EPUAP Programme: Oxford 2007, 30 August to 1 September

epuap 

Mission Statement 

Executive Committee Members: 

Trustees: 

EPUAP Business Office: 

E U R O P E A N P R E S S U R E U L C E R A D V I S O R Y PA N E L 

Trustees of the European Pressure Ulcer Advisory Panel 

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. 

Tom Defloor: President (Belgium) 

Denis Colin: Past President (France) 

Michael Clark: Recorder (UK) 

Jacqui Fletcher: Deputy Recorder (UK) 

Marco Romanelli: Past President (Italy) 

George Cherry: Secretary/Treasurer (UK) 

Carol Dealey: President Elect (UK) 

Christina Lindholm (Sweden) 

Andrea Bellingeri (Italy) 

Manuel Gago-Fornells (Spain) 

Lena Gunningberg (Sweden) 

Ruud Halfens (Netherlands) 

Hilde Heyman (Belgium) 

Helvi Hietanen (Finland) 

Cristina Miguens (Portugal) 

Zena Moore (Eire) 

Cees Oomens (Netherlands) 

Anna Polak (Poland) 

Joseph Schols (Netherlands) 

Lisette Schoonhoven (Netherlands) 

José Verdu Soriano (Spain) 

Jan Weststrate (Netherlands) 

Anne Witherow (Northern Ireland) 

Administrator: Christine Cherry (UK) 

14 Aston Street 

Oxford, OX4 1EP, UK 

Tel: +44 (0)1865 791725 

Fax: +44 (0)1865 791725 

E-mail: oxfordwound@aol.com 

Volume 8, Number 1, 2007 1

2 

epuap 

Dr Michael Clark 


Letter from the Editor 

A challenging time for pressure ulcer prevention and treatment? 

WE are fast approaching the annual EPUAP Open Meeting this 

year to be held in Oxford from 30 August to 1 September 2007. 

It is exciting to return to Oxford where the first two EPUAP 

Open Meetings were held back in 1997 and 1998. 

In 1997 we had 32 presentations (including 23 free papers) and seven 

poster presentations whereas ten years later the number of presentations and 

posters has increased to over 50 presentations (23 free papers and 35 posters). 

This increase in the volume of material marks the growth of our society 

and the enduring interest in pressure ulcers. However for many these are 

challenging times with health service budgets and staff under pressure with 

consequent effects upon attendances at conferences with reducing delegate 

numbers – thankfully these pressures have not seen a marked decline in interest 

for the EPUAP Open Meeting and the Business Office should be thanked 

for its efforts to promote the Oxford meeting and next year’s conference 

to be held in Bruges in Belgium. This issue of the EPUAP Review carries the 

first announcement of this event in 2008 and please enter the dates in your 

diary now! 

What highlights should delegates in Oxford watch out for? News of the 

rapidly evolving new clinical practice guideline will be shared during the conference 

with considerable effort expended by EPUAP Trustees and Members 

over the past few months to achieve a review of all relevant publications upon 

pressure ulcer prevention. The work of the EPUAP Nutrition and pressure 

ulcers working group will be highlighted this year – this group have achieved 

a clinical practice guideline, a multi-national survey of nutritional practice 

as related to pressure ulcer prevention and management, two peer reviewed 

publications and at least two book chapters since coming into being in 2003. 

One of the recent publications from this group is reprinted in this issue of the 

EPUAP Review with thanks to the Journal of Wound Care. The nutrition group 

began to prepare for the multi-national survey by describing current pressure 

ulcer initiatives within the surveyed countries (Germany, the Netherlands 

and the United Kingdom) and this issue of the Review contains the report on 

recent Dutch initiatives with other countries to follow in subsequent issues. 

To show that the work of the EPUAP moves quickly one further highlight for 

Oxford is not included on the formal programme as the initiative began after 

the programme was completed earlier this year – this initiative collected views 

upon potential changes in the current four stage pressure ulcer classification 

across Europe and the results will be presented for the first time in Oxford. 

So for a variety of reasons you should be in Oxford in late August and I look 

forward to welcoming you to the conference. 

Michael Clark 

Editor and EPUAP Recorder 

Volume 8, Number 1, 2007

epuap 

Dr Tom Defloor 


Letter from the President 

Reflections on the role of the European Pressure Ulcer Advisory Panel 

IN recent years, there has been an increasing emphasis upon Evidence 

Based Practice (EVP) in decision making in healthcare. While there 

are many reasons for this our patients and the societies in which we live 

demand that we, as healthcare professionals, work in accordance with 

the available research evidence combined with our clinical experience, the 

opinions and wishes of patients, and the available resources. The EPUAP 

continues to provide support for healthcare professionals in meeting these 

high expectations. 

How can the EPUAP best help meet these expectations given that the 

mission of the charity 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. Research then forms a key element of our mission not through 

the funding of major projects but in the past, and hopefully in the future to, 

the EPUAP stimulated research by awarding small grants to make pilot studies 

possible and to explore the potential of new research projects. 

Another key element is our role in education – perhaps at this time primarily 

of healthcare professionals through the use of the annual Open Meetings 

as a strong discussion forum where clinical experiences can be shared. The 

annual open meetings have proven to be an excellent way to encourage networking, 

the exchange of research data and clinical experiences leading to the 

development of formal position statements and other guidance documents. 

No doubt this year’s Open Meeting in Oxford will continue this tradition. 

A major undertaking in 2007 has been the collaboration with the US National 

Pressure Ulcer Advisory Panel on new evidence based clinical practice 

guidelines. This is a major opportunity to enhance the quality of pressure 

ulcer care and is certainly the biggest project that the EPUAP has undertaken 

since its foundation, with the new guideline available in 2008. 

Whilst the guideline project is our most ambitious effort to date, new 

challenges will occur as the EPUAP matures over the following years. Among 

these I would expect attention to focus upon issues such as pressure ulcer 

pathophysiology, risk assessment, and the cost effectiveness of our interventions 

given that relatively little is known regarding these key areas. The EPUAP has 

a pivotal role as a body able to identify these shortcomings and ensure that 

they will be high on the wider research agenda. 

Identifying new research areas and developing clinical practice guidelines 

are important steps but in themselves may be insufficient to close the gap 

between research and clinical practice. Therefore, to maximise the likelihood 

of our clinical guidelines being used in clinical practice, we need coherent 

dissemination and implementation strategies that are both effective and efficient. 

The need for improved dissemination and implementation strategies 

in my opinion will be the most important challenge for the EPUAP in the 

next decade. 

Thank you! Kind regards. 

Tom Defloor 

President 


4 

epuap 

Carol Dealey 


Letter from the President Elect 

AS we approach the 10 th EPUAP conference, I feel it is an opportune 

moment to look backwards at where we started and forwards 

to this year’s conference. It is interesting to note that in 1997 we 

were pleased to welcome Dr Andrew Salzberg, the then President 

of the National Pressure Ulcer Advisory Panel (NPUAP) to share the American 

Experience with us. In 1997 we were also focussed on our pressure ulcer 

guidelines, which have subsequently very successful and have been translated 

into many different European languages, thanks to the hard work of many 

of EPUAP Trustees. 

Ten years on and we will again be welcoming the NPUAP President Dr 

Joyce Black and other members of NPUAP to the conference. This time much 

of the focus of our collaboration will be outside the conference on our joint 

Pressure Ulcer Guideline work. As both societies were conscious that their 

individual guidelines were very dated, it seemed an opportune time to collaborate 

and produce joint guidelines. This is an exciting and challenging 

venture and we hope that members of both societies will become engaged in 

the process. More information can be found in Katrien Vanderwee’s paper 

in this issue of the EPUAP Review and also on our website: 

 

An important aspect of any conference is the science to underpin clinical 

practice. This year will be no different and the programme indicates some 

interesting sessions and I hope there will be plenty of debate around the 

topics on offer. As well as learning more about developments in Europe and 

USA there will also be an opportunity to learn more about pressure ulcer 

activity in Japan. Professor Ohura, the Secretary General of the Japanese 

Society for Pressure Ulcers and other members of the society will providing 

a unique opportunity to learn more about the great strides that have been 

made in Japan in the last few years. 

So it only remains for me to say that this has been an exciting ten years 

and EPUAP has come a long way in that time. I hope that the next ten years 

will be just as exciting. In the meantime, when all the conference delegates 

expect to be enjoying Oxford and all it has to offer in some of the social 

events around the conference, I just hope that we will have good weather 

for that evening boat trip with the jazz band! 

Carol Dealey 

President Elect 


epuap News 

Dr George Cherry 

One of the social events 

taking place during the 

10th Anniversary Meeting 

at Oxford will be an 

evening boat trip, with 

jazz and buffet supper. 


from the Business Office 

THE EPUAP, in reaching the milestone of having its 10th anniversary 

meeting in Oxford this year, in August, has made many 

accomplishments in its relatively short history of which it should 

be proud. One of these is the publication (in 2006) of the book 

Science and practice of pressure ulcer management, edited by Marco Romanelli. In 

the chapter that I contributed: ‘EPUAP Advisory Panel, a means of identifying 

and dealing with a major health problem with a European Health Initiative’ 

(which is one of twenty-two other chapters in the book) I described how 

the organisation was formed with an inaugural meeting in London in 1996 

consisting of representatives from thirteen European countries, and the 

USA. Many of those that attended this meeting have supported the EPUAP 

over the years by making major contributions to our mission statement: ‘the 

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

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

research and the education of the public’. 

