: 020 7972 4710 Fax: 020 7972 4405
Mr David Gray, 15 Tarbothill Rd, Aberdeen, AB22 8RF, Scotland.
Tel: 01224 681818 (703125), Fax: 01224 708665 (703125)
Mr Mark Green, 1 Greenwood Avenue, Horwich, BL6 6FA, UK.
Dr Laszlo Gulacsi, Bem ter 8, H–4026 Debrecent, Hungary.
Mrs Lena Gunningberg, Department of Nursing Research and Development,
University Hospital, 75185 Uppsala, Sweden. Tel: +46 18 611 3194,
Fax: +46 18 611 3025 lena.gunningberg@adm.uas.lul.se
M Susan Gwynne, C.I. Adulti, Ospedale G Pasquinucci, via Aurelia Sud 1,
Massa 54100, Italy.
Dr Jeen RE Haalboom, Dept. of Internal Medicine, University Hospital,
Heidelberglaan 100, Utrecht 3508, The Netherlands.
Tel: 00 31 30 250 6214, Fax: 00 31 30 253 9060
Dr Satsue Hagisawa, Qita Medical University, School of Nursing, Hasama, Qita
879-5593, Japan.
Mr Kurt Halbwachs, Smith & Nephew GmbH, Concorde Business Park D2/
Top 11, 2320 Schwechat, Austria.
Dr Ruud Halfens, Praaglaan 123, 6229 HR Maastricht, The Netherlands.
Ms Samantha Hall, Acordis Speciality Fibre Ltd. Lockhurst Lane, Coventry,
CV6 5RS, England.
Ms Tracey Hamlyn, 61 Lydford Park Road, Peverell, Plymouth, PL3 4LQ,
England Tel: 01752 670601
Mr Mark Hammonds, Coronary Care Unit, James Cook University Hospital,
Marton Road, Middlesborough, TS4 3BW, England
Tel: 01642 854801, Tel: 01642 854196
Miss Jane Hampton, 25 Trentham St, Southfields, London, SW18 5AS
England. Tel: 020 8846 6544 Fax: 020 8846 6543
Dr Carita Hansson, Dept of Dermatology, Wound Healing Centre,
Sahlgrenska University Hospital, 41345 Göteborg, Sweden
Tel: +46 31 342 1000 Fax: +46 31 821 871
Prof Keith Harding, Director, Wound Healing Research Unit, UWCM, Cardiff
Medicentre, Heath Park, Cardiff, CF14 4UJ, Wales, UK
Tel: 02920 682 176, Fax: 02920 754 217 HardingKG@cf.ac.uk
Ms Elizabeth Hardy, Northumbria Healthcare NHS Trust, Wallsend Health
Centre, The Green, Wallsend, Tyne and Wear NE28 7PD England. Tel: 0191
220 5928, Fax: 0191 220 5943
Ms Diane Hargrove, Seton Healthcare, Tubiton House, Medlock Street,
Oldham, OL1 3HS, England. Tel: 0161 652 2222, Fax: 0161 621 2627
Ms Judy Harker, Room 15 Chalmers Keddie Building, Royal Oldham Hospital,
Rochdale Road, Oldham, OL1 2JH, England Tel: 0161 627 8701
Fax: 0161 627 8554, judy.harker@oldham-tr.nwest.nhs.uk
Mrs Lucy Harper, 50 Somersall Street, Mansfield, Notts., NG19 6EP, England.
