EPUAP Programme: Oxford 2007, 30 August to 1 September
EPUAP Programme: Oxford 2007, 30 August to 1 September
EPUAP Programme: Oxford 2007, 30 August to 1 September
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
epuap<br />
Mission Statement<br />
Executive Committee Members:<br />
Trustees:<br />
<strong>EPUAP</strong> Business Office:<br />
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<br />
Trustees of the European Pressure Ulcer Advisory Panel<br />
The European Pressure Ulcer Advisory Panel’s objective is <strong>to</strong> provide the<br />
relief of persons suffering from, or at risk of pressure ulcers, in particular<br />
through research and the education of the public.<br />
Tom Defloor: President (Belgium)<br />
Denis Colin: Past President (France)<br />
Michael Clark: Recorder (UK)<br />
Jacqui Fletcher: Deputy Recorder (UK)<br />
Marco Romanelli: Past President (Italy)<br />
George Cherry: Secretary/Treasurer (UK)<br />
Carol Dealey: President Elect (UK)<br />
Christina Lindholm (Sweden)<br />
Andrea Bellingeri (Italy)<br />
Manuel Gago-Fornells (Spain)<br />
Lena Gunningberg (Sweden)<br />
Ruud Halfens (Netherlands)<br />
Hilde Heyman (Belgium)<br />
Helvi Hietanen (Finland)<br />
Cristina Miguens (Portugal)<br />
Zena Moore (Eire)<br />
Cees Oomens (Netherlands)<br />
Anna Polak (Poland)<br />
Joseph Schols (Netherlands)<br />
Lisette Schoonhoven (Netherlands)<br />
José Verdu Soriano (Spain)<br />
Jan Weststrate (Netherlands)<br />
Anne Witherow (Northern Ireland)<br />
Administra<strong>to</strong>r: Christine Cherry (UK)<br />
14 As<strong>to</strong>n Street<br />
<strong>Oxford</strong>, OX4 1EP, UK<br />
Tel: +44 (0)1865 791725<br />
Fax: +44 (0)1865 791725<br />
E-mail: oxfordwound@aol.com<br />
Volume 8, Number 1, <strong>2007</strong> 1
2<br />
epuap<br />
Dr Michael Clark<br />
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<br />
Letter from the Edi<strong>to</strong>r<br />
A challenging time for pressure ulcer prevention and treatment?<br />
WE are fast approaching the annual <strong>EPUAP</strong> Open Meeting this<br />
year <strong>to</strong> be held in <strong>Oxford</strong> from <strong>30</strong> <strong>August</strong> <strong>to</strong> 1 <strong>September</strong> <strong>2007</strong>.<br />
It is exciting <strong>to</strong> return <strong>to</strong> <strong>Oxford</strong> where the first two <strong>EPUAP</strong><br />
Open Meetings were held back in 1997 and 1998.<br />
In 1997 we had 32 presentations (including 23 free papers) and seven<br />
poster presentations whereas ten years later the number of presentations and<br />
posters has increased <strong>to</strong> over 50 presentations (23 free papers and 35 posters).<br />
This increase in the volume of material marks the growth of our society<br />
and the enduring interest in pressure ulcers. However for many these are<br />
challenging times with health service budgets and staff under pressure with<br />
consequent effects upon attendances at conferences with reducing delegate<br />
numbers – thankfully these pressures have not seen a marked decline in interest<br />
for the <strong>EPUAP</strong> Open Meeting and the Business Office should be thanked<br />
for its efforts <strong>to</strong> promote the <strong>Oxford</strong> meeting and next year’s conference<br />
<strong>to</strong> be held in Bruges in Belgium. This issue of the <strong>EPUAP</strong> Review carries the<br />
first announcement of this event in 2008 and please enter the dates in your<br />
diary now!<br />
What highlights should delegates in <strong>Oxford</strong> watch out for? News of the<br />
rapidly evolving new clinical practice guideline will be shared during the conference<br />
with considerable effort expended by <strong>EPUAP</strong> Trustees and Members<br />
over the past few months <strong>to</strong> achieve a review of all relevant publications upon<br />
pressure ulcer prevention. The work of the <strong>EPUAP</strong> Nutrition and pressure<br />
ulcers working group will be highlighted this year – this group have achieved<br />
a clinical practice guideline, a multi-national survey of nutritional practice<br />
as related <strong>to</strong> pressure ulcer prevention and management, two peer reviewed<br />
publications and at least two book chapters since coming in<strong>to</strong> being in 2003.<br />
One of the recent publications from this group is reprinted in this issue of the<br />
<strong>EPUAP</strong> Review with thanks <strong>to</strong> the Journal of Wound Care. The nutrition group<br />
began <strong>to</strong> prepare for the multi-national survey by describing current pressure<br />
ulcer initiatives within the surveyed countries (Germany, the Netherlands<br />
and the United Kingdom) and this issue of the Review contains the report on<br />
recent Dutch initiatives with other countries <strong>to</strong> follow in subsequent issues.<br />
To show that the work of the <strong>EPUAP</strong> moves quickly one further highlight for<br />
<strong>Oxford</strong> is not included on the formal programme as the initiative began after<br />
the programme was completed earlier this year – this initiative collected views<br />
upon potential changes in the current four stage pressure ulcer classification<br />
across Europe and the results will be presented for the first time in <strong>Oxford</strong>.<br />
So for a variety of reasons you should be in <strong>Oxford</strong> in late <strong>August</strong> and I look<br />
forward <strong>to</strong> welcoming you <strong>to</strong> the conference.<br />
Michael Clark<br />
Edi<strong>to</strong>r and <strong>EPUAP</strong> Recorder<br />
Volume 8, Number 1, <strong>2007</strong>
epuap<br />
Dr Tom Defloor<br />
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<br />
Letter from the President<br />
Reflections on the role of the European Pressure Ulcer Advisory Panel<br />
IN recent years, there has been an increasing emphasis upon Evidence<br />
Based Practice (EVP) in decision making in healthcare. While there<br />
are many reasons for this our patients and the societies in which we live<br />
demand that we, as healthcare professionals, work in accordance with<br />
the available research evidence combined with our clinical experience, the<br />
opinions and wishes of patients, and the available resources. The <strong>EPUAP</strong><br />
continues <strong>to</strong> provide support for healthcare professionals in meeting these<br />
high expectations.<br />
How can the <strong>EPUAP</strong> best help meet these expectations given that the<br />
mission of the charity is <strong>to</strong> provide the relief of persons suffering from or at<br />
risk of pressure ulcers, in particular through research and the education of<br />
the public. Research then forms a key element of our mission not through<br />
the funding of major projects but in the past, and hopefully in the future <strong>to</strong>,<br />
the <strong>EPUAP</strong> stimulated research by awarding small grants <strong>to</strong> make pilot studies<br />
possible and <strong>to</strong> explore the potential of new research projects.<br />
Another key element is our role in education – perhaps at this time primarily<br />
of healthcare professionals through the use of the annual Open Meetings<br />
as a strong discussion forum where clinical experiences can be shared. The<br />
annual open meetings have proven <strong>to</strong> be an excellent way <strong>to</strong> encourage networking,<br />
the exchange of research data and clinical experiences leading <strong>to</strong> the<br />
development of formal position statements and other guidance documents.<br />
No doubt this year’s Open Meeting in <strong>Oxford</strong> will continue this tradition.<br />
A major undertaking in <strong>2007</strong> has been the collaboration with the US National<br />
Pressure Ulcer Advisory Panel on new evidence based clinical practice<br />
guidelines. This is a major opportunity <strong>to</strong> enhance the quality of pressure<br />
ulcer care and is certainly the biggest project that the <strong>EPUAP</strong> has undertaken<br />
since its foundation, with the new guideline available in 2008.<br />
Whilst the guideline project is our most ambitious effort <strong>to</strong> date, new<br />
challenges will occur as the <strong>EPUAP</strong> matures over the following years. Among<br />
these I would expect attention <strong>to</strong> focus upon issues such as pressure ulcer<br />
pathophysiology, risk assessment, and the cost effectiveness of our interventions<br />
given that relatively little is known regarding these key areas. The <strong>EPUAP</strong> has<br />