One of our first accomplishments was producing evidence based guidelines 

on prevention and management of pressure ulcers. This initial work was 

done nine years ago and at that time there was a paucity of evidence. Tom 

Defloor our present president and Carol Dealey our president-elect in their 

article in this issue describe the new major prevention guideline project which 

is being co-ordinated by Katrien Vanderwee. (www.pressureulcerguidlines. 

org). We have also included in this issue a list of stakeholders which includes 

other societies, industry and individuals. 

In order to carry out such a project without support from industry would 

be impossible, though the EPUAP is contributing financially to the project. 

We are pleased that three companies have made major financial contributions 

and these are Numico, Huntleigh and KCI. We anticipate our other 

corporate sponsors will become part of this initiative. 

The Tenth Anniversary meeting which will begin on Thursday 30 August 

should be a great success and, as you can read in Tom Defloor’s article, 

there has been a major increase in abstract submission along with quality. 

The programme can be seen in this issue, together with a registration form 

if you have not yet registered. 

Also in this issue, Jos Schols has produced an article on ‘Pressure ulcer 

care in the Netherlands; a short historical review’. In addition we have obtained 

permission from the Journal of Wound Care to reprint an article ‘Evaluation 

of the dissemination and implementation of a nutritional guideline 

for pressure ulcer care’ which was published by members of the nutritional 

working group of the EPUAP. 

The Business Office has played an important role in the development 

of the EPUAP since its initial organisation. This includes organising all of 

the annual meetings starting with the first two here in Oxford followed by 

Amsterdam, Le Mans, Pisa, Budapest, Tampere, Berlin and the World Union 

meeting in Paris. In addition the office publishes the Review and is responsible 

for the EPUAP website which is extremely popular. 


EUROPEAN PRESSURE ULCER ADVISORY PANEL 

6 

epuap EPUAP 

Educational material is distributed to practitioners and others interested 

in pressure ulcers. The success has been due to the individuals working in 

the office, but probably more importantly has been the liaison established 

through the office and our corporate sponsors, who without their support 

we could not continue to meet our charity’s mission statement. 

We look forward to welcoming you to Oxford at our Tenth Anniversary 

Meeting. 

Dr George W. Cherry 

Secretary Treasurer EPUAP 


Programme: Oxford 2007, 30 August to 1 September 

Theme – Ten years of progress: the EPUAP past, present and future 

Thursday, 30 August Academic Centre · John Radcliffe Hospital · Headington 

09:30 (Coach transportation from St Anne’s College to Academic Centre, John Radcliffe) 

Registration 

10:30–12:00 KCI Symposium (Lecture Theatre 2) 

Integrated Therapy System for Better Wound Care: 

The Science and Practice of Pressure Ulcer management 

Overview holistic approach – George Cherry 

Basic Science and Clinical Evidence – Paul Banwell 

Surgical Management of the Pressure Ulcer – Raymund Horch 

General management of VAC Therapy – Kath Vowden 

10:30–12:00 Gaymar Symposium (Lecture Theatre 1) 

An Update on the Shear Force Initiative 

Chair: Dr Tom Stewart 

History of the Shear Force Initiative – Tom Stewart 

The Combined Effect of Pressure and Shear on Capillary Closure in the 

Microscale of Skeletal Muscle Tissue – Amit Gefen 

What Are the Effects of Pressure and Shear on Tissue – Laura Edsberg 

Can we define a damage threshold for soft tissues under sustained 

mechanical loading? – Cees Oomens 

12:00–13:00 Exhibition opening and lunch in Tingewick Hall 

13:00 Opening of Conference – Tom Defloor 

Chairs: Carol Dealey and Marco Romanelli 

13:15 The EPUAP past, present and future – Carol Dealey 

13:40 Highlights of the free papers and poster presentations – 

Mike Clark and Jacqui Fletcher, and Anna Polak panel report 


13:40 Nutrition and pressure ulcers: 

the work of the EPUAP Nutritional Working Group – Judith Meijers 

14:20 Tea and commercial exhibition Tingewick Hall 

Chairs: Zena Moore and Jan Weststrate 

14:50 Introduction to the conference scientific sessions 

14:55 Shear forces – Cees Oomens 

15:15 Redistributing pressure – Tom Defloor 

15:35 Heel pressure ulcers – Jeannie Donnelly 

15:55 Skin care, continence and pressure ulcers – Lisette Schoonhoven 

16:15 Presentation to EPUAP Award winner 

16:30 Coffee Break and commercial exhibition in Tingewick Hall 

16:45–18.15 Smith & Nephew Symposium: (Lecture Theatre 2) 

18:15 (Coach transportation to St Anne’s College from Academic Centre, John Radcliffe) 

19:30 (Coach transportation from St Anne’s College to Salter’s Boatyard) 

EPUAP PROGRAMME, OXFORD, 2007 

20:00–23:00 Social Event: Thames Jazz Boat Trip with Buffet Supper (Abingdon Road) 

Friday, 31 August Academic Centre · John Radcliffe Hospital · Headington 

08:00 (Coach transportation from St Anne’s College to Academic Centre, John Radcliffe) 

08:30 Poster presentations 

08:30 Randomised Controlled Trials Consort workshop – Jane Nixon 

09:30 Free Papers Session 1 (Lecture Theatre 1) 

Chairs: Michael Clark and Hilde Heyman 

Deep Tissue Injury: State of the Science – Joyce Black, USA 

A Collaborative Statewide Initiative Across Care Settings Reduces 

Pressure Ulcers in the USA – Elizabeth A. Ayello, USA 

The Challenge: Determining Neglect in the Development of a 

Pressure Ulcer – Kath Vowden, UK 

An approximation to the cost of the treatment of Pressure Ulcers 

in Spain – Joan-Enric Torra I Bou, Spain 

Care Dependency Scale: An effective Alarm System for pressure 

ulcer risk? – Doris Wilborn, Germany 



8 

09:30 Free Papers Session 2 (Lecture Theatre 2) 

Chairs: Jacqui Fletcher and Cristina Miguens 

A Systematic Review of Pressure Ulcers and Quality of Life – 

Claudia Gorecki, UK 

Cytokine and chemokine transport through the epidermis upon sustained 

mechanical loading – L Cornelissen, The Netherlands 

Effectiveness of two cushions in the prevention of heel pressure ulcers – 

Alexander Heyneman, Belgium 

A randomized, blinded, conventional treatment controlled trial 

evaluating the efficacy of injected activated macrophage suspension 

in decubital ulcers – Zuloff-Shani Adi 

Evaluation of pressure relieving head supports – 

Vinoth K. Ranganathan, USA 

Cutaneo-adipose flaps on perforating arteries in combination with Pulsed 

Galvanic Stimulation PGS) to enhance treatments of 3 rd –4 th degree 

decubitus ulcers. – Argentina Vidrascu, Romania 

10:30 Coffee and commercial exhibition in Tingewick Hall 

11:00 Scientific session 1: Heel Pressure Ulcers 

Chairs: Anne Witherow and Christina Lindholm 

Jeanne Donnelly, Mark Collier, Richard Goossens 

Scientific session 2: Shear forces. ‘Can we find a relationship between 

external pressure and shear and internal deformation?’ 

Chairs: Cees Oomens and José Verdu Soriano 

Dan Bader, Karlien Ceelen 

How dangerous is shear? – Cees Oomens 

Can we find a relationship between external pressure and shear and 

internal deformation? – Karlien Ceelen 

12:30 Exhibition and Lunch in Tingewick Hall 

12:30 Highlights and unique advances in the field of Pressure Ulcer care 

in Japan 

The Japanese Society for Pressure Ulcers – Lecture Theatre 1 

(Lunch in the room) 

Chairs: Dan Bader and George Cherry 

1) Recent trends in pressure ulcer management in Japan – Prof. H Sanada 

2) Japanese wound assessment “Design P” – Prof. T. Moriguchi 

3) Guidelines for Pressure Ulcer care and treatment in Japan – Prof. S Ichioka 

4) Japanese Risk Factors for Pressure Ulcers – Prof. T.Ohura 

5) New concepts of Pressure Ulcers from the shear force and 

pressure perspective: 

a) Mechanism and Measurements – Prof. M Takahashi 

(engineering viewpoints) 

b) Clinical Evidence – Prof. T Ohura 

14:10 Scientific session 3 – Pressure redistribution 

Chairs: Ruud Halfens and Anna Polak 

Katrien Vanderwee, Zena Moore 

Scientific session 4 – Skin care 

Chairs: Carol Dealey and Manuel Gago-Fornells 

Alan Cottenden, Sue Bale 


15:30 Tea and commercial exhibition in Tingewick Hall 

16:00 Free papers Session 3 (Lecture Theatre 1) 