Tel: 01623 456063 lucy@ntlworld,com
Ms Joy Harris, Smith & Nephew Medical Ltd, PO Box 81, Hessle Rd, Hull,
HU3 2BN, UK. Tel: 01482 225181 (x 2645), 01482 673106
Mr Kenny Harris, Davenant, 18a Lordsgate Lane, Burscough, Ormskirk, L40
7ST, UK
Mr William Haughton, 211 Spital Road, Bromborough, Wirral, Merseyside,
CH62 2AF, England. Tel: 0151 334 8461
Mrs Linda Haywood, 25 Avalanche Road, Southwell, Portland, Dorset, DT5
2DT, England. Tel: 01305 252812
Ms Arja Heikinheimo, Kuntokatu 8, 15900 Lahti, Finland Tel: +358 3 819
4857, Fax: +358 3 819 7850 arja.heikinheimo@phks.fi
Ms Jussi Heikkila, Kuoppatie 4, PO Box 25, Helsinki, 00731 Finland
Tel: +358 9 346 2574, Fax: +358 9 346 2576 jussi.heikila@icfgroup.fi
Dr Eva-Lisa Heinrichs, ConvaTec Ltd, Swakeleys House, Milton Rd, Ickenham,
Uxbridge, Middlesex, UB10 8NS, England.
Tel: 01895 628330, Fax: 01895 628332
Volume 3, Number 2, 2001 63

EUROPEAN PRESSURE ULCER ADVISORY PANEL
Ms Taina Hemmila, Kuoppatie 4, PO Box 25, Helsinki, 00731 Finland
Tel: +358 9 346 2574, Fax: +358 9 346 2576 taina.hemmila@icfgroup.fi
Mr Jan Hermkens, Weymar Straat 8, Maasbree, 5993 CT, The Netherlands.
Tel: +31 77 465 2676, Fax: +31 77 465 1599 jan.hermkens@wxs.nl
Ms Hilde Heyman, Karel VD, Woestynelaan 40, 2630 Aartselaar, Belgium
Tel: +31 3 289 4087
Ms Helvi Hietanen, Tonttumuorinkija 1, 02200 Espoo, Finland.
Tel: +35 85 001 02947, Fax: +35 89 412 5074 hetu.hietanen@magabaud.fi
Mrs Deborah Hofman, Wound Healing Institute, Dept of Derm., Churchill
Hospital, Headington, Oxford, OX3 7LJ, England
Tel: 01865 228268, Fax: 01865 228233
Mrs Monica Hofmann-Rosener, HNE Healthcare, Im Hulsenfeld 19, 40721
Hilden, Germany. Tel: +49 2013 97110
Fax: +49 2013 971146 hne.hofrose@t-online.de
Mrs Helen Hollinworth, 10 Cages Way, Melton, Woodbridge, Suffolk,
IP121TE, England Tel: 01473 296557
Ms Alison Hopkins, Primary Care, Mile End Hospital, Bancroft Rd, London
E1 4DG, England. Tel: 020 7377 7000 (ext 4331) Fax: 020 7377 7802
Ms Hovannouhi Houniet, Nutricia Netherlands, Postbus 1, Zoetermeer, 2700
MZ, Netherlands. Tel: 00 31 353 9370
Ms Ansa Iivanainen, Potnolankatu 5, Mikkeli, 50120 Finland.
Tel: +358 15 150 632, Fax: +358 15 355 6686 ansa.iivanainen@mikkeliamk.fi
Prof Agnes Jacquerye, Clinique Universitaires de Brusselles, Route de Lemik
808, 1070 Brusselles, Belgium.
Tel: +32 2 555 4567, Fax: +32 2 555 3665
Sister Sian James, Wound Healing Office, East 5, Whitchurch Hospital, Park
Road, Whitchurch, Cardiff CF4 7XB, UK
Mr Torsten Johansen, Smith & Nephew A/S, Naerum Hovedgade 2, 2850
Haerum, Denmark
Ms Elisabeth Jolink, Rijnstate Hospital, PO Box 9555, 6800 TA Arnhem,
The Netherlands. Tel: +31 26 378 6973
Dr Wilhelm Jung, Wound Manage. Division, Smith & Nephew Medical Ltd,
PO Box 81, Hessle Rd, Hull, HU3 2BN, England.
Tel: 01482 673030 Fax: 01482 673106
T Kaldijk, Academisch Ziekenhuis Maastricht, Postbus 5800, 6202 AZ,
Maastricht, The Netherlands. Tel: 00 31 43 387 5912, Fax: 00 31 43 387 5142
Mr Raija Kannininen, Perkionkuja 5B, 01670 Vantaa 67, Finland.