a pivotal role as a body able <strong>to</strong> identify these shortcomings and ensure that<br />
they will be high on the wider research agenda.<br />
Identifying new research areas and developing clinical practice guidelines<br />
are important steps but in themselves may be insufficient <strong>to</strong> close the gap<br />
between research and clinical practice. Therefore, <strong>to</strong> maximise the likelihood<br />
of our clinical guidelines being used in clinical practice, we need coherent<br />
dissemination and implementation strategies that are both effective and efficient.<br />
The need for improved dissemination and implementation strategies<br />
in my opinion will be the most important challenge for the <strong>EPUAP</strong> in the<br />
next decade.<br />
Thank you! Kind regards.<br />
Tom Defloor<br />
President<br />
Volume 8, Number 1, <strong>2007</strong> 3
4<br />
epuap<br />
Carol Dealey<br />
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<br />
Letter from the President Elect<br />
AS we approach the 10 th <strong>EPUAP</strong> conference, I feel it is an opportune<br />
moment <strong>to</strong> look backwards at where we started and forwards<br />
<strong>to</strong> this year’s conference. It is interesting <strong>to</strong> note that in 1997 we<br />
were pleased <strong>to</strong> welcome Dr Andrew Salzberg, the then President<br />
of the National Pressure Ulcer Advisory Panel (NPUAP) <strong>to</strong> share the American<br />
Experience with us. In 1997 we were also focussed on our pressure ulcer<br />
guidelines, which have subsequently very successful and have been translated<br />
in<strong>to</strong> many different European languages, thanks <strong>to</strong> the hard work of many<br />
of <strong>EPUAP</strong> Trustees.<br />
Ten years on and we will again be welcoming the NPUAP President Dr<br />
Joyce Black and other members of NPUAP <strong>to</strong> the conference. This time much<br />
of the focus of our collaboration will be outside the conference on our joint<br />
Pressure Ulcer Guideline work. As both societies were conscious that their<br />
individual guidelines were very dated, it seemed an opportune time <strong>to</strong> collaborate<br />
and produce joint guidelines. This is an exciting and challenging<br />
venture and we hope that members of both societies will become engaged in<br />
the process. More information can be found in Katrien Vanderwee’s paper<br />
in this issue of the <strong>EPUAP</strong> Review and also on our website:<br />
<br />
An important aspect of any conference is the science <strong>to</strong> underpin clinical<br />
practice. This year will be no different and the programme indicates some<br />
interesting sessions and I hope there will be plenty of debate around the<br />
<strong>to</strong>pics on offer. As well as learning more about developments in Europe and<br />
USA there will also be an opportunity <strong>to</strong> learn more about pressure ulcer<br />
activity in Japan. Professor Ohura, the Secretary General of the Japanese<br />
Society for Pressure Ulcers and other members of the society will providing<br />
a unique opportunity <strong>to</strong> learn more about the great strides that have been<br />
made in Japan in the last few years.<br />
So it only remains for me <strong>to</strong> say that this has been an exciting ten years<br />
and <strong>EPUAP</strong> has come a long way in that time. I hope that the next ten years<br />
will be just as exciting. In the meantime, when all the conference delegates<br />
expect <strong>to</strong> be enjoying <strong>Oxford</strong> and all it has <strong>to</strong> offer in some of the social<br />
events around the conference, I just hope that we will have good weather<br />
for that evening boat trip with the jazz band!<br />
Carol Dealey<br />
President Elect<br />
Volume 8, Number 1, <strong>2007</strong>
epuap News<br />
Dr George Cherry<br />
One of the social events<br />
taking place during the<br />
10th Anniversary Meeting<br />
at <strong>Oxford</strong> will be an<br />
evening boat trip, with<br />
jazz and buffet supper.<br />
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<br />
from the Business Office<br />
THE <strong>EPUAP</strong>, in reaching the miles<strong>to</strong>ne of having its 10th anniversary<br />
meeting in <strong>Oxford</strong> this year, in <strong>August</strong>, has made many<br />
accomplishments in its relatively short his<strong>to</strong>ry of which it should<br />
be proud. One of these is the publication (in 2006) of the book<br />
Science and practice of pressure ulcer management, edited by Marco Romanelli. In<br />
the chapter that I contributed: ‘<strong>EPUAP</strong> Advisory Panel, a means of identifying<br />
and dealing with a major health problem with a European Health Initiative’<br />
(which is one of twenty-two other chapters in the book) I described how<br />
the organisation was formed with an inaugural meeting in London in 1996<br />
consisting of representatives from thirteen European countries, and the<br />
USA. Many of those that attended this meeting have supported the <strong>EPUAP</strong><br />
over the years by making major contributions <strong>to</strong> our mission statement: ‘the<br />
European Pressure Ulcer Advisory Panel’s objective is <strong>to</strong> provide the relief<br />
of person suffering from, or at risk of pressure ulcers, in particular through<br />
research and the education of the public’.<br />
One of our first accomplishments was producing evidence based guidelines<br />
on prevention and management of pressure ulcers. This initial work was<br />
done nine years ago and at that time there was a paucity of evidence. Tom<br />
Defloor our present president and Carol Dealey our president-elect in their<br />
article in this issue describe the new major prevention guideline project which<br />
is being co-ordinated by Katrien Vanderwee. (www.pressureulcerguidlines.<br />
org). We have also included in this issue a list of stakeholders which includes<br />
other societies, industry and individuals.<br />
In order <strong>to</strong> carry out such a project without support from industry would<br />
be impossible, though the <strong>EPUAP</strong> is contributing financially <strong>to</strong> the project.<br />
We are pleased that three companies have made major financial contributions<br />
and these are Numico, Huntleigh and KCI. We anticipate our other<br />
corporate sponsors will become part of this initiative.<br />
The Tenth Anniversary meeting which will begin on Thursday <strong>30</strong> <strong>August</strong><br />
should be a great success and, as you can read in Tom Defloor’s article,<br />
there has been a major increase in abstract submission along with quality.<br />
The programme can be seen in this issue, <strong>to</strong>gether with a registration form<br />
if you have not yet registered.<br />
Also in this issue, Jos Schols has produced an article on ‘Pressure ulcer<br />
care in the Netherlands; a short his<strong>to</strong>rical review’. In addition we have obtained<br />
permission from the Journal of Wound Care <strong>to</strong> reprint an article ‘Evaluation<br />
of the dissemination and implementation of a nutritional guideline<br />
for pressure ulcer care’ which was published by members of the nutritional<br />
working group of the <strong>EPUAP</strong>.<br />
The Business Office has played an important role in the development<br />
of the <strong>EPUAP</strong> since its initial organisation. This includes organising all of<br />
the annual meetings starting with the first two here in <strong>Oxford</strong> followed by<br />
Amsterdam, Le Mans, Pisa, Budapest, Tampere, Berlin and the World Union<br />
meeting in Paris. In addition the office publishes the Review and is responsible<br />
for the <strong>EPUAP</strong> website which is extremely popular.<br />
Volume 8, Number 1, <strong>2007</strong> 5
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
6<br />
epuap <strong>EPUAP</strong><br />
Educational material is distributed <strong>to</strong> practitioners and others interested<br />
in pressure ulcers. The success has been due <strong>to</strong> the individuals working in<br />
the office, but probably more importantly has been the liaison established<br />
through the office and our corporate sponsors, who without their support<br />
we could not continue <strong>to</strong> meet our charity’s mission statement.<br />
We look forward <strong>to</strong> welcoming you <strong>to</strong> <strong>Oxford</strong> at our Tenth Anniversary<br />
Meeting.<br />
Dr George W. Cherry<br />
Secretary Treasurer <strong>EPUAP</strong><br />