Chairs: Lisette Schoonhoven and Lena Gunningberg 

Are record data on pressure ulcers reliable? A comparison between paper- 

based records and electronic health records – Lena Gunningberg, Sweden 

Demographics of Pressure Ulcers: An Analysis of the International 

Pressure Ulcer Prevalence TM Survey – Catherine VanGilder, USA 

Frequency of pressure ulcers in one emergency hospital and one 

rehabilitation centre in Harare, Zimbabwe – Martin Sibanda, Zimbabwe 

Risk Assessment Tools for the Prevention of Pressure Ulcers – A Cochrane 

Systematic Review – Zena Moore, Ireland 

Pressure Ulcers Risk Evaluation (PURE) Project – Jane Nixon, UK 

SAFE or SORRY? Does every patient at risk for pressure ulcers get 

adequate prevention? – Betsie van Gaal, The Netherlands 

16:00 Free papers Session 4 (Lecture Theatre 2) 

Chairs: Jos Schols and Helvi Hietanen 

Continuous monitoring of the interface pressure distribution and body 

movement during bed rest at ICU – Kozue Sakai, Japan 

Simultaneous measurement of blood flow and compressive loads applied 

to the skin – Hitomi Sugiyama, Japan 

Development and Evaluation of a new Self-regulating Alternating Pressure 

Air Cushion – Gojiro Nakagami, Japan 

Knowledge, attitudes and practice of nursing staff about pressure ulcer 

prevention and treatment – a survey in a Swedish health care setting – 

Ulrika Källman, Sweden 

Pressure Ulcers – Prevention and Prevalence on Intensive Care; 

Observing trends from 2001 to 2006 – Nils Lahmann, Germany 

17:30 Annual General Meeting 

18:00 (Coach transportation from Academic Centre, John Radcliffe to St Anne’s College) 

20:00–22:00 Gala dinner at St Anne’s College 

EPUAP PROGRAMME, OXFORD, 2007 

Saturday, 1 September St Anne’s College 

09:30 Welcome and overview of the day – Carol Dealey 

09:50 Special hands-on Workshops 

Shear Forces (Duncan Bain/Michael Clark) 

Heel pressures (Jacqui Fletcher/Tom Defloor) 

11:20 Tea and pastries 

11:50 Pressure redistribution without mattresses (Heidi Guy/Jacqui Fletcher) 

Sacral skin care (Trudie Young/Tom Defloor) 

13:25 

(In each of the four sessions the second-named individual is there to help the 

first to lead!) 

Summary and close – Carol Dealey 

14:00–17:00 Optional paid Tour to Blenheim Palace, Woodstock (5 miles from Oxford) 

Birthplace of Winston Churchill 


Societies 

A.I.S.Le.C. (Italian Society on Wound Management) 

Association of Tissue Viability Nurses – West Midlands Group 

(United Kingdom) 

Bedfordshire and Hertfordshire Tissue Viability Nurses 

Forum (United Kingdom) 

GNEAUPP (Grupo Nacional para el Estudio y Asesoramiento 

de las Úlceras por Presión y Heridas Crónicas – Spanish 

pressure ulcers and Chronic Wounds Advisory Board) 

North East Tissue Viability Nurses Group (England) 

North Wales Tissue Viability Nurses (United Kingdom) 

Qld Health, Pressure Ulcer Prevention Program and 

Collaborative (Australia) 

The Wound Care Association of New South Wales (Australia) 

Tissue Viability Society (United Kingdom) 

Wound care Society (United Kingdom) 

Industry 

10 

epuap 

Numico 

Huntleigh 

KCI 

ConvaTec UK 

Distrac Wellcare Products (Belgium) 

Individual Stakeholders 

Arede da Cruz Ana Patricia Gomes (Portugal) 

Ariza Zafra Francisco Jose (Spain) 

Asuncion Sancho Pons Maria (Spain) 

Ayello Elizabeth (USA) 

Barradas Julia (Portugal) 

Benbow Maureen (United Kingdom) 

Bigler Gerda (Switzerland) 

Bird Lorraine (United Kingdom) 

Birmingham Meg (USA) 

Boken Carole (United Kingdom) 

Bonomini Joanna (United Kingdom) 

Bots Th.C.M. (Netherlands) 

Brás Silvia (Portugal) 

Broadbent Gail (United Kingdom) 

Buckland Richard (United Kingdom) 

Burckhardt Marion (Germany) 

Burge Rebecca (United Kingdom) 

Cabete Dulce (Portugal) 

Cardello John (USA) 


The EPUAP Prevention Guideline Project Stakeholders 

Carrion Andoni (Spain) 

Carroll Lucy (Ireland) 

Casaleiro Alves Adélia Maria (Portugal) 

Casanova Pablo Lopez (Spain) 

Chambers Tina (United Kingdom) 

Chandler Alison (United Kingdom) 

Chatwin David (United Kingdom) 

Cobb Ann (United Kingdom) 

Cole Nicky (United Kingdom) 

Conway Joanne (United Kingdom) 

Cooper Sally-Ann (United Kingdom) 

Correia Isabel Maria Lopes (Portugal) 

Craven Barbara (United Kingdom) 

Croukamp Belinda (South Africa) 

da Cunha Amorim Rodrigues Susana (Portugal) 

Da Silva Sousa Hélder Daniel (Portugal) 

Dan (Australia) 

Davies Patricia (United Kingdom) 

Dawson Patricia (United Kingdom) 

De Melo Figueiredo Rocha Ana Paula (Portugal) 

De Wolf Dirk (Belgium) 

Descombes Leonora (United Kingdom) 

Di Tullio Nazzareno (Italy) 

Diazpi Jesus (Spain) 

Dimitrova Jivka (United Kingdom) 

Domingues Hugo (Portugal) 

Edwards Jane(United Kingdom) 

Elliott Judy (United Kingdom) 

Ellis Sam (United Kingdom) 

Erickson Sara (USA) 

Esperanço Nuno Jorge Rodrigues (Portugal) 

Falcao Elciane (Brazil) 

Fearnley Helen (United Kingdom) 

Fentiman Sara (United Kingdom) 

Ferreira Jaime (Portugal) 

Firth Linda (United Kingdom) 

Fisher Shirley (United Kingdom) 

Fontaine Stan (Belgium) 

Fowler Ann (United Kingdom) 

Foy Caroline (United Kingdom) 

Fredén Marie-Lousie (Sweden) 

Fulton Pamela (United Kingdom) 

Fyfe Lynn (United Kingdom) 

Gago-Fornells Manuel (Spain) 

Garcia-FernandezFrancisco P. (Spain) 

Garrido Villoldo Antonio (Spain) 

Gatto Pauline (United Kingdom) 

Gebhardt KS (United Kingdom) 

Gilmartin Sheila (Ireland) 

Giovanni Romboli (Italy) 


Godar Susan (United Kingdom) 

Gouveia João (Portugal) 

Grier Janet (United Kingdom) 

Grove Jo-Anna (United Kingdom) 

Guerra Marcos (Venezuela) 

Harimurti Kuntjoro (Indonesia) 

Harvey Dee (United Kingdom) 

Haughton William (United Kingdom) 

Heaney Fiona (Ireland) 

Heylen Ria (Belgium) 

Higson Francesca (United Kingdom) 

Hogan Jeanette (United Kingdom) 

Hucker Melanie (United Kingdom) 

Hughes Caroline (United Kingdom) 

Hunter Caroline (United Kingdom) 

Idoia Beistegui Alejandre (Spain) 

Iivanainen Ansa (Finland) 

Irving Valerie (United Kingdom) 

Izaskun (Spain) 

Jansen Bea (Netherlands) 

Jiménez Francisco Zafra (Spain) 

Jones George Marcia (USA) 

Jones Jo (United Kingdom) 

Jones Ruth (United Kingdom) 

Jordan Paula (United Kingdom) 

Kelly Fiona (United Kingdom) 

Koopman Eddy (Netherlands) 

Kurtulus Zeynep (Turkey) 

Leonard Sylvia (United Kingdom) 

Lindgren Margareta (Sweden) 

Loffredo (Netherlands) 

Malcato Ester (Portugal) 

Maloney Trevor (United Kingdom) 

Malrait Nathalie (Belgium) 

Marques Luiz Gustavo Castro (Brasil) 

Marshall Caroline (United Kingdom 

Martin Karen (USA) 

Martinez Maria Blanca (Spain) 

Mason Margaret (United Kingdom) 

Mathieson-Devereaux G (USA) 

McCauley Jacqueline (Ireland ) 

Mcintyre June (South Africa) 

Mcquillan Sarah (United Kingdom) 

Mistiaen Patriek (The Netherlands) 

Moore Monica (United Kingdom) 

Moorhead Anne (United Kingdom) 

Morgan Sharon (United Kingdom) 

Mullin Allison (United Kingdom) 

Murphy Debbie (United Kingdom) 