Tel: 00 358 9 270 92790, Fax: 00 358 9 270 92798
Greger Karlsson, Smith & Nephew AB, Textilvagen 7, 3tr, S–120 30 Stockholm,
Sweden.
Mrs Anne Keogh, 8 Glenavon Road, Kings Heath, Birmingham, B14 5BL,
England. Tel: 0121 604 2287, Fax: 0121 697 8377
Dr Morris Kerstein, 1214 Valley Road, Villanova, PA 19085, USA
Tel: 001 215 762 8402 Fax: 001 215 762 8389
Mrs Penny Keynton-Hook, Department of Professional Studies, Sussex Weald
and Downs NHS Trust, 9 College Lane, Chichester, PO19 4FX, England.
Tel: 01203 815336 (0402 891835) Fax: 01203 815413
Mrs Brenda King, 12 Beckton Ave, Waterthorpe, Sheffield, S20 7NA, England.
Tel: 0114 271 6416, Fax: 0114 271 6417, brenda.king@virgin.net
Prof Luther Kloth, Dept of Physical Therapy, Marquette University, PO Box
1881, Milwaukee, WI 53201-1881 USA
Tel: 001 414 288 3381 Fax: 001 414 288 5987
Mrs Cathy Knowles, Tissue Viability Specialist, Royal Devon and Exeter
Hospital (Wonford), Barrack Road, Exeter, EX2 5DW, England.
Tel: 01392 402846 Fax: 01392 402774
Mr E. Koopman, Deventer Ziekenh Stg, Fesevurstraat 7, 7415 CM Deventer,
The Netherlands. Tel: +31 (0)570 646 078
Prof. Andrzej Kubler, Chalublinskiego 1A, Wroclan, 50368 Poland.
Tel: +48 71 328 1534, Fax: +48 71 328 5087
andrzej.kubler@anest.am.wroc.pl
Mr Erik Küppers, HNE Healthcare, Im Hulsenfeld 19, 40721 Hilden,
Germany. Tel: +49 2013 97110 Fax: +49 2013 971146
hne.kueppers@t-online.de
Mr Jan van Laere, Smith & Nephew SA, Avenue du Four a Briques 3B, 1140
Bruxelles, Belgium.
Ms J Leenman, Albert Cuyplaan 17, Woudenberg LD 3931, The
Netherlands. Tel: 00 31 33 286 2303 Fax: 00 31 33 693 2740
Mr Derek Lemon, 13 Victoria Road, Northampton, NN1 5ED, England.
Tel: 01604 604763 Fax: 01604 604763
Miss Ruth Lester, 64 Wellington Road, Edgbaston, Birmingham, B15 2ET,
England. Tel: 0121440 4937, Fax: 0121 440 7708
ruthlester@compuserve.com
Mr Nigel Lewis, Smith & Nephew Healthcare Ltd, Healthcare House, Goulton
Street, Hull, HU3 4DJ, England.
Ms Sarah Lewis, 14 Lancaster Road, Walthamstow, London, E17 6AJ, England.
Tel: 020 8503 3921 sarah.lewis@uclh.org
Mr Wouter Lioen, Sampli NV, Schamperij 9, B–9667 Horebeue, Belgium.
Tel: 00 32 55 45 5867, Fax: 00 32 55 45 6986
Dr Christina Lindholm, Uppsala University Hospital, Uppsala, 75185, Sweden.
Tel: 00 46 18 66 3087. Fax: 00 46 87 15 44 42
Dr Maarten Lubbers, Surgeon AMC, Meibergdreef 9 1105 AZ, Amsterdam,
The Netherlands. Tel: 00 31 20 566 9111, Fax: 00 31 20 697 2988
Ms Yvonne Lutgens, Nieuwe Uilenburgerstraat 10B, 10011 LP Amsterdam,
The Netherlands. Tel: +31 20 566 9111 Fax: +31 20 566 9221
y.h.lutgens@amc.uva.nl
Ms Gysesl Machteld, De Domk 4, Mortsel, B–2640, Belgium
Tel: 00 32 3455 2660 Fax: 00 32 3457 3419
Mrs Helga Magnusson, Mölnlycke Health Care, PO Box 13080, 40503
Göteborg, Sweden
Mrs Peta Matthews, Southern Cottage, Jenkins Lane, St Leonards, Tring,
Herts, HP23 6NW, England. Tel: 01494 758751
Mr Andrew Cox Martin, Dept of Medical Engineering, Salisbury District
Hospital, Salisbury, Wilts, SP2 8BJ, England.