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<br />
<strong>Programme</strong>: <strong>Oxford</strong> <strong>2007</strong>, <strong>30</strong> <strong>August</strong> <strong>to</strong> 1 <strong>September</strong><br />
Theme – Ten years of progress: the <strong>EPUAP</strong> past, present and future<br />
Thursday, <strong>30</strong> <strong>August</strong> Academic Centre · John Radcliffe Hospital · Heading<strong>to</strong>n<br />
09:<strong>30</strong> (Coach transportation from St Anne’s College <strong>to</strong> Academic Centre, John Radcliffe)<br />
Registration<br />
10:<strong>30</strong>–12:00 KCI Symposium (Lecture Theatre 2)<br />
Integrated Therapy System for Better Wound Care:<br />
The Science and Practice of Pressure Ulcer management<br />
Overview holistic approach – George Cherry<br />
Basic Science and Clinical Evidence – Paul Banwell<br />
Surgical Management of the Pressure Ulcer – Raymund Horch<br />
General management of VAC Therapy – Kath Vowden<br />
10:<strong>30</strong>–12:00 Gaymar Symposium (Lecture Theatre 1)<br />
An Update on the Shear Force Initiative<br />
Chair: Dr Tom Stewart<br />
His<strong>to</strong>ry of the Shear Force Initiative – Tom Stewart<br />
The Combined Effect of Pressure and Shear on Capillary Closure in the<br />
Microscale of Skeletal Muscle Tissue – Amit Gefen<br />
What Are the Effects of Pressure and Shear on Tissue – Laura Edsberg<br />
Can we define a damage threshold for soft tissues under sustained<br />
mechanical loading? – Cees Oomens<br />
12:00–13:00 Exhibition opening and lunch in Tingewick Hall<br />
13:00 Opening of Conference – Tom Defloor<br />
Chairs: Carol Dealey and Marco Romanelli<br />
13:15 The <strong>EPUAP</strong> past, present and future – Carol Dealey<br />
13:40 Highlights of the free papers and poster presentations –<br />
Mike Clark and Jacqui Fletcher, and Anna Polak panel report<br />
Volume 8, Number 1, <strong>2007</strong>
13:40 Nutrition and pressure ulcers:<br />
the work of the <strong>EPUAP</strong> Nutritional Working Group – Judith Meijers<br />
14:20 Tea and commercial exhibition Tingewick Hall<br />
Chairs: Zena Moore and Jan Weststrate<br />
14:50 Introduction <strong>to</strong> the conference scientific sessions<br />
14:55 Shear forces – Cees Oomens<br />
15:15 Redistributing pressure – Tom Defloor<br />
15:35 Heel pressure ulcers – Jeannie Donnelly<br />
15:55 Skin care, continence and pressure ulcers – Lisette Schoonhoven<br />
16:15 Presentation <strong>to</strong> <strong>EPUAP</strong> Award winner<br />
16:<strong>30</strong> Coffee Break and commercial exhibition in Tingewick Hall<br />
16:45–18.15 Smith & Nephew Symposium: (Lecture Theatre 2)<br />
18:15 (Coach transportation <strong>to</strong> St Anne’s College from Academic Centre, John Radcliffe)<br />
19:<strong>30</strong> (Coach transportation from St Anne’s College <strong>to</strong> Salter’s Boatyard)<br />
<strong>EPUAP</strong> PROGRAMME, OXFORD, <strong>2007</strong><br />
20:00–23:00 Social Event: Thames Jazz Boat Trip with Buffet Supper (Abingdon Road)<br />
Friday, 31 <strong>August</strong> Academic Centre · John Radcliffe Hospital · Heading<strong>to</strong>n<br />
08:00 (Coach transportation from St Anne’s College <strong>to</strong> Academic Centre, John Radcliffe)<br />
08:<strong>30</strong> Poster presentations<br />
08:<strong>30</strong> Randomised Controlled Trials Consort workshop – Jane Nixon<br />
09:<strong>30</strong> Free Papers Session 1 (Lecture Theatre 1)<br />
Chairs: Michael Clark and Hilde Heyman<br />
Deep Tissue Injury: State of the Science – Joyce Black, USA<br />
A Collaborative Statewide Initiative Across Care Settings Reduces<br />
Pressure Ulcers in the USA – Elizabeth A. Ayello, USA<br />
The Challenge: Determining Neglect in the Development of a<br />
Pressure Ulcer – Kath Vowden, UK<br />
An approximation <strong>to</strong> the cost of the treatment of Pressure Ulcers<br />
in Spain – Joan-Enric Torra I Bou, Spain<br />
Care Dependency Scale: An effective Alarm System for pressure<br />
ulcer risk? – Doris Wilborn, Germany<br />
Volume 8, Number 1, <strong>2007</strong> 7
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
8<br />
09:<strong>30</strong> Free Papers Session 2 (Lecture Theatre 2)<br />
Chairs: Jacqui Fletcher and Cristina Miguens<br />
A Systematic Review of Pressure Ulcers and Quality of Life –<br />
Claudia Gorecki, UK<br />
Cy<strong>to</strong>kine and chemokine transport through the epidermis upon sustained<br />
mechanical loading – L Cornelissen, The Netherlands<br />
Effectiveness of two cushions in the prevention of heel pressure ulcers –<br />
Alexander Heyneman, Belgium<br />
A randomized, blinded, conventional treatment controlled trial<br />
evaluating the efficacy of injected activated macrophage suspension<br />
in decubital ulcers – Zuloff-Shani Adi<br />
Evaluation of pressure relieving head supports –<br />
Vinoth K. Ranganathan, USA<br />
Cutaneo-adipose flaps on perforating arteries in combination with Pulsed<br />
Galvanic Stimulation PGS) <strong>to</strong> enhance treatments of 3 rd –4 th degree<br />
decubitus ulcers. – Argentina Vidrascu, Romania<br />
10:<strong>30</strong> Coffee and commercial exhibition in Tingewick Hall<br />
11:00 Scientific session 1: Heel Pressure Ulcers<br />
Chairs: Anne Witherow and Christina Lindholm<br />
Jeanne Donnelly, Mark Collier, Richard Goossens<br />
Scientific session 2: Shear forces. ‘Can we find a relationship between<br />
external pressure and shear and internal deformation?’<br />
Chairs: Cees Oomens and José Verdu Soriano<br />
Dan Bader, Karlien Ceelen<br />
How dangerous is shear? – Cees Oomens<br />
Can we find a relationship between external pressure and shear and<br />
internal deformation? – Karlien Ceelen<br />
12:<strong>30</strong> Exhibition and Lunch in Tingewick Hall<br />
12:<strong>30</strong> Highlights and unique advances in the field of Pressure Ulcer care<br />
in Japan<br />
The Japanese Society for Pressure Ulcers – Lecture Theatre 1<br />
(Lunch in the room)<br />
Chairs: Dan Bader and George Cherry<br />
1) Recent trends in pressure ulcer management in Japan – Prof. H Sanada<br />
2) Japanese wound assessment “Design P” – Prof. T. Moriguchi<br />
3) Guidelines for Pressure Ulcer care and treatment in Japan – Prof. S Ichioka<br />
4) Japanese Risk Fac<strong>to</strong>rs for Pressure Ulcers – Prof. T.Ohura<br />
5) New concepts of Pressure Ulcers from the shear force and<br />
pressure perspective:<br />
a) Mechanism and Measurements – Prof. M Takahashi<br />
(engineering viewpoints)<br />
b) Clinical Evidence – Prof. T Ohura<br />
14:10 Scientific session 3 – Pressure redistribution<br />
Chairs: Ruud Halfens and Anna Polak<br />
Katrien Vanderwee, Zena Moore<br />
Scientific session 4 – Skin care<br />
Chairs: Carol Dealey and Manuel Gago-Fornells<br />
Alan Cottenden, Sue Bale<br />
Volume 8, Number 1, <strong>2007</strong>
15:<strong>30</strong> Tea and commercial exhibition in Tingewick Hall<br />
16:00 Free papers Session 3 (Lecture Theatre 1)<br />
Chairs: Lisette Schoonhoven and Lena Gunningberg<br />
Are record data on pressure ulcers reliable? A comparison between paper-<br />
based records and electronic health records – Lena Gunningberg, Sweden<br />
Demographics of Pressure Ulcers: An Analysis of the International<br />
Pressure Ulcer Prevalence TM Survey – Catherine VanGilder, USA<br />
Frequency of pressure ulcers in one emergency hospital and one<br />
rehabilitation centre in Harare, Zimbabwe – Martin Sibanda, Zimbabwe<br />
Risk Assessment Tools for the Prevention of Pressure Ulcers – A Cochrane<br />
Systematic Review – Zena Moore, Ireland<br />
Pressure Ulcers Risk Evaluation (PURE) Project – Jane Nixon, UK<br />
SAFE or SORRY? Does every patient at risk for pressure ulcers get<br />
adequate prevention? – Betsie van Gaal, The Netherlands<br />
16:00 Free papers Session 4 (Lecture Theatre 2)<br />
Chairs: Jos Schols and Helvi Hietanen<br />
Continuous moni<strong>to</strong>ring of the interface pressure distribution and body<br />
movement during bed rest at ICU – Kozue Sakai, Japan<br />
Simultaneous measurement of blood flow and compressive loads applied<br />
<strong>to</strong> the skin – Hi<strong>to</strong>mi Sugiyama, Japan<br />
Development and Evaluation of a new Self-regulating Alternating Pressure<br />
Air Cushion – Gojiro Nakagami, Japan<br />
Knowledge, attitudes and practice of nursing staff about pressure ulcer<br />
prevention and treatment – a survey in a Swedish health care setting –<br />
Ulrika Källman, Sweden<br />
Pressure Ulcers – Prevention and Prevalence on Intensive Care;<br />
Observing trends from 2001 <strong>to</strong> 2006 – Nils Lahmann, Germany<br />