Murphy Fiona (United Kingdom) 

Nikolaos Stoufis (Greece) 

Noble Jenny (USA) 

Nunes das Neves Marcia (Brasil) 

O’Brien Gillian (Ireland) 

O’Brien Mark (United Kingdom) 

O’Flynn Linda (United Kingdom) 

Oldfield Amy (United Kingdom) 

Ørskov Anne (Denmark) 

THE EPUAP PREVENTION GUIDELINE PROJECT STAKEHOLDERS 

Pagnamenta Fania (United Kingdom) 

Pagnamenta Fania (United Kingdom) 

Pancorbo-Hidalgo Pedro L. (Spain) 

Parnham Alison (United Kingdom) 

Patten Hannah (United Kingdom) 

Pauline Beldon (United Kingdom) 

Peach Victoria (United Kingdom) 

Pearce Maureen (United Kingdom) 

Pearson Anne (United Kingdom) 

Penman Karen (United Kingdom) 

Preece Jane (United Kingdom) 

Proudman Michelle (United Kingdom) 

Puntriano Elianor M. (USA) 

Purser Kate (United Kingdom) 

Quesada Ramos Cristina (Spain) 

Rascoe Shelly (USA) 

Reed Anne (United Kingdom) 

Rigby Paul (Netherlands) 

Rmtaohua (China) 

Rocco (Italy) 

Rodrigues de Figueiredo Rogério Manuel (Portugal) 

Sancho Pons Maria Asuncion (Spain) 

Scott Eileen M (United Kingdom) 

Scott Pamela (United Kingdom) 

Shah Zubida (United Kingdom) 

Sharp Ailsa (United Kingdom) 

Sharp Catherine Anne (Australia) 

Shipperley Terry (United Kingdom) 

Shipton Tracey (United Kingdom) 

Silva Debora (Portugal) 

Sims Joyce (United Kingdom) 

Smith Angela (United Kingdom) 

Soares da Costa Cristiana Violante (Portugal) 

Solinas Claudio (Italy) 

Sousa Oliveira Ana Cristina (Portugal) 

Stanway Sylvia (United Kingdom) 

Starkey Christine (USA) 

Stephen-Haynes jackie (United Kingdom) 

Stephenson Heather (United Kingdom) 

Stevens Julie (United Kingdom) 

Suárez Aurora (Mexico) 

Taylor Adrienne (United Kingdom) 

Teixeira José (Portugal) 

Trettler Elisabeth(Austria) 

Turner Mary (USA) 

Van Genechten Nancy (Belgium) 

Vanwalleghem Geert (Belgium) 

Walford Gill (United Kingdom) 

Walsh Nuala (United Kingdom) 

Wannell Linda (United Kingdom) 

Weafer Karen (United Kingdom) 

Williams Dominic (United Kingdom) 

Wilson Lyn (United Kingdom) 

Woodd Denise (United Kingdom) 

Woods John (U.S.A.) 

Woodward Paul (New Zealand) 

Young Clarissa (Australia ) 

Zarnitsky (France) 


12 

epuap Eleventh 


Annual EPUAP Meeting, Bruges, 3–6 September 2008 

KNOWN as the Venice of the North, Bruges is one of the most beautiful 

cities in Europe. It is situated in the western part of Belgium 

and only a short distance away from the Belgian Coast. The capital 

of Belgium, Brussels, is only 100 km away. 

It was a justified motive that prompted UNESCO in 2000 to include the 

entire historical city centre on the World Heritage list. Walking along the 

maze of winding cobbled alleys and romantic canals, you imagine yourself 

to be in medieval times. The wealth of museums is a striking image of this 

city’s stirring history. 

Bruges is also home to contemporary culture, such as the new Concert 

Hall, which is one of the most prominent music complexes in Flanders. The 

restaurants in Bruges which offer gastronomic cuisine and the exclusive hotels 

are a true feast for those who enjoy the good things in life. 

The conference venue is the medieval Hospital of Saint John, which is 

located in the historic center of Bruges. 

Saint John’s Hospital was one of the oldest existing in Europe, however, 

in 1978 it ceased to be a hospital and was turned into a museum. Originally 

its purpose was to provide food and shelter for pilgrims, passers by, and 

travelling salesmen, and to take care of the sick if they were not contagious. 

It was run by Brothers and Sisters from a religious order. Today one can visit 

the old pharmacy, the collection of historic medical equipment, and some 

of the former hospital wards. 


epuap News 

Domiciliary services: Institutional services: 

General Practitioners (n = 7,500) University hospitals (n = 8) 

Physical therapists (n = 14,000) General hospitals (n = 86) 

Occupational therapists (n = 2,800) Psychiatric hospitals (n = 43) 

Speech therapists (n = 4,500) 

Dieticians (n = 2,500) Rehabilitation clinics (n = 23) 

Dentists (n = 8,000) 


from The Netherlands 

PRESSURE ULCER CARE IN THE NETHERLANDS: A SHORT HISTORICAL OVERVIEW 

JMGA Schols MD PhD 1 , RJG Halfens FEANS PhD 2 , JMM Meijers MSc 2 , JTM Weststrate RN PhD 3 

1. Department Tranzo, Tilburg University & Department of General Practice, Faculty of Health, Medicine and Life 

Sciences, Maastricht University; and Vivre Maastricht 

2. Faculty of Health, Medicine and Life Sciences, Department of Health Care and Nursing Science, Maastricht University 

3. Netherlands Centre for Excellence in Nursing, Utrecht. 

This article gives a short overview of the developments 

in pressure ulcer care (PU-care) in The Netherlands. 

THE Dutch health care system is characterized by 

relatively sharp boundaries among community 

health care services, hospital services and longterm 

care services. All three kinds of health care 

services have their own regulations and financing systems. 1 

Table 1 shows the most important health care services in 

The Netherlands. 

Pressure ulcers are an important problem in all health 

care settings, as is shown in Table 2, in which the prevalence 

rates for pressure ulcers in the last eight years are shown for 

university hospitals, general hospitals, home care, nursing 

homes and residential homes. 2 

In The Netherlands some interesting developments 

Table 1. Health care services in The Netherlands 

Residential homes (old people’s homes) (n = 1,340) 

Home care services (nursing) (n = 175) Nursing homes (n = 345) 

Community mental help (n = 46) www.minvws.nl www.rivm.nl 

Table 2. Prevalence of pressure ulcers (%) 1998–2006 in different health care sectors in The Netherlands. 2 

have been taking place in PU-care during the last two 

decades (Table 3). They will be addressed in this article. 

Developments in PU-care before 1995 

Before 1995 the policy to take care for patients suffering 

from pressure ulcers originated in the various health care 

services themselves and the PU-care itself was carried out 

by individual professionals. Depending on the enthusiasm 

of particular professionals, more or less attention was paid 

to the problem of pressure ulcers in health care facilities. 

Furthermore, in most cases it was the expertise of individual 

professionals which was leading in PU-care. 

In 1985/1986 the first National Guidelines on PU 

prevention and Treatment (from The Dutch Institute for 

1998 1999 2000 2001 2002 2003 2004 2005 2006 

University Hospital 13,2 14,4 15,8 18,4 16,5 14,7 14,8 15,6 15,2 

General Hospital 23,3 20,3 20,9 22,3 22,3 22,2 18,7 17,0 14,8 

Nursing Home 32,4 28,3 32,1 33,4 33,0 28,8 30,5 25,4 24,2 

Residential Home 15,4 11,6 13,6 14,6 16,2 13,3 16,1 13,3 10,5 

Home Care 21,3 17,7 17,7 20,5 18,5 16,7 14,2 12,2 9,7 



Healthcare Improvement (CBO–PU guidelines) became 

available of which a first review took place in 1992. 

These guidelines offered professionals practice based 

and consensus based information to improve their performance 

in PU-care; yet they did not launch health care 

sector specific as well as national activities to improve PUcare 

all over the country. 

So, before 1995, the quality and intensity of pressure 

ulcer care showed a varied picture all over the country. 

Developments in PU-care since 1995 

Since the mid-nineties interesting developments in Dutch 

PU-care have been taking place. (Table 3) 

In 1995 a national steering committee on PU was 

established to develop a national strategy to improve PUcare 

in the total Health Care System of the Netherlands. 

Attention and alertness on pressure ulcers in home care, 

long-term institutional care and hospital care was provoked 

and the importance of implementing PU-guidelines was 

promoted. 

In 1996 and 1997 national legislation on quality of 

care and on registration of health care disciplines came 

into operation. These laws facilitated the process of professionalisation 

of most health care disciplines (e.g., doctors. 

nurses) and urged them to improve their performance in 

patient care. 

In the meantime the evidence-based era had started 

and the development of EB-guidelines received an extra 

impulse. 

In the time period 1998–2003 a second review and 

more evidence based founding of the national CBO–PUguidelines 

took place and sector specific PU-guidelines for 

general practitioners, home care and nursing home care 

appeared. However, no national strategy or initiative was 

used to disseminate and implement these guidelines. 