Tel: 01722 425138 Fax: 01722 416227 bill@medengsdh.demon.co.uk
Dr Stella Maurizio, Burn Unit/CTO, via Zuretti 29, Torino, 10137 Italy. Tel:
+39 11 693 3423/5, Fax: +39 11 693 3425
Mr Anton Mayrhauser, Ketzergasse 39 (FA Sunmed), 1232 Vienna, Austria
Tel: +43 1699 2299 Fax: +43 1699 2299-1 mayrhauser@ sunmed.at
Mr Ray McDermott, Smith & Nephew Ltd, Pottery Road, Kill O’the Grange,
Dun Laoghaire, Co. Dublin, Ireland.
Dr Alistair McLeod, Huntleigh Technology PLC, 310-312 Dallow Road, Luton,
LU1 1TD, England. Tel: 01582 745768, Fax: 01582 745862
Ms Mary McMahon, St Joseph’s Ward, Cappagh National Orthopaedic
Hospital, Finglas, Dublin 11, Ireland.
Dr Sylvie Meaume, Hopital Charles Foix, 7 Avenue de la Republique, Ivry sur
Seine, 94205, France Tel: 00 33 149 594 504,
Fax: 00 33 149 594 524 sylvie.meaume@cfx.ap-hop-paris.fr
Dr Julian Minns, Dept of Medical Physics, Dryburn Hosp, Durham, DH1 5TW,
England. Tel: 0191 333 2220, Fax: 0191 386 5695 jminns@compuserve.com
Mr Peter Mitchell, 40-60 West Thebarton Road, Thebarton, South Australia
5031, Australia.
Ulla Moe, Product Manager, Huntleigh Healthcare, Hejreskouvej 18a, 3490
Kvistgard, Denmark. Tel: 00 45 49 138 486, Fax: 00 45 49 138 487
Prof Fabrizio Moffa, Vulnera C50, Matteotti 35, Turin 10121, Italy.
Tel: +39 011 544 747, Fax: +39 011 533 649 r.cassino@sicurdata.it
Ms Sue Moody, Smith & Nephew Medical Ltd, PO Box 81, Hessle Rd, Hull,
HU3 2BN, England.
Ms Louise Morris, 3 Bowood Lane, St Peters, Worcester, WR5 3UT, England.
Tel: 01905 769337 garethandlouise@talk21.com
64
Volume 3, Number 2, 2001

EPUAP MEMBERS
Ms Libby Morrison, Worldwide Clinical Research Group, Johnson & Johnson
Medical, Gargrave, North Yorkshire, BD23 3RX, England.
Mr Olavi Murros, Kuoppatie 4, PO Box 25, 00731, Finland.
Tel: +358 9 346 2574, Fax: +358 9 346 2576 olavi.murros@kolumbus.fi
Mrs Jeanette Nelson, Vibro-Pulse Ltd, Colomendy Industrial Estate, Denbigh,
N Wales, LL16 5TS, UK Tel: 01745 811200, Fax: 01745 817142
epetern@aol.com
Mr Peter Nelson, Vibro-Pulse Ltd, Colomendy Ind. Estate, Denbigh, N Wales,
LL16 5TS, UK Tel: 01745 811206, Fax: 01745 817142 epetern@aol.com
Ms Kaoru Nishide, Smith & Nephew KK, Shiba-Nikkei-Yuraku Bld, 1-10-13
Shiba, Minato-ku, Tokyo 105-0014, Japan. Tel: 00 81 3544 35721,
Fax: 00 81 3544 35722 kaoru.nishide@smith-nephew.com
Mrs Jane Nixon, Park View House, Parkside, Bingley, BD16 3DG, England.