17:<strong>30</strong> Annual General Meeting<br />
18:00 (Coach transportation from Academic Centre, John Radcliffe <strong>to</strong> St Anne’s College)<br />
20:00–22:00 Gala dinner at St Anne’s College<br />
<strong>EPUAP</strong> PROGRAMME, OXFORD, <strong>2007</strong><br />
Saturday, 1 <strong>September</strong> St Anne’s College<br />
09:<strong>30</strong> Welcome and overview of the day – Carol Dealey<br />
09:50 Special hands-on Workshops<br />
Shear Forces (Duncan Bain/Michael Clark)<br />
Heel pressures (Jacqui Fletcher/Tom Defloor)<br />
11:20 Tea and pastries<br />
11:50 Pressure redistribution without mattresses (Heidi Guy/Jacqui Fletcher)<br />
Sacral skin care (Trudie Young/Tom Defloor)<br />
13:25<br />
(In each of the four sessions the second-named individual is there <strong>to</strong> help the<br />
first <strong>to</strong> lead!)<br />
Summary and close – Carol Dealey<br />
14:00–17:00 Optional paid Tour <strong>to</strong> Blenheim Palace, Woods<strong>to</strong>ck (5 miles from <strong>Oxford</strong>)<br />
Birthplace of Wins<strong>to</strong>n Churchill<br />
Volume 8, Number 1, <strong>2007</strong> 9
Societies<br />
A.I.S.Le.C. (Italian Society on Wound Management)<br />
Association of Tissue Viability Nurses – West Midlands Group<br />
(United Kingdom)<br />
Bedfordshire and Hertfordshire Tissue Viability Nurses<br />
Forum (United Kingdom)<br />
GNEAUPP (Grupo Nacional para el Estudio y Asesoramien<strong>to</strong><br />
de las Úlceras por Presión y Heridas Crónicas – Spanish<br />
pressure ulcers and Chronic Wounds Advisory Board)<br />
North East Tissue Viability Nurses Group (England)<br />
North Wales Tissue Viability Nurses (United Kingdom)<br />
Qld Health, Pressure Ulcer Prevention Program and<br />
Collaborative (Australia)<br />
The Wound Care Association of New South Wales (Australia)<br />
Tissue Viability Society (United Kingdom)<br />
Wound care Society (United Kingdom)<br />
Industry<br />
10<br />
epuap<br />
Numico<br />
Huntleigh<br />
KCI<br />
ConvaTec UK<br />
Distrac Wellcare Products (Belgium)<br />
Individual Stakeholders<br />
Arede da Cruz Ana Patricia Gomes (Portugal)<br />
Ariza Zafra Francisco Jose (Spain)<br />
Asuncion Sancho Pons Maria (Spain)<br />
Ayello Elizabeth (USA)<br />
Barradas Julia (Portugal)<br />
Benbow Maureen (United Kingdom)<br />
Bigler Gerda (Switzerland)<br />
Bird Lorraine (United Kingdom)<br />
Birmingham Meg (USA)<br />
Boken Carole (United Kingdom)<br />
Bonomini Joanna (United Kingdom)<br />
Bots Th.C.M. (Netherlands)<br />
Brás Silvia (Portugal)<br />
Broadbent Gail (United Kingdom)<br />
Buckland Richard (United Kingdom)<br />
Burckhardt Marion (Germany)<br />
Burge Rebecca (United Kingdom)<br />
Cabete Dulce (Portugal)<br />
Cardello John (USA)<br />
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<br />
The <strong>EPUAP</strong> Prevention Guideline Project Stakeholders<br />
Carrion Andoni (Spain)<br />
Carroll Lucy (Ireland)<br />
Casaleiro Alves Adélia Maria (Portugal)<br />
Casanova Pablo Lopez (Spain)<br />
Chambers Tina (United Kingdom)<br />
Chandler Alison (United Kingdom)<br />
Chatwin David (United Kingdom)<br />
Cobb Ann (United Kingdom)<br />
Cole Nicky (United Kingdom)<br />
Conway Joanne (United Kingdom)<br />
Cooper Sally-Ann (United Kingdom)<br />
Correia Isabel Maria Lopes (Portugal)<br />
Craven Barbara (United Kingdom)<br />
Croukamp Belinda (South Africa)<br />
da Cunha Amorim Rodrigues Susana (Portugal)<br />
Da Silva Sousa Hélder Daniel (Portugal)<br />
Dan (Australia)<br />
Davies Patricia (United Kingdom)<br />
Dawson Patricia (United Kingdom)<br />
De Melo Figueiredo Rocha Ana Paula (Portugal)<br />
De Wolf Dirk (Belgium)<br />
Descombes Leonora (United Kingdom)<br />
Di Tullio Nazzareno (Italy)<br />
Diazpi Jesus (Spain)<br />
Dimitrova Jivka (United Kingdom)<br />
Domingues Hugo (Portugal)<br />
Edwards Jane(United Kingdom)<br />
Elliott Judy (United Kingdom)<br />
Ellis Sam (United Kingdom)<br />
Erickson Sara (USA)<br />
Esperanço Nuno Jorge Rodrigues (Portugal)<br />
Falcao Elciane (Brazil)<br />
Fearnley Helen (United Kingdom)<br />
Fentiman Sara (United Kingdom)<br />
Ferreira Jaime (Portugal)<br />
Firth Linda (United Kingdom)<br />
Fisher Shirley (United Kingdom)<br />
Fontaine Stan (Belgium)<br />
Fowler Ann (United Kingdom)<br />
Foy Caroline (United Kingdom)<br />
Fredén Marie-Lousie (Sweden)<br />
Ful<strong>to</strong>n Pamela (United Kingdom)<br />
Fyfe Lynn (United Kingdom)<br />
Gago-Fornells Manuel (Spain)<br />
Garcia-FernandezFrancisco P. (Spain)<br />
Garrido Villoldo An<strong>to</strong>nio (Spain)<br />
Gat<strong>to</strong> Pauline (United Kingdom)<br />
Gebhardt KS (United Kingdom)<br />
Gilmartin Sheila (Ireland)<br />
Giovanni Romboli (Italy)<br />
Volume 8, Number 1, <strong>2007</strong>
Godar Susan (United Kingdom)<br />
Gouveia João (Portugal)<br />
Grier Janet (United Kingdom)<br />
Grove Jo-Anna (United Kingdom)<br />
Guerra Marcos (Venezuela)<br />
Harimurti Kuntjoro (Indonesia)<br />
Harvey Dee (United Kingdom)<br />
Haugh<strong>to</strong>n William (United Kingdom)<br />
Heaney Fiona (Ireland)<br />
Heylen Ria (Belgium)<br />
Higson Francesca (United Kingdom)<br />
Hogan Jeanette (United Kingdom)<br />
Hucker Melanie (United Kingdom)<br />
Hughes Caroline (United Kingdom)<br />
Hunter Caroline (United Kingdom)<br />
Idoia Beistegui Alejandre (Spain)<br />
Iivanainen Ansa (Finland)<br />
Irving Valerie (United Kingdom)<br />
Izaskun (Spain)<br />
Jansen Bea (Netherlands)<br />
Jiménez Francisco Zafra (Spain)<br />
Jones George Marcia (USA)<br />
Jones Jo (United Kingdom)<br />
Jones Ruth (United Kingdom)<br />
Jordan Paula (United Kingdom)<br />
Kelly Fiona (United Kingdom)<br />
Koopman Eddy (Netherlands)<br />
Kurtulus Zeynep (Turkey)<br />
Leonard Sylvia (United Kingdom)<br />
Lindgren Margareta (Sweden)<br />
Loffredo (Netherlands)<br />
Malca<strong>to</strong> Ester (Portugal)<br />
Maloney Trevor (United Kingdom)<br />
Malrait Nathalie (Belgium)<br />
Marques Luiz Gustavo Castro (Brasil)<br />
Marshall Caroline (United Kingdom<br />
Martin Karen (USA)<br />
Martinez Maria Blanca (Spain)<br />
Mason Margaret (United Kingdom)<br />
Mathieson-Devereaux G (USA)<br />
McCauley Jacqueline (Ireland )<br />
Mcintyre June (South Africa)<br />
Mcquillan Sarah (United Kingdom)<br />
Mistiaen Patriek (The Netherlands)<br />
Moore Monica (United Kingdom)<br />
Moorhead Anne (United Kingdom)<br />
Morgan Sharon (United Kingdom)<br />
Mullin Allison (United Kingdom)<br />
Murphy Debbie (United Kingdom)<br />
Murphy Fiona (United Kingdom)<br />
Nikolaos S<strong>to</strong>ufis (Greece)<br />
Noble Jenny (USA)<br />
Nunes das Neves Marcia (Brasil)<br />
O’Brien Gillian (Ireland)<br />
O’Brien Mark (United Kingdom)<br />
O’Flynn Linda (United Kingdom)<br />
Oldfield Amy (United Kingdom)<br />
Ørskov Anne (Denmark)<br />
THE <strong>EPUAP</strong> PREVENTION GUIDELINE PROJECT STAKEHOLDERS<br />
Pagnamenta Fania (United Kingdom)<br />
Pagnamenta Fania (United Kingdom)<br />
Pancorbo-Hidalgo Pedro L. (Spain)<br />
Parnham Alison (United Kingdom)<br />
Patten Hannah (United Kingdom)<br />
Pauline Beldon (United Kingdom)<br />
Peach Vic<strong>to</strong>ria (United Kingdom)<br />
Pearce Maureen (United Kingdom)<br />
Pearson Anne (United Kingdom)<br />
Penman Karen (United Kingdom)<br />
Preece Jane (United Kingdom)<br />
Proudman Michelle (United Kingdom)<br />
Puntriano Elianor M. (USA)<br />
Purser Kate (United Kingdom)<br />
Quesada Ramos Cristina (Spain)<br />
Rascoe Shelly (USA)<br />
Reed Anne (United Kingdom)<br />
Rigby Paul (Netherlands)<br />
Rmtaohua (China)<br />
Rocco (Italy)<br />
Rodrigues de Figueiredo Rogério Manuel (Portugal)<br />
Sancho Pons Maria Asuncion (Spain)<br />
Scott Eileen M (United Kingdom)<br />
Scott Pamela (United Kingdom)<br />
Shah Zubida (United Kingdom)<br />
Sharp Ailsa (United Kingdom)<br />
Sharp Catherine Anne (Australia)<br />
Shipperley Terry (United Kingdom)<br />
Ship<strong>to</strong>n Tracey (United Kingdom)<br />
Silva Debora (Portugal)<br />
Sims Joyce (United Kingdom)<br />
Smith Angela (United Kingdom)<br />
Soares da Costa Cristiana Violante (Portugal)<br />
Solinas Claudio (Italy)<br />
Sousa Oliveira Ana Cristina (Portugal)<br />
Stanway Sylvia (United Kingdom)<br />
Starkey Christine (USA)<br />
Stephen-Haynes jackie (United Kingdom)<br />
Stephenson Heather (United Kingdom)<br />
Stevens Julie (United Kingdom)<br />
Suárez Aurora (Mexico)<br />
Taylor Adrienne (United Kingdom)<br />
Teixeira José (Portugal)<br />
Trettler Elisabeth(Austria)<br />
Turner Mary (USA)<br />
Van Genechten Nancy (Belgium)<br />
Vanwalleghem Geert (Belgium)<br />
Walford Gill (United Kingdom)<br />
Walsh Nuala (United Kingdom)<br />