14 

National Guidelines: 

1985/1986: First National Guidelines on PU prevention and treatment (CBO). 

1992: First review of National Guidelines (CBO). 

2002: Second review of National Guidelines (CBO). Guidelines more and more EB. 

Professional Guidelines (based on CBO-guidelines but targeted on different professionals or health care sectors): 

1999: Dutch PU guidelines for General Practitioners. 

2003: Dutch PU guidelines for Home Care. 

2003: Dutch PU guidelines for Nursing Home Care (SALODE). 

Other important national developments: 

1995: Installation of a national steering group on PU. 

1996: Dutch National Law on Quality of Care. 

1997: Dutch National Law on Registration of Health care disciplines. (Wet BIG). 

1998: Start of yearly national measurement of PU prevalence in different Health Care Sectors (Maastricht University). 

>2000: Trend towards chain supply of healthcare services. including PU-care. 

2004/2005: PU (prevalence) acknowledged as an important quality indicator in health care (incorporated in main national 

health care quality improving programmes). 

2005: Introduction of a National Centre for Pressure Ulcer prevention at the Netherlands Centre for Excellence in 

Nursing and start of wider implementation of PU-guidelines by breakthrough projects. 

www.minvws.nl; www.rivm.nl; www.cbo.nl; www.verpleeghuisartsen.nl 

Table 3. Developments in PU-care in the last two decades. 

Implementation of the sector specific guidelines is 

mostly initiated by multidisciplinary PU-committees appointed 

within the different health care organizations 

themselves. Within the different organizations – home 

care, hospital and nursing home – the tasks and responsibilities 

of the different health care professionals have 

gradually become more clear during the last ten years. Although 

the physician has overall responsibility for the care 

and treatment a patient receives, the nursing staff looks at 

the risk factors for PU and assesses the status of the PUwounds, 

if present. In collaboration with the medical staff 

often the actual treatment of the wound is discussed. The 

nursing staff, therefore, has an important task in identifying 

and monitoring the risk a patient has in developing PU 

(e.g., by using a PU-risk assessment tool), taking adequate 

preventive measures and performing the actual wound 

treatment (i.e., cleaning of the wound and applying the 

adequate dressings). Today, many organizations have tissue 

viability nurses who have followed a specific educational 

programme and who have more authority in determining 

the integral patient specific PU-care, including the 

actual wound treatment. Furthermore, physiotherapists 

and occupational therapists are involved in PU-prevention 

(helping and teaching the patient and/or nurses in performing 

adequate transfers and achieving the right relief 

of pressure and shear forces) and dieticians are involved 

in managing nutritional problems in PU-patients. 

Since 1998, the prevalence, prevention and treatment 

of pressure ulcers is measured yearly within many healthcare 

organizations in The Netherlands (already more 

than 500 in 2007!). For this measurement a standardized 

validated instrument has been developed, which is used 

consistently in each patient of the participating organizations. 

Data are gathered regarding quality indicators regarding 

pressure ulcers on ward and organizational level. 

Based on these measurements each organization receives 

an overview of their own results as well as the national 


esults, which they can use for comparison. 

It has been shown that measuring prevalence yearly, 

has a positive and facilitating effect on the quality of PUcare 

in all participating organizations. 2 

Advanced developments in PU-care since 2000 

Gradually, in the course of years, it has become clear 

(as pointed out at the beginning of this article) that the 

boundaries between different health care sectors in The 

Netherlands hamper the achievement of adequate continuity 

of care, which in fact is an important marker for quality 

of care. Therefore, since 2000, the focus is more and more 

on realizing an adequate chain supply of care. 1 

This also counts for achieving an adequate approach 

to pressure ulcer care throughout all health care services, 

following the principles of integral disease management 

and realizing a care chain supply of tailor-made care for 

the patients. 

At this moment, no one discusses the fact that an adequate 

approach to pressure ulcers requires optimal and 

complementary collaboration as well as bridging the gaps 

between all care providers and health care professionals 

involved. Therefore, this is a real challenge for: 

• collaboration in the medical axis 

• collaboration in the nursing axis 

• collaboration between the medical and the nursing 

axis; 

and it involves also a challenge to: 

• organize integral pressure ulcer care with mutual, 

complementary strengthening of community care 

services and institutional care services. 

Fitting in this trend, all over the country, experiments 

are taking place to achieve adequate transmural PU-care 

by implementing transmural PU-guidelines, which have 

been developed by integrating sector specific guidelines. 

For the implementation of these guidelines transmural 

PU-committees, with members from different organizations 

(home care, hospital care and nursing home care) 

are appointed. 

Another important actual development, with respect 

to the implementation of guidelines, are the breakthrough 

projects within the cure and care sector initiated by the 

Government. Pressure ulcers are one of the topics in these 

breakthrough projects. A lot of facilities enhance their 

care regarding PU in participating in the breakthrough 

project. In a comparable project already more then 40 

nursing homes implemented the pressure ulcer guidelines 

for nursing homes. 3 

It the meantime, it also has become clear that nurses 

play an important role in achieving adequate continuity of 

care for the patient throughout the total health care chain, 

in which especially patients with chronic diseases often 

move between home and hospital care. between hospital 

and nursing home or home and nursing home and vice 

versa. 

In the case of PU-care this has led to the phenomenon 

of link nurses within the context of pressure ulcer prevention 

and treatment. 

Most patients really appreciate the continuous attention, 

that is achieved by this way of organizing PU-care 

throughout the health care system. 

NEWS FROM THE NETHERLANDS 

Dutch PU-care and challenges for the future 

Despite all these developments the most important problem 

remains the adequate implementation and firmly rooting 

of guidelines in daily PU-care. Solving this problem will be 

the most important challenge for Dutch PU-care. 

Regular assessment of quality of care may act as a facilitator 

in enhancing the actual quality of care. Therefore, 

the most important actors in Dutch health care (government, 

health care organizations, insurance companies 

and organizations of patients themselves) have agreed 

upon a new system of continuous (yearly) and integral 

measurement of quality of care. This system involves the 

yearly measurement of a set of indicators for quality of 

care, corresponding with the structure, the process and 

the outcome of care. The quality of PU-care is part of this 

system in which the yearly measurement of PU-prevalence 

will be a main outcome indicator for PU-care! 

Moreover, benchmarking will take place, in which different 

organizations can be compared more transparently 

to each other. 

Organisations are beginning to notice the value of 

measuring the incidence or prevalence in order to find the 

cause of the PU problem, they are faced with. In order to 

measure the incidence various computer programmes have 

been developed. One of them, The National Care Monitor 

is based on the PU indicators developed by the EPUAP. 

Finally, we all know that insufficient implementation of 

health care guidelines is an important problem of health 

care. This also counts for many other countries all over the 

world. However, the goal of this article is not to explore 

possible reasons and solutions for this problem. 

EPUAP may also play an important role in facilitating 

the implementation of PU-guidelines in different 

countries, by exploring and presenting the PU-care in her 

member countries and by enabling the different countries 

to learn from each other. 

In fact, it is known that the road to optimal PU-care 

has no finish line! Therefore, for the sake of the patients 

and despite all possible hampering conditions, we have to 

maintain working on: 

• implementing and rooting of evidence based 

PU-guidelines; 

• lowering PU-prevalence and incidence in our 

institutes and throughout the care chain as a whole; 

• being transparent with regard to our performance 

in PU-care; and 

• achieving a constant high standard of PU-care. 

Clearly, if we try hard, we will eventually succeed in 

this, so that our patients can feel themselves really safe in 

our hands. 

References: 

1. Rooij, E van. Droyan Kodner L. Rijsemus T. Schrijvers 

G. ed. Health and Health Care in The Netherlands. Elsevier 

Gezondheidszorg, Maarssen, 2002. 

2. Halfens RJG, Jansen MAP and Meijers JMM, National 

measurement of prevalence of care problems. Department of 

Health Care Studies, Section of Nursing Science, 

Maastricht University, 2006. 

3. SALODE-project (NVVA); see 

 


16 

epuap 


Guideline Evaluation, Implementation and Dissemination 

EVALUATION OF THE DISSEMINATION AND IMPLEMENTATION OF A NUTRITIONAL GUIDELINE 

FOR PRESSURE ULCER CARE 

• Objective: In 2004 the European Pressure Ulcer Advisory Panel nutritional working group developed a nutritional 

guideline for pressure ulcer prevention and treatment. This study investigated the degree to which the guideline was 

disseminated and implemented in clinical practice. 

• Method: A cross-sectional study was undertaken in health-care organisations in the Netherlands, Germany and 

the UK. A printed, standardised questionnaire which followed Rogers’ model of the innovation-decision process was 

developed, translated and distributed to 1087 health-care organisations. 

• Results: The response rate was 33% (n = 363). Sixty-one per cent of respondents knew of the guideline. Twentyfive 

per cent had applied it to their clinical practice and used it for nutritional screening. The main barrier to the 

provision of nutritional support appeared to be lack of knowledge and skills. 