Tel: 01904 434114, Fax: 01904 434101 jen@york.ac.uk
Mrs Pia Obank, Lane End Surgery, Finings Road, Lane End, Bucks, HP14 3ES,
England Tel: 01494 883364
Miss Louise O’Connor, 37 Clough House Drive, Leigh, Lancashire, WN7 2GD,
England. Tel: 0161 291 3227 louise.oconnor@smunt.nwest.nhs.uk
Dr Cathy O’Neill, Huntleigh Healthcare, 312 Dallow Road, Luton, LU1 1TD,
England. Tel: 01582 745736, Fax: 01582 459100 cathy.oneill@hunhcare.co.uk
Sabine Onillon, Smith & Nephew AG, Hans-Huber Strasse 38, Postfach CH–
Soluthurn, Switzerland.
Mrs Nwando Onugha, 3 Wood Close, Salfords, Redhill, Surrey, RH1 5EE,
England. Tel: 01293 823176
Dr Cees Oomens, Eindhoven Univ of Technology, Mech Eng Dept, PO Box
513, 5600 MB, Eindhoven, The Netherlands. Tel: +31 40 247 2818,
Fax: +31 40 244 7355 oomens@wfw.wtb.tue.nl
Ms Sarah Pankhurst, Wollaton Vale Health Centre, Wollaton, Nottingham,
NG8 2GR, England. Tel: 0115 928 8861, 0590
Mrs Anne-Marie Perrin, 13 Pettitts Lane, Dry Drayton, Cambs, CB3 8BT,
England. Tel: 01954 780467 Fax: 01954 789729
Dr Carla Pezzuto, Torino via Garibaldi 6, 10121, Italy. Tel: 00 39 011 521 5909
Dr Maria Pietropaolo, via val Trompia 56, Rome 00141, Italy
Tel: +39 06 871 92 983, Fax: +39 06 494 0594
Dr Elaine Pina, Comissao de Controlo de Infeccao, Hopital sto Antonio dos
Capuchos, Alameda sto Antonio, Dos Capuchos, 1150 Lisbon, Portugal.
Mrs Monica Pittarello, Vulnera-Corso, Matteotti 35, Torino, 10121 Italy.
Tel: +39 011 544 747, Fax: +39 011 533 649 r.cassino@sicurdata.it
Dr Chryssanthi Plati, Univ of Athens, Fragokklissias 12 Str, 15125 Marousi,
Athens, Greece. Tel/Fax: +301 61 98 619
Mrs Fiona Preece, Staff Development Education Centre, Worcester Royal
Infirmary NHS Trust, Ronkswood Branch, Newtown Rd, Worcester, WR5 1HN,
England. Tel: 01905 760604, Fax: 01905 760580
Mrs Maria Priami, Univ of Athens, Fragokklissias 12 Str, Marousi, 15125
Athens, Greece. Tel/Fax: +301 61 98 619
Dr Patricia Price, Wound Healing Research Unit, Cardiff Medi Centre, Heath
Park, Cardiff, CF14 4UJ, Wales. Tel: 02920 682 179, Fax: 02920 754 217
pricepe@cf.ac.uk
Mr Terence Price, Seers Bough, Wilton Lane, Jordans, Beaconsfield, HP9
2RG, England. Tel: 01494 874 589
Mr Marcus Raphael, B Braun Medical Ltd, Thorncliffe Park, Sheffield, S35
2PW, England. Tel: 0114 225 9127
Fax: 0114 225 9123 marcus.raphael@bbraun.com
Mr Claude Regnier, B. Braun Biotrol SA, 69 Rue de la Grange Aux Belles,
75010 Paris, France.
Brukhard Reis, Smith & Nephew GmbH, Medical Division, Max-Planck-Strasse
1–3, D–34253 Lohfelden, Germany
Prof Elia Ricci, Vulnera-Corso, Matteotti 35, Turino 10121, Italy
Tel: +39 011 544 747 Fax: +39 011 533 649 r.cassino@sicurdata.it
Dr Marina Ritter, Polyheal Ltd, 44 Bar Jehuda Str, Nesher, 20300 Israel
Tel: +972 4 820 7917, Fax: +972 4 820 7919 marina@polyheal.co.il
Dr Vladimire Ritter, Polyheal Ltd, 44 Bar Jehuda Str, Nesher, 20300 Israel
Tel: +972 4 820 7917, Fax: +972 4 820 7919
Dr Cassino Roberto, Vulnera-Corso, Matteotti 35, Torino 10121, Italy.