Wannell Linda (United Kingdom)<br />
Weafer Karen (United Kingdom)<br />
Williams Dominic (United Kingdom)<br />
Wilson Lyn (United Kingdom)<br />
Woodd Denise (United Kingdom)<br />
Woods John (U.S.A.)<br />
Woodward Paul (New Zealand)<br />
Young Clarissa (Australia )<br />
Zarnitsky (France)<br />
Volume 8, Number 1, <strong>2007</strong> 11
12<br />
epuap Eleventh<br />
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<br />
Annual <strong>EPUAP</strong> Meeting, Bruges, 3–6 <strong>September</strong> 2008<br />
KNOWN as the Venice of the North, Bruges is one of the most beautiful<br />
cities in Europe. It is situated in the western part of Belgium<br />
and only a short distance away from the Belgian Coast. The capital<br />
of Belgium, Brussels, is only 100 km away.<br />
It was a justified motive that prompted UNESCO in 2000 <strong>to</strong> include the<br />
entire his<strong>to</strong>rical city centre on the World Heritage list. Walking along the<br />
maze of winding cobbled alleys and romantic canals, you imagine yourself<br />
<strong>to</strong> be in medieval times. The wealth of museums is a striking image of this<br />
city’s stirring his<strong>to</strong>ry.<br />
Bruges is also home <strong>to</strong> contemporary culture, such as the new Concert<br />
Hall, which is one of the most prominent music complexes in Flanders. The<br />
restaurants in Bruges which offer gastronomic cuisine and the exclusive hotels<br />
are a true feast for those who enjoy the good things in life.<br />
The conference venue is the medieval Hospital of Saint John, which is<br />
located in the his<strong>to</strong>ric center of Bruges.<br />
Saint John’s Hospital was one of the oldest existing in Europe, however,<br />
in 1978 it ceased <strong>to</strong> be a hospital and was turned in<strong>to</strong> a museum. Originally<br />
its purpose was <strong>to</strong> provide food and shelter for pilgrims, passers by, and<br />
travelling salesmen, and <strong>to</strong> take care of the sick if they were not contagious.<br />
It was run by Brothers and Sisters from a religious order. Today one can visit<br />
the old pharmacy, the collection of his<strong>to</strong>ric medical equipment, and some<br />
of the former hospital wards.<br />
Volume 8, Number 1, <strong>2007</strong>
epuap News<br />
Domiciliary services: Institutional services:<br />
General Practitioners (n = 7,500) University hospitals (n = 8)<br />
Physical therapists (n = 14,000) General hospitals (n = 86)<br />
Occupational therapists (n = 2,800) Psychiatric hospitals (n = 43)<br />
Speech therapists (n = 4,500)<br />
Dieticians (n = 2,500) Rehabilitation clinics (n = 23)<br />
Dentists (n = 8,000)<br />
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<br />
from The Netherlands<br />
PRESSURE ULCER CARE IN THE NETHERLANDS: A SHORT HISTORICAL OVERVIEW<br />
JMGA Schols MD PhD 1 , RJG Halfens FEANS PhD 2 , JMM Meijers MSc 2 , JTM Weststrate RN PhD 3<br />
1. Department Tranzo, Tilburg University & Department of General Practice, Faculty of Health, Medicine and Life<br />
Sciences, Maastricht University; and Vivre Maastricht<br />
2. Faculty of Health, Medicine and Life Sciences, Department of Health Care and Nursing Science, Maastricht University<br />
3. Netherlands Centre for Excellence in Nursing, Utrecht.<br />
This article gives a short overview of the developments<br />
in pressure ulcer care (PU-care) in The Netherlands.<br />
THE Dutch health care system is characterized by<br />
relatively sharp boundaries among community<br />
health care services, hospital services and longterm<br />
care services. All three kinds of health care<br />
services have their own regulations and financing systems. 1<br />
Table 1 shows the most important health care services in<br />
The Netherlands.<br />
Pressure ulcers are an important problem in all health<br />
care settings, as is shown in Table 2, in which the prevalence<br />
rates for pressure ulcers in the last eight years are shown for<br />
university hospitals, general hospitals, home care, nursing<br />
homes and residential homes. 2<br />
In The Netherlands some interesting developments<br />
Table 1. Health care services in The Netherlands<br />
Residential homes (old people’s homes) (n = 1,340)<br />
Home care services (nursing) (n = 175) Nursing homes (n = 345)<br />
Community mental help (n = 46) www.minvws.nl www.rivm.nl<br />
Table 2. Prevalence of pressure ulcers (%) 1998–2006 in different health care sec<strong>to</strong>rs in The Netherlands. 2<br />
have been taking place in PU-care during the last two<br />
decades (Table 3). They will be addressed in this article.<br />
Developments in PU-care before 1995<br />
Before 1995 the policy <strong>to</strong> take care for patients suffering<br />
from pressure ulcers originated in the various health care<br />
services themselves and the PU-care itself was carried out<br />
by individual professionals. Depending on the enthusiasm<br />
of particular professionals, more or less attention was paid<br />
<strong>to</strong> the problem of pressure ulcers in health care facilities.<br />
Furthermore, in most cases it was the expertise of individual<br />
professionals which was leading in PU-care.<br />
In 1985/1986 the first National Guidelines on PU<br />
prevention and Treatment (from The Dutch Institute for<br />
1998 1999 2000 2001 2002 2003 2004 2005 2006<br />
University Hospital 13,2 14,4 15,8 18,4 16,5 14,7 14,8 15,6 15,2<br />
General Hospital 23,3 20,3 20,9 22,3 22,3 22,2 18,7 17,0 14,8<br />
Nursing Home 32,4 28,3 32,1 33,4 33,0 28,8 <strong>30</strong>,5 25,4 24,2<br />
Residential Home 15,4 11,6 13,6 14,6 16,2 13,3 16,1 13,3 10,5<br />
Home Care 21,3 17,7 17,7 20,5 18,5 16,7 14,2 12,2 9,7<br />
Volume 8, Number 1, <strong>2007</strong> 13
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Healthcare Improvement (CBO–PU guidelines) became<br />
available of which a first review <strong>to</strong>ok place in 1992.<br />
These guidelines offered professionals practice based<br />
and consensus based information <strong>to</strong> improve their performance<br />
in PU-care; yet they did not launch health care<br />
sec<strong>to</strong>r specific as well as national activities <strong>to</strong> improve PUcare<br />
all over the country.<br />
So, before 1995, the quality and intensity of pressure<br />
ulcer care showed a varied picture all over the country.<br />
Developments in PU-care since 1995<br />
Since the mid-nineties interesting developments in Dutch<br />
PU-care have been taking place. (Table 3)<br />
In 1995 a national steering committee on PU was<br />
established <strong>to</strong> develop a national strategy <strong>to</strong> improve PUcare<br />
in the <strong>to</strong>tal Health Care System of the Netherlands.<br />
Attention and alertness on pressure ulcers in home care,<br />
long-term institutional care and hospital care was provoked<br />
and the importance of implementing PU-guidelines was<br />
promoted.<br />
In 1996 and 1997 national legislation on quality of<br />
care and on registration of health care disciplines came<br />
in<strong>to</strong> operation. These laws facilitated the process of professionalisation<br />
of most health care disciplines (e.g., doc<strong>to</strong>rs.<br />
nurses) and urged them <strong>to</strong> improve their performance in<br />
patient care.<br />
In the meantime the evidence-based era had started<br />
and the development of EB-guidelines received an extra<br />
impulse.<br />
In the time period 1998–2003 a second review and<br />
more evidence based founding of the national CBO–PUguidelines<br />
<strong>to</strong>ok place and sec<strong>to</strong>r specific PU-guidelines for<br />
general practitioners, home care and nursing home care<br />
appeared. However, no national strategy or initiative was<br />
used <strong>to</strong> disseminate and implement these guidelines.<br />
14<br />
National Guidelines:<br />
1985/1986: First National Guidelines on PU prevention and treatment (CBO).<br />
1992: First review of National Guidelines (CBO).<br />
2002: Second review of National Guidelines (CBO). Guidelines more and more EB.<br />
Professional Guidelines (based on CBO-guidelines but targeted on different professionals or health care sec<strong>to</strong>rs):<br />
1999: Dutch PU guidelines for General Practitioners.<br />
2003: Dutch PU guidelines for Home Care.<br />
2003: Dutch PU guidelines for Nursing Home Care (SALODE).<br />
Other important national developments:<br />
1995: Installation of a national steering group on PU.<br />
1996: Dutch National Law on Quality of Care.<br />
1997: Dutch National Law on Registration of Health care disciplines. (Wet BIG).<br />