• Conclusion: One year after its dissemination, more than half of respondents knew of the guideline, with one in 

four applying it to their practice. The guideline was better disseminated and implemented in the Netherlands and UK 

than in Germany, where only 4% of participants had used it. 

• Declaration of interest: Numico Netherlands gave EPUAP an unrestricted educational grant. 

J.M.M. Meijers, 1 MSc, RN, Researcher/PhD Student; 

J.M.G.A. Schols, MD, PhD, Professor, Department of General Practice, 

Maastricht University and Department Tranzo, Tilburg University, 

the Netherlands; 

P.A. Jackson, MPhil, BSc, RGN, RHV, RNT, RCNT, Senior Lecturer, School 

of Nursing and Midwifery, University of Southampton, UK; 

G. Langer, PhD, RN, Coordinator of the German Centre for Evidencebased 

Nursing, Martin Luther University, Halle-Wittenberg, 

Germany; 

M. Clark, PhD, Senior Research Fellow, Wound Healing Research Unit, 

Cardiff, UK; 

R.J.G. Halfens, 1 FEANS, PhD, Associate Professor. 

1. Faculty of Health, Medicine and Life Sciences, Department of Health 

Care and Nursing Science, Maastricht University, the Netherlands. 

E-mail: j.meijers@zw.unimaas.nl 

PRESSURE Ulcers are a common, expensive and 

painful health-care problem, with prevalence rates 

ranging from 3% to 66% in heath-care organisations. 

1,2 The estimated annual treatment costs are 

21.07 billion in the UK, 22.4 billion in the USA and 20.6 

million in the Netherlands. 3,4 

A pressure ulcer is defined as localised damage to the 

skin and underlying tissue caused by pressure, shear, friction 

or a combination of these. 5 The development of pressure 

ulcers depends on extrinsic and intrinsic risk factors. The 

most important extrinsic risk factors are pressure, shear and 

friction, which lead to mechanical loading and secondary 

damage to the skin and soft tissue. 6 Intrinsic factors have 

an effect on tissue viability and consequently influence the 

pathophysiological response to mechanical loading. Studies 

have found significant associations with age, sex, limited 

activity, incontinence (bowel and bladder), infection and 

nutritional status. The relative influence of each of these 

intrinsic risk factors is still unclear. 7–9 

A 2003 Cochrane review indicated that there is no 

strong scientific evidence for a direct relationship between 

poor nutrition and pressure ulcer development and healing, 

and a causal relationship has never been established, 

although the methodological quality of the studies reviewed 

is weak. 10 Nevertheless, individual studies have demonstrated 

that an adequate nutritional intake may help protect 

against pressure ulcer development and improve the rate 

of healing. 11–14 

A recent meta-analysis by Stratton et al on enteral nutritional 

support in the prevention and treatment of pressure 

ulcers pointed out that, in four randomised controlled trials 

(RCTs), oral nutritional supplements (250–500Kcal for 

two to 26 weeks) were associated with a significantly lower 

incidence (25%) of pressure ulcer development in ‘at–risk’ 

patients compared with routine care. 15 Furthermore, some 

studies showed a trend towards improved healing with 

high protein nutritional supplements when compared 

with studies using standard formulae. However, Stratton et 

al indicated that more robust RCT studies are needed to 

scientifically confirm the latter finding. 

As nutritional status can be easily influenced by patient 

and practitioner interventions, clinical guidelines could set 

out the optimum management approach. Such guidelines 

provide an important bridge between research findings 

and clinical practice, 16 can aid the implementation of evidence-based 

research and give structural directions on how 

to provide efficient and adequate care, thereby improving 

quality of care. 17 

A study of previous pressure ulcer prevention and 

treatment guidelines concluded that most paid less than 

adequate attention to nutrition. 18 The European Pressure 

Ulcer Advisory Panel (EPUAP) therefore set up a nutritional 

working group comprising practitioners from European 

countries to develop a clinical nutritional guideline on 


pressure ulcer prevention and treatment. The guideline 

was launched in 2004 and translated into eight languages. 

It covers the whole nutritional cycle (screening, assessment, 

intervention, evaluation and follow-up) and includes 

weight recommendations. It emphasises the importance of 

incorporating nutritional activities structurally into daily 

pressure ulcer management. The most essential elements 

of the guideline have been mapped into a decision tree. 19 

The guideline has been disseminated via the EPUAP’s 

network, which comprises its conferences, internet site, 

members and publication, and through the nutritional 

industry. 19 

However, the availability of clinical guidelines does not 

automatically lead to their use in daily practice. In 2005 

the EPUAP nutrition working group therefore decided to 

explore the degree to which the nutritional guideline had 

been disseminated and implemented in clinical practice in 

Germany, the Netherlands and UK. 

In this study the term ‘dissemination’ is defined as 

distribution and does not necessarily include action. ‘Implementation’ 

is defined as the actual use of the guideline 

in daily practice. 20 

Model of innovation-decision process 

Rogers’ model of the innovation-decision process 21 was 

chosen as a framework for this study because, unlike other 

models in this field, it incorporates specific stages of the dissemination 

and implementation process. The model charts 

the five stages through which an individual (or another 

decision-making unit, such as a group, society, economy or 

country) moves across the innovation-decision process (Box 

1 Knowledge 

An individual becomes aware of and reads a guideline. 

‘What?’, ‘how?’ and ‘why?’ are the critical questions 

2 Persuasion 

Occurs when the individual develops a negative or 

positive attitude towards the guideline 

3 Decision 

The individual chooses to adopt or reject the 

innovation. Adoption is defined as ‘having this guideline 

present in practice because it is the best course of 

action available’, and rejection as ‘not adopting this 

guideline’ 

4 Implementation 

The guideline is put into practice. Uncertainty about 

the outcomes of working with this guideline can still be 

a problem at this stage 

5 Confirmation 

The individual looks for support for his or her decision 

to use the guideline. This decision can be reversed if 

the individual is exposed to conflicting messages or 

barriers to its use 

Box 1. The five steps of Rogers’ innovation-decision process 

GUIDELINE EVALUATION, IMPLEMENTATION AND DISSEMINATION 

1). These stages typically follow each other in a time-ordered 

manner. The first three stages of the model are comparable 

to the dissemination of a guideline because the participant 

is not yet actively using it. 

The study participants were mapped in accordance 

with Rogers’ model, thereby providing an insight into the 

percentage of participants in the various stages of dissemination 

and implementation one year after the launch of the 

guideline. 

Method 

A cross-sectional design was used. In total, 1087 clinical 

health-care organisations (300 from the Netherlands, 300 

in Germany and 487 in the UK) were invited to participate 

in the study at the end of 2005. A national coordinator in 

each country invited the selected health-care organisations, 

which comprised hospitals, nursing homes and home care, 

to participate in the postal survey. The national coordinators 

were members of EPUAP nutritional working group. 

The health-care organisations’ addresses were selected 

from several relevant databases in all three participating 

countries. The UK and Netherlands used more targeted 

databases, and Germany a more general database. The 

questionnaires were sent to managers of the health-care 

organisations, who were asked to allocate them to whoever 

was primarily involved in nutritional policy for pressure 

ulcer prevention and treatment. 

Ethical approval was not required as the questionnaire 

focused on organisational aspects and patients were not 

directly involved. 

The standardised questionnaire was developed by the 

EPUAP nutritional working group, following the Rogers’ 

implementation stages. It included twenty-four items: eight 

questions had a dichotomous outcome; two questions included 

four-point ordinal scales (always—never), and the 

remaining questions had a Likert scale ranging from four 

points to ten. 

For the knowledge stage, two questions enquired about 

awareness of the guideline and whether it had been read, 

and one question asked about the dissemination channel. 

For the persuasion stage, one question enquired about attitudes 

towards the guideline. 

For the decision stage, two questions asked about the 

presence of this guideline in practice. 

For the implementation stage, respondents working 

in areas that had incorporated the EPUAP guideline into 

practice were asked eleven questions about its actual use in 

order to ascertain whether it was being followed correctly. 

Several recommendations, such as screening of nutritional 

status (when, who, how often, content), assessment, interventions, 

evaluation and follow-up were explicitly tested. 

For the confirmation stage, two questions enquired 

about barriers to nutritional support within pressure ulcer 

prevention and treatment. 

In addition, respondents’ demographic characteristics 

were defined under five items (profession, workplace, frequency 

of involvement in pressure ulcer care, membership 

of a pressure ulcer committee and involvement in pressure 

ulcer policy). 

Members of the EPUAP nutritional working group 

translated the questionnaires into Dutch, German and 

English, checking content similarity. 



Statistical analysis 

Statistical analyses were performed using SPSS version 

13.0. The statistical analysis included descriptive frequency 

distributions of all variables. Differences between analyses 

were performed per country independently and for the total 

sample. In some questions multiple answers were possible, 

so the total could be more than 100%. 

Results 

The sample 

In total, 363 organisations returned the questionnaires: 146 

Dutch, 50 German and 167 UK. This yielded a response rate 

of 33% (49% for the Netherlands, 17% for Germany and 

34% for the UK). No information was available as to why 

organisations did not respond. 