+39 011 544 747 Fax: +39 011 533 649 r.cassino@sicurdata.it
Dr Marco Romanelli, Department of Dermatology, University of Pisa, Via
Roma 67, 56126 Pisa, Italy. Tel: 00 39 050 992 436 Fax: 00 39 050 551 124
Prof Lior Rosenberg, 13 Harduf Street, Omer 84965, Israel
Tel: +972 764 00880, Fax: +972 764 03033 proflior@netvision.net.il
Voula Rossetto, Smith & Nephew Medical Ltd, PO Box 81, Hessle Rd, Hull,
HU3 2BN, England.
Dr Vincenzo Ruggiero, Clinica villa Bianca Martina, Franca Taranto Italie,
74100 Taranto, Italy Tel: +39 080 449 0234
Mrs Linda Russell, Queens Hospital, Burton Hospitals NHS Trust, Belvedere
Rd, Burton on Trent, Staffs, DE13 0RB, England.
Tel: 01283 511511 (x 2272)
Dr David Ryan, General 1W, Freeman Hospital, Newcastle upon Tyne, NE7
7DN, England. Tel: 0191 284311 (x 26423) Fax: 0191 223401
David.Ryan@nuth.northg.nhs.uk
Prof Terence Ryan, Wound Healing Institute, Department of Dermatology,
Churchill Hospital, Headington, Oxford, OX3 7LJ, England.
Tel: 01865 228269, Fax: 01865 228233
Dr Paini Salminen-Peltola, Kuusaankuja 2, Jarvenpaa, 04430 Finland
paivi.salminen-peltola@hus.fi
Ms Margarita Sanchez, CI Cacandvas 27/31 SN, Corbera de Llobregat, 08757
Barcelona, Spain. msanchez@icnpharm.com
Mr Bob Sandham, Smith & Nephew Medical Ltd, PO Box 81, Hessle Rd, Hull,
HU3 2BN, England.
Andre Santos, Smith & Nephew Lda, Galerias do Alto da Barra, Av. Das
Descobertas, Piso 3 No 59, Alto da Barra – 2780 Oeiras, Portugal.
Dr Wayne Schroeder, 8023 Vantage Drive, PO Box 659508, San Antonio,
78265-9508 Texas, USA. Tel: 001 210 554 5396
Fax: 001 210 255 6988 schroedw@kci1.com
Mrs Eileen Scott, Professorial Unit of Surgery, North Tees & Hartlepool NHS
Trust, Stockton on Tees, TS19 8PE, England.
Tel: 01642 624087 Fax: 01642 624165
Mr Tony Seaney, Niaraga Holdings plc, 88a High Street, Shoreham-by-Sea,
West Sussex, BN43 5DB, England.
Dr Joseph Selkon, 4 Ethelred Court, Oxford, OX3 9DA, England.
Tel: 01865 764098, Fax: 01865 764098
Dr Zina Serafim, R.D. Estefania 5–3° D, Lisboa, Portugal. 1150–120.