1998: Start of yearly national measurement of PU prevalence in different Health Care Sec<strong>to</strong>rs (Maastricht University).<br />
>2000: Trend <strong>to</strong>wards chain supply of healthcare services. including PU-care.<br />
2004/2005: PU (prevalence) acknowledged as an important quality indica<strong>to</strong>r in health care (incorporated in main national<br />
health care quality improving programmes).<br />
2005: Introduction of a National Centre for Pressure Ulcer prevention at the Netherlands Centre for Excellence in<br />
Nursing and start of wider implementation of PU-guidelines by breakthrough projects.<br />
www.minvws.nl; www.rivm.nl; www.cbo.nl; www.verpleeghuisartsen.nl<br />
Table 3. Developments in PU-care in the last two decades.<br />
Implementation of the sec<strong>to</strong>r specific guidelines is<br />
mostly initiated by multidisciplinary PU-committees appointed<br />
within the different health care organizations<br />
themselves. Within the different organizations – home<br />
care, hospital and nursing home – the tasks and responsibilities<br />
of the different health care professionals have<br />
gradually become more clear during the last ten years. Although<br />
the physician has overall responsibility for the care<br />
and treatment a patient receives, the nursing staff looks at<br />
the risk fac<strong>to</strong>rs for PU and assesses the status of the PUwounds,<br />
if present. In collaboration with the medical staff<br />
often the actual treatment of the wound is discussed. The<br />
nursing staff, therefore, has an important task in identifying<br />
and moni<strong>to</strong>ring the risk a patient has in developing PU<br />
(e.g., by using a PU-risk assessment <strong>to</strong>ol), taking adequate<br />
preventive measures and performing the actual wound<br />
treatment (i.e., cleaning of the wound and applying the<br />
adequate dressings). Today, many organizations have tissue<br />
viability nurses who have followed a specific educational<br />
programme and who have more authority in determining<br />
the integral patient specific PU-care, including the<br />
actual wound treatment. Furthermore, physiotherapists<br />
and occupational therapists are involved in PU-prevention<br />
(helping and teaching the patient and/or nurses in performing<br />
adequate transfers and achieving the right relief<br />
of pressure and shear forces) and dieticians are involved<br />
in managing nutritional problems in PU-patients.<br />
Since 1998, the prevalence, prevention and treatment<br />
of pressure ulcers is measured yearly within many healthcare<br />
organizations in The Netherlands (already more<br />
than 500 in <strong>2007</strong>!). For this measurement a standardized<br />
validated instrument has been developed, which is used<br />
consistently in each patient of the participating organizations.<br />
Data are gathered regarding quality indica<strong>to</strong>rs regarding<br />
pressure ulcers on ward and organizational level.<br />
Based on these measurements each organization receives<br />
an overview of their own results as well as the national<br />
Volume 8, Number 1, <strong>2007</strong>
esults, which they can use for comparison.<br />
It has been shown that measuring prevalence yearly,<br />
has a positive and facilitating effect on the quality of PUcare<br />
in all participating organizations. 2<br />
Advanced developments in PU-care since 2000<br />
Gradually, in the course of years, it has become clear<br />
(as pointed out at the beginning of this article) that the<br />
boundaries between different health care sec<strong>to</strong>rs in The<br />
Netherlands hamper the achievement of adequate continuity<br />
of care, which in fact is an important marker for quality<br />
of care. Therefore, since 2000, the focus is more and more<br />
on realizing an adequate chain supply of care. 1<br />
This also counts for achieving an adequate approach<br />
<strong>to</strong> pressure ulcer care throughout all health care services,<br />
following the principles of integral disease management<br />
and realizing a care chain supply of tailor-made care for<br />
the patients.<br />
At this moment, no one discusses the fact that an adequate<br />
approach <strong>to</strong> pressure ulcers requires optimal and<br />
complementary collaboration as well as bridging the gaps<br />
between all care providers and health care professionals<br />
involved. Therefore, this is a real challenge for:<br />
• collaboration in the medical axis<br />
• collaboration in the nursing axis<br />
• collaboration between the medical and the nursing<br />
axis;<br />
and it involves also a challenge <strong>to</strong>:<br />
• organize integral pressure ulcer care with mutual,<br />
complementary strengthening of community care<br />
services and institutional care services.<br />
Fitting in this trend, all over the country, experiments<br />
are taking place <strong>to</strong> achieve adequate transmural PU-care<br />
by implementing transmural PU-guidelines, which have<br />
been developed by integrating sec<strong>to</strong>r specific guidelines.<br />
For the implementation of these guidelines transmural<br />
PU-committees, with members from different organizations<br />
(home care, hospital care and nursing home care)<br />
are appointed.<br />
Another important actual development, with respect<br />
<strong>to</strong> the implementation of guidelines, are the breakthrough<br />
projects within the cure and care sec<strong>to</strong>r initiated by the<br />
Government. Pressure ulcers are one of the <strong>to</strong>pics in these<br />
breakthrough projects. A lot of facilities enhance their<br />
care regarding PU in participating in the breakthrough<br />
project. In a comparable project already more then 40<br />
nursing homes implemented the pressure ulcer guidelines<br />
for nursing homes. 3<br />
It the meantime, it also has become clear that nurses<br />
play an important role in achieving adequate continuity of<br />
care for the patient throughout the <strong>to</strong>tal health care chain,<br />
in which especially patients with chronic diseases often<br />
move between home and hospital care. between hospital<br />
and nursing home or home and nursing home and vice<br />
versa.<br />
In the case of PU-care this has led <strong>to</strong> the phenomenon<br />
of link nurses within the context of pressure ulcer prevention<br />
and treatment.<br />
Most patients really appreciate the continuous attention,<br />
that is achieved by this way of organizing PU-care<br />
throughout the health care system.<br />
NEWS FROM THE NETHERLANDS<br />
Dutch PU-care and challenges for the future<br />
Despite all these developments the most important problem<br />
remains the adequate implementation and firmly rooting<br />
of guidelines in daily PU-care. Solving this problem will be<br />
the most important challenge for Dutch PU-care.<br />
Regular assessment of quality of care may act as a facilita<strong>to</strong>r<br />
in enhancing the actual quality of care. Therefore,<br />
the most important ac<strong>to</strong>rs in Dutch health care (government,<br />
health care organizations, insurance companies<br />
and organizations of patients themselves) have agreed<br />
upon a new system of continuous (yearly) and integral<br />
measurement of quality of care. This system involves the<br />
yearly measurement of a set of indica<strong>to</strong>rs for quality of<br />
care, corresponding with the structure, the process and<br />
the outcome of care. The quality of PU-care is part of this<br />
system in which the yearly measurement of PU-prevalence<br />
will be a main outcome indica<strong>to</strong>r for PU-care!<br />
Moreover, benchmarking will take place, in which different<br />
organizations can be compared more transparently<br />
<strong>to</strong> each other.<br />
Organisations are beginning <strong>to</strong> notice the value of<br />
measuring the incidence or prevalence in order <strong>to</strong> find the<br />
cause of the PU problem, they are faced with. In order <strong>to</strong><br />
measure the incidence various computer programmes have<br />
been developed. One of them, The National Care Moni<strong>to</strong>r<br />
is based on the PU indica<strong>to</strong>rs developed by the <strong>EPUAP</strong>.<br />
Finally, we all know that insufficient implementation of<br />
health care guidelines is an important problem of health<br />
care. This also counts for many other countries all over the<br />
world. However, the goal of this article is not <strong>to</strong> explore<br />
possible reasons and solutions for this problem.<br />