Respondents comprised nurses (59%), dietitians 

(18%), physicians (6%) and other (mostly managers) 

(17%). Eighty-six per cent were members of a pressure ulcer 

committee or involved in pressure ulcer policy. Forty-nine 

per cent worked in a hospital setting, 26% in a long-term 

care setting and 22% in a home care. Most participants were 

involved daily or weekly in the care of patients at risk of or 

who had a pressure ulcer. 

Knowledge stage 

Sixty-one per cent of participants were aware of the EPUAP 

nutritional guideline. Significantly more were from the UK 

and Netherlands than from Germany (p=0.01) (Table 1). 

The most frequently mentioned dissemination channel 

was the EPUAP internet site (19%), followed by professional 

journals (17%) and conferences (16%). 

In the Netherlands the nutritional industry played a 

significant (p=0.02) and major role in dissemination of the 

guideline, and the EPUAP internet site played a significantly 

minor role (p=0.01) compared with Germany and the UK. 

Persuasion stage 

Respondents who had read the guideline stated that it 

mostly confirmed their views about the importance of nutrition 

in pressure ulcer prevention and treatment. Only 1% 

disagreed with the guideline, leaving 99% with a positive 

attitude towards its content. 

Decision stage 

Of the respondents who had read the guideline, 25% stated 

that they were applying its content to their daily practice 

(Netherlands: 26%, Germany: 9%, UK: 26%). 

The guideline was significantly (p=0.01) more evident 

in daily practice in the UK and Netherlands than in Germany. 

The guideline was mainly used in hospitals (61%), 

followed by home-care organisations (17%) and long-term 

institutional care (17%). 

More dietitians (29%) than nurses (25%) or physicians 

(11%) used it in practice. 

Implementation stage 

As the stages typically follow each other in a time-ordered 

manner, only responses from participants who used this 

guideline in their daily practice were analysed. As only two 

used the guideline in Germany, these were not taken into 

account in the later stages as this sample was too small for 

further analysis. 

18 

• Screening Every participant screened patients; screening 

was most likely to take place ‘sometimes’, followed by ‘always’ 

and then ‘rarely’, although this percentage was much 

lower for patients with pressure ulcers. Full results for this 

and other aspects relating to the implementation stage are 

given in Table 2. 

• Assessment Weight and weight history were most frequently 

mentioned in responses. Health-care organisations 

in the Netherlands mentioned weight history significantly 

more often than those in the UK (p = 0.03). In the UK, body 

mass index (BMI) and use of a nutritional screening tool 

were mentioned sig-nificantly more frequently than in the 

Netherlands (p = 0.01). 

• Intervention When a nutritional problem was identified, 

the most commonly identified intervention was oral 

supplements, followed by normal feeding, particularly in 

the UK, where this was significantly more frequent than 

in the Netherlands (p = 0.01). Parenteral feeding was also 

mentioned less frequently in the Netherlands than in the 

UK (p = 0.01). 

• Evaluation Weight gain was the outcome measure most 

frequently used to evaluate the success or failure of nutritional 

intervention, followed by pressure ulcer healing. 

Biochemical parameters were mentioned significantly more 

frequently in the UK than in the Netherlands (p = 0.01). 

Thirteen per cent of health-care organisations in both countries 

still used none of these outcome measures. 

• Follow-up In the Netherlands and UK patients were 

most likely to be screened regularly or more often if their 

condition indicated. Patients were screened at first contact 

in fewer than one in ten organisations. No one stated that 

they never screened patients. 

Confirmation stage 

Here, the individual looks for support for his or her decision 

to use the guideline. The individual could reverse their 

decision if exposed to barriers to implementation. Figure 1 

shows the most important barriers to nutritional support. 

Discussion 

The goal of this study was to investigate the degree to 

which the EPUAP nutritional guideline on pressure ulcer 

prevention and management had been disseminated and 

implemented in clinical health-care organisations within 

the Netherlands, Germany and UK. 

Sixty-one per cent of the study participants were aware 

of the EPUAP nutritional guideline, and of these 99% had a 

positive attitude towards it. Moreover, 25% of those who were 

aware of the guideline had used it in their daily practice. 

However, it is important to note that, due to the low 

response rate, the questionnaire might present a skewed 

view of the current state of implementation across the three 

countries. 

The guideline was launched in 2004 with no specific 

strategy for its dissemination and implementation. One year 

later a relatively large number of the participating organisations 

already knew of it, especially in the Netherlands (59%) 

and UK (75%), and a smaller number had actually applied 

it to practice (26% and 26% respectively). 

In Germany, only 22% of health-care organisations were 

aware of the guideline and 9% had used it in daily practice. 

However, these results may be influenced by selection bias 


Figure 1. Barriers to nutritional 

support in pressure ulcer patients 

(n = 61). 

Netherlands Germany UK Total 

Total sample 146 50 167 363 


Incomplete questionnaires 

Knowledge stage 

4 1 9 14 

No. of people who responded 142 49 158 349 

No. of respondents who used 

dissemination channels (%) 

Dissemination channel: 

85 (60)*† 11 (22)‡ 119 (75) 215 (62) 

• EPUAP review 4%† 0%‡ 18% 11% 

• EPUAP internet site 3%*† 38% 28% 19% 

• Other professional journal 17% 31% 15% 17% 

• Industry 28%*† 0% 0% 11% 

• EPUAP conference 13%* 0% 15% 14% 

• Other conference 22%*† 6% 13% 16% 

• Colleagues 10%*† 0% 5% 7% 

• Other 

Persuasion stage 

2%* 25% 6% 6% 

No. of people who responded 85 

Consequence of knowing: 

11 119 215 

• Positive attitude 90% 99% 100% 99% 

• Negative attitude 

Decision stage 

1% 0% 0% 1% 

No. of people who responded 85 11 119 215 

% who used guideline 

in their daily practice 

26%* 9%‡ 26% 25% 

* Significant (p


20 

Netherlands UK Total 

Number of respondents 22 31 53 

Should nutritional screening be undertaken 

on every patient? 

• At risk of pressure ulceration? 

— Always 19% 38% 31% 

— Sometimes 67% 55% 59% 

— Rarely 14% 7% 10% 

— Never 

• With pressure ulcers? 

0% 0% 0% 

— Always 38% 47% 44% 

— Sometimes 57% 53% 54% 

— Rarely 5% 0% 2% 

— Never 0% 0% 0% 

Assessment includes: 

• Weight 86% 61% 72% 

• Body mass index 18%* 68% 48% 

• Weight history 96%* 52% 70% 

• Clinical judgement 46% 65% 57% 

• Nutritional screening tool 23%* 81% 57% 

Nutritional interventions: 

• Normal feeding 32%* 71% 56% 

• Oral supplements 96% 99% 96% 

• Tube feeding 36%* 52% 46% 

• Parenteral feeding 5%* 39% 26% 

Evaluation — outcome measures to record 

success or failure of intervention: 

• No measurement 5% 19% 13% 

• Weight gain 86% 74% 77% 

• Development of PU 68% 52% 59% 

• Improvement in PU healing 82%* 65% 72% 

• Biochemical parameters 18%* 51% 43% 

Follow up — how frequently screened? 

• At first contact only 5% 10% 8% 

• At regular intervals 57%* 33% 44% 

• When condition indicates 29% 43% 37% 

• Never 0% 0% 0% 

• Don’t know 10% 13% 12% 

* Significant (p < 0.005) differences between 

the Netherlands and UK 

Table 2. Results for the implementation stage 

as most German participants were not aware of the EPUAP, 

which has few German members and communicates mainly 

in English, which may be a barrier for German-speaking 

countries. Furthermore, in Germany there is a national 

expert standard which professionals are expected to use as 

the guideline for pressure ulcer prevention and treatment. 

Lastly, the German addresses were randomly selected from 

a general database, whereas in the UK all NHS trusts were 

selected and in the Netherlands addresses were taken from 

a targeted database. Any of these factors could have influenced 

the results. 

Interestingly, of the 61% of respondents who were aware 

of the guideline, 99% had a positive attitude towards it, yet 

only one in four of the organisations used it. One reason 

for this could be that implementation of guidelines is a time 

consuming process, 20 and this study took place too soon 

after the launch. 

Another reason may be that if implementation strategies 

are not treated as an integral part of the development 

process of clinical guidelines, then implementation in 

daily practice may be hampered. 20 While dissemination of 

a guideline may increase awareness among the target audience, 

it is not sufficient to bring behavioural change in the 

absence of an active implementation strategy. 22 One year, 

therefore, may be too short a time in which to measure the 

effects on daily practice of guidelines disseminated without 

an implementation strategy. 

Moreover, practitioners struggle when implementing 

guidelines, despite their enthusiasm. This seems to be because 

they experience a number of barriers. Understanding 

these barriers will enable the development of strategies for 

increasing the use of guidelines in daily practice. 23,24 

This study showed that the most important barrier to 

implementation of the guideline was lack of knowledge and 

skills, followed by lack of clarity about who is responsible 

for nutritional support, and inability to access nutritional 

support. 