Tel: +351 1 354 9154
Mrs Catherine Sharp, 3 Salisbury Street, South Hurstville, Sydney 2221,
Australia Tel. & Fax: +61 2 958 50393 Tel: +61 2 938 53588
Fax: +61 2 938 51086 catherine 410@hotmail.com
Miss Helen Shearer, 164 Scalby Road, Scarborough, North Yorkshire, TO12
6TB, England Tel: 01723 3754525 hcs164@hotmail.com
Mr Andy Smallwood, NHS Purchasing & Supply Agency, 80 Lightfoot Street,
Chester, CH2 3AD, England. Tel: 01244 586807 Fax: 01244 586828
andy.smallwood@doh.gsi.gov.uk
Ms Helen Smyth, Anglia Polytechnic University, School of Healthcare Practice,
24 Park Road, Chelmsford, Essex CM1 1LL, England
Tel: 01245 493131 (x 4142), Fax: 01245 250368 h.smyth@apu.ac.uk
Mr Javier Soldevilla, Agreda Avda de Navarra, 8-10, 4-D, Logrono, 26001,
Spain. Tel: +34 41 251 392, Fax: +34 41 22 03 44
Mr Steve Spurgin, Smith & Nephew Medical Ltd, PO Box 81, Hessle Road,
Hull, HU3 2BN, England. Tel: 01482-673742 Fax: 01482-673106
Mrs Julie Stevens, 11 Portland Road, Ashford, Middlesex, TW15 3BU,
England. Tel: 01784 242312 Work: 020 8321 2435 Fax: 020 8321 2272
Tel:
Volume 3, Number 2, 2001 65

EUROPEAN PRESSURE ULCER ADVISORY PANEL
Mrs Fiona Stephens, 16 Strangford Rd, Tankerton, Whitstable, Kent, CT5 2EP,
England. Tel: 01227 459371 Fax: 01227 812268
r.f.stephens@btinternet.com
Dr Thomas Stewart, Gaymar Industries Inc, 10 Center Drive, Orchard Park,
NY-14127, USA
Mrs Lesley Stockton, Department of Psychology, Manchester University,
Oxford Road, Manchester, England Tel: 01942 682217,
Fax: 01942 681995 otlesely@yahoo.co.uk
Mrs Varda Swager, Hoshav Serufa Doan Nah, Hof Ha Carmel, 30850, Israel.
Tel: +972 4984 2928 Fax: +972 4854 2750
Dr Ian Swain, Dept of Medical Physics and Bio. Engineering, Salisbury District
Hospital, Salisbury, SP2 8BJ, England. Tel: 01722 336262 (x 4065), 425263
Ms Anna-Britta Tallberg, Vaksala Svia, 75594 Uppsala, Sweden
Tel: +46 18 31 7412, Fax: +46 18 611 2460
Mrs Adrienne Taylor, Salford Community Health Care NHS Trust, The
Willows Centre for Health Care, Lords Avenue, Salford M5 2JR England.
Tel: 0161 737 0330 Fax: 0161 745 8042
Mrs Ann Withington, 10 Barnfield Crescent, Wellington, Telford, Shropshire
TF1 2ES, England. Tel: 01952 641222
Dr Helene Wolff, Fyra Dalersgatan 32, 41319, Sweden Tel: 00 46 342 1000
Mrs Frances Worboys, 2 The Poplars, Cheshunt, Herts, EN7 6AR, England.
Tel: 01992 626100
Ms Trudie Young, School of Nursing, Glan Clwyd Hospital, Bodelwyddan,
Denbighshire, LL18 5UJ, UK Tel: 01745 583910 Fax: 01745 534960
Mr Arkadiusz Zbronski, ul Kasztanowa 27, Olsztyn, 10–156 Poland.
real@cso.com.pl
Mr Ireneusz Zbronski, ul Kasztanowa 27, Olsztyn, 10–156 Poland.
real@cso.com.pl
Mr Jintiene Zeilstra, Academisch Zienhuis Groningen, Postbus 30001
Groningen, Secretarial Dermatologie TI 250, 97008 B, The Netherlands.
Tel: 00 31 50 361 2520 Fax: 00 31 50 361 2624 j.t.zeilstra@derm.az.nl
Dr M Barend ter Haar, BES Rehab Ltd, 9 Cow Lane, Fulbourn, Cambridge,
CB1 5HB, England. Tel: 01223 882105, Fax: 01223 882105
b.e.s.rehab@btconnect.com
Mrs Susan Thomas, 3 Tylston Meadow, Liphook, Hants, GU30 7YB, England.