<strong>EPUAP</strong> may also play an important role in facilitating<br />
the implementation of PU-guidelines in different<br />
countries, by exploring and presenting the PU-care in her<br />
member countries and by enabling the different countries<br />
<strong>to</strong> learn from each other.<br />
In fact, it is known that the road <strong>to</strong> optimal PU-care<br />
has no finish line! Therefore, for the sake of the patients<br />
and despite all possible hampering conditions, we have <strong>to</strong><br />
maintain working on:<br />
• implementing and rooting of evidence based<br />
PU-guidelines;<br />
• lowering PU-prevalence and incidence in our<br />
institutes and throughout the care chain as a whole;<br />
• being transparent with regard <strong>to</strong> our performance<br />
in PU-care; and<br />
• achieving a constant high standard of PU-care.<br />
Clearly, if we try hard, we will eventually succeed in<br />
this, so that our patients can feel themselves really safe in<br />
our hands.<br />
References:<br />
1. Rooij, E van. Droyan Kodner L. Rijsemus T. Schrijvers<br />
G. ed. Health and Health Care in The Netherlands. Elsevier<br />
Gezondheidszorg, Maarssen, 2002.<br />
2. Halfens RJG, Jansen MAP and Meijers JMM, National<br />
measurement of prevalence of care problems. Department of<br />
Health Care Studies, Section of Nursing Science,<br />
Maastricht University, 2006.<br />
3. SALODE-project (NVVA); see <br />
<br />
Volume 8, Number 1, <strong>2007</strong> 15
16<br />
epuap<br />
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<br />
Guideline Evaluation, Implementation and Dissemination<br />
EVALUATION OF THE DISSEMINATION AND IMPLEMENTATION OF A NUTRITIONAL GUIDELINE<br />
FOR PRESSURE ULCER CARE<br />
• Objective: In 2004 the European Pressure Ulcer Advisory Panel nutritional working group developed a nutritional<br />
guideline for pressure ulcer prevention and treatment. This study investigated the degree <strong>to</strong> which the guideline was<br />
disseminated and implemented in clinical practice.<br />
• Method: A cross-sectional study was undertaken in health-care organisations in the Netherlands, Germany and<br />
the UK. A printed, standardised questionnaire which followed Rogers’ model of the innovation-decision process was<br />
developed, translated and distributed <strong>to</strong> 1087 health-care organisations.<br />
• Results: The response rate was 33% (n = 363). Sixty-one per cent of respondents knew of the guideline. Twentyfive<br />
per cent had applied it <strong>to</strong> their clinical practice and used it for nutritional screening. The main barrier <strong>to</strong> the<br />
provision of nutritional support appeared <strong>to</strong> be lack of knowledge and skills.<br />
• Conclusion: One year after its dissemination, more than half of respondents knew of the guideline, with one in<br />
four applying it <strong>to</strong> their practice. The guideline was better disseminated and implemented in the Netherlands and UK<br />
than in Germany, where only 4% of participants had used it.<br />
• Declaration of interest: Numico Netherlands gave <strong>EPUAP</strong> an unrestricted educational grant.<br />
J.M.M. Meijers, 1 MSc, RN, Researcher/PhD Student;<br />
J.M.G.A. Schols, MD, PhD, Professor, Department of General Practice,<br />
Maastricht University and Department Tranzo, Tilburg University,<br />
the Netherlands;<br />
P.A. Jackson, MPhil, BSc, RGN, RHV, RNT, RCNT, Senior Lecturer, School<br />
of Nursing and Midwifery, University of Southamp<strong>to</strong>n, UK;<br />
G. Langer, PhD, RN, Coordina<strong>to</strong>r of the German Centre for Evidencebased<br />
Nursing, Martin Luther University, Halle-Wittenberg,<br />
Germany;<br />
M. Clark, PhD, Senior Research Fellow, Wound Healing Research Unit,<br />
Cardiff, UK;<br />
R.J.G. Halfens, 1 FEANS, PhD, Associate Professor.<br />
1. Faculty of Health, Medicine and Life Sciences, Department of Health<br />
Care and Nursing Science, Maastricht University, the Netherlands.<br />
E-mail: j.meijers@zw.unimaas.nl<br />
PRESSURE Ulcers are a common, expensive and<br />
painful health-care problem, with prevalence rates<br />
ranging from 3% <strong>to</strong> 66% in heath-care organisations.<br />
1,2 The estimated annual treatment costs are<br />
21.07 billion in the UK, 22.4 billion in the USA and 20.6<br />
million in the Netherlands. 3,4<br />
A pressure ulcer is defined as localised damage <strong>to</strong> the<br />
skin and underlying tissue caused by pressure, shear, friction<br />
or a combination of these. 5 The development of pressure<br />
ulcers depends on extrinsic and intrinsic risk fac<strong>to</strong>rs. The<br />
most important extrinsic risk fac<strong>to</strong>rs are pressure, shear and<br />
friction, which lead <strong>to</strong> mechanical loading and secondary<br />
damage <strong>to</strong> the skin and soft tissue. 6 Intrinsic fac<strong>to</strong>rs have<br />
an effect on tissue viability and consequently influence the<br />
pathophysiological response <strong>to</strong> mechanical loading. Studies<br />
have found significant associations with age, sex, limited<br />
activity, incontinence (bowel and bladder), infection and<br />
nutritional status. The relative influence of each of these<br />
intrinsic risk fac<strong>to</strong>rs is still unclear. 7–9<br />
A 2003 Cochrane review indicated that there is no<br />
strong scientific evidence for a direct relationship between<br />
poor nutrition and pressure ulcer development and healing,<br />
and a causal relationship has never been established,<br />
although the methodological quality of the studies reviewed<br />
is weak. 10 Nevertheless, individual studies have demonstrated<br />
that an adequate nutritional intake may help protect<br />
against pressure ulcer development and improve the rate<br />
of healing. 11–14<br />
A recent meta-analysis by Strat<strong>to</strong>n et al on enteral nutritional<br />
support in the prevention and treatment of pressure<br />
ulcers pointed out that, in four randomised controlled trials<br />
(RCTs), oral nutritional supplements (250–500Kcal for<br />
two <strong>to</strong> 26 weeks) were associated with a significantly lower<br />
incidence (25%) of pressure ulcer development in ‘at–risk’<br />
patients compared with routine care. 15 Furthermore, some<br />
studies showed a trend <strong>to</strong>wards improved healing with<br />
high protein nutritional supplements when compared<br />
with studies using standard formulae. However, Strat<strong>to</strong>n et<br />
al indicated that more robust RCT studies are needed <strong>to</strong><br />
scientifically confirm the latter finding.<br />
As nutritional status can be easily influenced by patient<br />
and practitioner interventions, clinical guidelines could set<br />
out the optimum management approach. Such guidelines<br />
provide an important bridge between research findings<br />
and clinical practice, 16 can aid the implementation of evidence-based<br />
research and give structural directions on how<br />
<strong>to</strong> provide efficient and adequate care, thereby improving<br />
quality of care. 17<br />
A study of previous pressure ulcer prevention and<br />
treatment guidelines concluded that most paid less than<br />
adequate attention <strong>to</strong> nutrition. 18 The European Pressure<br />
Ulcer Advisory Panel (<strong>EPUAP</strong>) therefore set up a nutritional<br />
working group comprising practitioners from European<br />
countries <strong>to</strong> develop a clinical nutritional guideline on<br />
Volume 8, Number 1, <strong>2007</strong>
pressure ulcer prevention and treatment. The guideline<br />
was launched in 2004 and translated in<strong>to</strong> eight languages.<br />
It covers the whole nutritional cycle (screening, assessment,<br />
intervention, evaluation and follow-up) and includes<br />
weight recommendations. It emphasises the importance of<br />
incorporating nutritional activities structurally in<strong>to</strong> daily<br />
pressure ulcer management. The most essential elements<br />
of the guideline have been mapped in<strong>to</strong> a decision tree. 19<br />
The guideline has been disseminated via the <strong>EPUAP</strong>’s<br />
network, which comprises its conferences, internet site,<br />
members and publication, and through the nutritional<br />
industry. 19<br />
However, the availability of clinical guidelines does not<br />
au<strong>to</strong>matically lead <strong>to</strong> their use in daily practice. In 2005<br />
the <strong>EPUAP</strong> nutrition working group therefore decided <strong>to</strong><br />