These barriers were also identified in previous studies. 

24–26 They were not explored further, so no extra information 

was available on which skills and knowledge were 

lacking. An insight into why these barriers exist will improve 

guideline implementation in clinical practice. 

As discussed, individual studies have indicated that 

adequate nutritional status has a positive effect on pressure 

ulcer prevention and healing. It is important that this 

relationship is made more explicit, and strong scientific evidence 

from robust RCTs is therefore needed. This will help 

to increase our understanding of the relationship between 

pressure ulceration and nutrition, and provide a stronger 

evidence base on which to implement new guidelines. 

Conclusion 

This study demonstrates that the EPUAP guideline on nutrition 

in pressure ulcer prevention and management was quite 

well disseminated in the Netherlands and UK. 

After only one year, two-thirds of participating healthcare 

organisations were aware of the guideline and one 

quarter had it in place. 

The main barrier to implementing nutritional support 

in pressure ulcer care was lack of knowledge and skills. 

Recommendations 

• A larger multi-country controlled study is needed on the 

dissemination and implementation of this European 

guideline. 

• There should be a greater focus on the barriers to implementing 

nutritional support in pressure ulcer care, with 

a view to creating an effective implementation strategy. 

• We should learn from examples of best practice relating to 

guideline implementation in different countries. 

• More robust RCTs are needed to strengthen the scientific 

evidence on the relationship between poor nutrition and 

the development of pressure ulcers and their healing. 


References 

1. Bours, G.J., Halfens, R.J., Lubbers, M. and Haalboom, J.R. 

The development of a national registration form to measure 

the prevalence of malnutrition in the Netherlands. Ostomy 

Wound Manage 1999; 45: 28–40. 

2. Tannen, A., Dassen, T., Bours, G. and Halfens, R. A comparison 

of pressure ulcer prevalence: concerted data collection 

in the Netherlands and Germany. Int J Nurs Stud 2004; 41: 6, 

607–612. 

3. Severens, J.L.A. Kosten van decubitus in Nederland. Afdeling 

MTA, Univesitair Medisch Centrum Radboud, Nijmegen, 

1999. 

4. Stratton, R.J., Green, C.J., Elia, M. Disease-related Malnutrition: 

An evidence-based approach to treatment (1st edn). CABI, 2003. 

5. EPUAP, Pressure Ulcer Treatment Guidelines, 2003. 

www.epuap.org/gltreatment.html 

6. Bouten, C.V., Oomens, C.W., Baaijens, F.P. and Bader, D.L. 

The etiology of pressure ulcers: skin deep or muscle bound? 

Arch Phys Med Rehabil 2003; 84: 616–619. 

7. Bours, G.J., De Laat, E., Halfens, R.J. and Lubbers, M. 

Prevalence, risk factors and prevention of pressure ulcers in 

Dutch intensive care units: results of a cross-sectional survey. 

Intensive Care Med 2001; 27: 10, 1599–1605. 

8. Bergquist, S. and Frantz, R. Pressure ulcers in communitybased 

older adults receiving home health care: prevalence, 

incidence and associated risk factors. Adv Wound Care 1999; 

12: 7, 339–351. 

9. Green, S.M., Winterberg, H., Franks, P.J. et al. Nutritional 

intake in community patients with pressure ulcers. J Wound 

Care 1999; 8: 325–330. 

10. Langer, G., Schloemer, G., Knerr, A. et al. Nutritional interventions 

for preventing and treating pressure ulcers. 

In: Cochrane Library, issue 4, 2003. 

11. Benati, G. and Pedone, V. Impact on pressure ulcer healing 

of an arginine-enriched nutritional solution in patients with 

severe cognitive impairment. Arch Gerontol Geriatr 2001; 33: 

1, 43–47. 

12. Bourdel-Marchasson, I., Barateau, M., Rondeau, V. et al. A 

multi-center trial of the effects of oral nutritional supplementation 

in critically ill older patients. Nutrition 2000; 16: 

1, 1–5. 

13. Chernoff, R.S., Milton, K.Y. and Lipschitz, D.A. The effect 

of a very high protein liquid formula on decubitus ulcer 

healing in long-term tube-fed institutionalised patients. 

J Am Diet Assoc 1990; 90: A-130–A-139. 


14. Houwing, R., Rozendaal, M., Wouters-Wesseling, W. et al. 

A randomised, double-blind assessment of the effect of 

nutritional supplementation on the prevention of pressure 

ulcers in hip-fracture patients. Clin Nutr 2003; 22: 4, 

401–405. 

15. Stratton, R.J., Ek, A.C., Engfer, M. et al. Enteral nutritional 

support in prevention and treatment of pressure ulcers: a 

systematic literature review and meta-analysis. Ageing Res Rev 

2005; 4: 422–450. 

16. Curry, S. Organzational interventions to encourage guideline 

implementation. Chest 2000; 118: (2 Suppl), 40S–46S. 

17. Grimshaw, J., Russell, I.T. Effects of clinical guidelines on 

medical practice: a systematic review of rigorous evaluations. 

Lancet 1993; 342: 1317–1322. 

18. Schols, J.M.G.A, Jager, de-van den Ende, M.A. Nutritional 

intervention in pressure ulcer guidelines: an inventory. 

Nutrition 2004; 20: 548–553. 

19. Clark, M., Schols, J.M., Benati, G. et al. Pressure ulcers and 

nutrition: a new European guideline. J Wound Care 2004; 13: 

7, 267–273. 

20. Greenhalgh, T., Robert, G., Bate, D. et al. How to Spread 

Good Ideas: A systematic review of the literature on diffusion, 

dissemination and sustainability of innovations in 

health care service delivery and organisation. Report for the 

National Co-ordination Centre for the NHS Service Delivery 

and Organisation R&D, 2004. 

21. Rogers, E.M. Diffusion of innovations. Free Press, 2003. 

22. Conroy, M. and Shannon, W. Clinical guidelines: 

their implementation in general practice. 

Br J Gen Pract 1995; 45: 396, 371–375. 

23. Grol, R. Successes and failures in the implementation of 

evidence-based guidelines for clinical practice. Med Care 2001; 

39: 8 (Suppl 2), 46–54. 

24. Parahoo, K. Barriers to, and facilitators of, research utilization 

among nurses in Northern Ireland. J Adv Nurs 2000; 31; 

1, 89–98. 

25. Meijers, J.M.M., Janssen, M.A.P., Cummings, G., Wallin, L. et 

al. Assessing the relationships between contextual factors and 

research utilization in nursing: systematic literature review. J 

Adv Nurs 2006; 55: 5, 622–635. 

26. Kajermo, K., Nordstrom, G., Krusebrant, A. et al. Barriers 

to and facilitators of research utilization, as perceived by a 

group of registered nurses in Sweden. J Adv Nurs 1998; 27: 4, 

798–807. 

This recent publication from the EPUAP Nutrition and Pressure Ulcers Working Group 

is reprinted with thanks to the Journal of Wound Care. 


22 

epuap 

Future Meetings 

AUGUST / SEPTEMBER 2007 

30 – 1 10th European Pressure Ulcer Advisory Panel 

Open Meeting 

Pressure Ulcers: 

putting knowledge into practice 

Academic Centre 

John Radcliffe Hospital, Oxford, UK 

Contact: EPUAP Business Office 

14 Aston Street 

Oxford, OX4 1EP, UK 

Tel: +44 (0)1865 791725 

Fax: +44 (0)1865 791725 


Website: www.epuap.org 

SEPTEMBER 2007 

26 – 28 17th Annual Meeting of the European 

Tissue Repair Society (ETRS) 

Measurements in Wound Healing – the conduit 

between the laboratory and the clinic 

Botley Park Country Club 

Southampton, UK 

www.etrs2007soton.com 

For further information contact: 

The ETRS Business Office 

14 Aston Street, Oxford, OX4 4EF, UK 

Tel: +44 (0)1865 791725 

Fax: +44 (0)1865 791725 


ETRS Website: www.etrs.org 

E-mail for Raj Mani: rm1@soton,ac.uk 


JUNE 2008 

4 – 8 Third Congress of World Union of Wound 

Healing Societies 

Toronto, Canada 

Abstract submissions to: 

www.worldunion2008.com 

Abstract submissions by 15 September 2007 

Notification by 15 December 2007 

Confirm your attendance by 15 January 2008 

SEPTEMBER 2008 

3 – 6 11th European Pressure Ulcer Advisory Panel 

Open Meeting 

Site Oud Sint-Jan 

Bruges, Belgium 


The EPUAP Business Office 


Tel: +44 (0)1865 791725 

Fax: +44 (0)1865 791725 


Website: www.epuap.org 

SEPTEMBER 2008 

24 – 26 18th Annual Meeting of the European 

Tissue Repair Society (ETRS) 

Malta 


The ETRS Business Office 


Tel: +44 (0)1865 791725 

Fax: +44 (0)1865 791725

EPUAP Programme: Oxford 2007, 30 August to 1 September

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