Tel: 01420 488999, Fax: 01420 489009 clinical@crownmed.co.uk
Ms Jean Thomson, 9 Goddards Lane, Aldbourne, Marlborough, Wilts, SN8
2DZ, England.
Mr Tore Tomter, Tordivelen 20, Hamar, N-2316 Norway.
Tel: +47 625 26272, Fax: +47 625 21211 tore@togemo.no
Mrs Hazel Tonge, Clinical Department, Beiersdorf UK Ltd, Yeoman’s Drive,
Blakelands, Milton Keynes, Bucks. MK14 5LS, England. Tel: 01908 211333,
Tel: 01908 211555
Dr Joan Enric Torra i Bou, Galle 5. Bis, Barcelona, 08021, Spain.
Tel: +34 3 731 0474
Mr Bart Van der Heyden, Slagmanstraat 48, 9080 Lochristi, Belgium.
Tel: +32 (0)9356 72 22 Fax: +32 (0)9356 69 15
bvanderheyden@attglobal.net
Mr Edwin Van der Zee, Krommekamp 232, Harderwijk, 3848 DT, The
Netherlands Tel: +31 341 4189214, Fax: +31 341 422957
vanderzee@globalxs.nl
Mrs Tracy Vernon, Doncaster Royal Infirmary, Armthorpe Road, Doncaster,
Yorks, DN2 5LT, England. Tel: 01302 366666 (ext. 3359) Fax: 01302 320098
Dr Senen Vilaro Coma, Facultat de Biologia, Department de Biologia Celular,
AVDA Diagonal 1645 1o Planta, 08028 Barcelona, Spain. Tel: 00 34 93 402
1550, Fax: 00 34 93 411 2967
Ms Heidi Vrijdagh, Huntleigh Healthcare, Stapelplein 70, 9000 Gent, Belgium
Tel: +32 9 265 8770, Fax: +32 9 265 8771
heidi.vrijdagh@huntleigh-healthcare.be
Ms Ann-Brigitte Vugelsang, Bogfinhevg 8, Hinnerup, 8382 Denmark.
Tel: +45 86 91 2811 anne-brig@hotmail.tele.dk
Ms Anna Watson, 72 The Paddocks, Hybreasal, South Circular Raod,
Kilmainham, Dublin 8, Ireland. Tel: +353 1 473 1605
Dr K-G. Werner, Compliance Network Physicians/Health Force Initiative, P.O.
Box 02 12 45, Berlin, D–10123, Germany.
Tel: +49 30 2472 1772, Fax: +49 30 2472 1773
Jan Weststrate, University Hospital Rotterdam, Room Z–646, P.O. Box 2040,
Rotterdam, 3000 CA, The Netherlands.
Tel: +31 10 463 4237, Fax: +31 10 463 4234
Miss Emma Wheat, 89 Llanishen Street, Heath, Cardiff, CF14 3QD, Wales, UK
Tel: 02920 404729 ewheat@uwic.ac.uk
Mr Arthur Wheeler, 1 Samsworth Close, Castor, Peterborough, Cambs. PE5
7BQ, England. Tel: 01733 380774
Ms Ada Wimmers, Boveny Ziekenhuis, Statenjachtstraat 1, 1034 CS,
Amsterdam, The Netherlands. Tel: +31 20 634 6346, Fax: +31 20 634 6730
66
Volume 3, Number 2, 2001

epuap Membership
EUROPEAN PRESSURE ULCER ADVISORY PANEL
Application Form, 2001–2002
MISSION STATEMENT
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relief of persons suffering from, or at risk of pressure ulcers, in particular
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Volume 3, Number 2, 2001 67

C O R P O R A T E M E M B E R S
A N D S P O N S O R S O F T H E
F O U R T H O P E N M E E T I N G
O F T H E E P U A P
3M
Augustine Medical
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Cook
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URGO
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Printed by Oxuniprint at Oxford University Press
© European Pressure Ulcer Advisory Panel, 2001
ISSN 1464–7796
68
Volume 3, Number 2, 2001