explore the degree <strong>to</strong> which the nutritional guideline had<br />
been disseminated and implemented in clinical practice in<br />
Germany, the Netherlands and UK.<br />
In this study the term ‘dissemination’ is defined as<br />
distribution and does not necessarily include action. ‘Implementation’<br />
is defined as the actual use of the guideline<br />
in daily practice. 20<br />
Model of innovation-decision process<br />
Rogers’ model of the innovation-decision process 21 was<br />
chosen as a framework for this study because, unlike other<br />
models in this field, it incorporates specific stages of the dissemination<br />
and implementation process. The model charts<br />
the five stages through which an individual (or another<br />
decision-making unit, such as a group, society, economy or<br />
country) moves across the innovation-decision process (Box<br />
1 Knowledge<br />
An individual becomes aware of and reads a guideline.<br />
‘What?’, ‘how?’ and ‘why?’ are the critical questions<br />
2 Persuasion<br />
Occurs when the individual develops a negative or<br />
positive attitude <strong>to</strong>wards the guideline<br />
3 Decision<br />
The individual chooses <strong>to</strong> adopt or reject the<br />
innovation. Adoption is defined as ‘having this guideline<br />
present in practice because it is the best course of<br />
action available’, and rejection as ‘not adopting this<br />
guideline’<br />
4 Implementation<br />
The guideline is put in<strong>to</strong> practice. Uncertainty about<br />
the outcomes of working with this guideline can still be<br />
a problem at this stage<br />
5 Confirmation<br />
The individual looks for support for his or her decision<br />
<strong>to</strong> use the guideline. This decision can be reversed if<br />
the individual is exposed <strong>to</strong> conflicting messages or<br />
barriers <strong>to</strong> its use<br />
Box 1. The five steps of Rogers’ innovation-decision process<br />
GUIDELINE EVALUATION, IMPLEMENTATION AND DISSEMINATION<br />
1). These stages typically follow each other in a time-ordered<br />
manner. The first three stages of the model are comparable<br />
<strong>to</strong> the dissemination of a guideline because the participant<br />
is not yet actively using it.<br />
The study participants were mapped in accordance<br />
with Rogers’ model, thereby providing an insight in<strong>to</strong> the<br />
percentage of participants in the various stages of dissemination<br />
and implementation one year after the launch of the<br />
guideline.<br />
Method<br />
A cross-sectional design was used. In <strong>to</strong>tal, 1087 clinical<br />
health-care organisations (<strong>30</strong>0 from the Netherlands, <strong>30</strong>0<br />
in Germany and 487 in the UK) were invited <strong>to</strong> participate<br />
in the study at the end of 2005. A national coordina<strong>to</strong>r in<br />
each country invited the selected health-care organisations,<br />
which comprised hospitals, nursing homes and home care,<br />
<strong>to</strong> participate in the postal survey. The national coordina<strong>to</strong>rs<br />
were members of <strong>EPUAP</strong> nutritional working group.<br />
The health-care organisations’ addresses were selected<br />
from several relevant databases in all three participating<br />
countries. The UK and Netherlands used more targeted<br />
databases, and Germany a more general database. The<br />
questionnaires were sent <strong>to</strong> managers of the health-care<br />
organisations, who were asked <strong>to</strong> allocate them <strong>to</strong> whoever<br />
was primarily involved in nutritional policy for pressure<br />
ulcer prevention and treatment.<br />
Ethical approval was not required as the questionnaire<br />
focused on organisational aspects and patients were not<br />
directly involved.<br />
The standardised questionnaire was developed by the<br />
<strong>EPUAP</strong> nutritional working group, following the Rogers’<br />
implementation stages. It included twenty-four items: eight<br />
questions had a dicho<strong>to</strong>mous outcome; two questions included<br />
four-point ordinal scales (always—never), and the<br />
remaining questions had a Likert scale ranging from four<br />
points <strong>to</strong> ten.<br />
For the knowledge stage, two questions enquired about<br />
awareness of the guideline and whether it had been read,<br />
and one question asked about the dissemination channel.<br />
For the persuasion stage, one question enquired about attitudes<br />
<strong>to</strong>wards the guideline.<br />
For the decision stage, two questions asked about the<br />
presence of this guideline in practice.<br />
For the implementation stage, respondents working<br />
in areas that had incorporated the <strong>EPUAP</strong> guideline in<strong>to</strong><br />
practice were asked eleven questions about its actual use in<br />
order <strong>to</strong> ascertain whether it was being followed correctly.<br />
Several recommendations, such as screening of nutritional<br />
status (when, who, how often, content), assessment, interventions,<br />
evaluation and follow-up were explicitly tested.<br />
For the confirmation stage, two questions enquired<br />
about barriers <strong>to</strong> nutritional support within pressure ulcer<br />
prevention and treatment.<br />
In addition, respondents’ demographic characteristics<br />
were defined under five items (profession, workplace, frequency<br />
of involvement in pressure ulcer care, membership<br />
of a pressure ulcer committee and involvement in pressure<br />
ulcer policy).<br />
Members of the <strong>EPUAP</strong> nutritional working group<br />
translated the questionnaires in<strong>to</strong> Dutch, German and<br />
English, checking content similarity.<br />
Volume 8, Number 1, <strong>2007</strong> 17
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
Statistical analysis<br />
Statistical analyses were performed using SPSS version<br />
13.0. The statistical analysis included descriptive frequency<br />
distributions of all variables. Differences between analyses<br />
were performed per country independently and for the <strong>to</strong>tal<br />
sample. In some questions multiple answers were possible,<br />
so the <strong>to</strong>tal could be more than 100%.<br />
Results<br />
The sample<br />
In <strong>to</strong>tal, 363 organisations returned the questionnaires: 146<br />
Dutch, 50 German and 167 UK. This yielded a response rate<br />
of 33% (49% for the Netherlands, 17% for Germany and<br />
34% for the UK). No information was available as <strong>to</strong> why<br />
organisations did not respond.<br />
Respondents comprised nurses (59%), dietitians<br />
(18%), physicians (6%) and other (mostly managers)<br />
(17%). Eighty-six per cent were members of a pressure ulcer<br />
committee or involved in pressure ulcer policy. Forty-nine<br />
per cent worked in a hospital setting, 26% in a long-term<br />
care setting and 22% in a home care. Most participants were<br />
involved daily or weekly in the care of patients at risk of or<br />
who had a pressure ulcer.<br />
Knowledge stage<br />
Sixty-one per cent of participants were aware of the <strong>EPUAP</strong><br />
nutritional guideline. Significantly more were from the UK<br />
and Netherlands than from Germany (p=0.01) (Table 1).<br />
The most frequently mentioned dissemination channel<br />
was the <strong>EPUAP</strong> internet site (19%), followed by professional<br />
journals (17%) and conferences (16%).<br />
In the Netherlands the nutritional industry played a<br />
significant (p=0.02) and major role in dissemination of the<br />
guideline, and the <strong>EPUAP</strong> internet site played a significantly<br />
minor role (p=0.01) compared with Germany and the UK.<br />
Persuasion stage<br />
Respondents who had read the guideline stated that it<br />
mostly confirmed their views about the importance of nutrition<br />
in pressure ulcer prevention and treatment. Only 1%<br />
disagreed with the guideline, leaving 99% with a positive<br />
attitude <strong>to</strong>wards its content.<br />
Decision stage<br />
Of the respondents who had read the guideline, 25% stated<br />
that they were applying its content <strong>to</strong> their daily practice<br />
(Netherlands: 26%, Germany: 9%, UK: 26%).<br />
The guideline was significantly (p=0.01) more evident<br />
in daily practice in the UK and Netherlands than in Germany.<br />
The guideline was mainly used in hospitals (61%),<br />
followed by home-care organisations (17%) and long-term<br />
institutional care (17%).<br />
More dietitians (29%) than nurses (25%) or physicians<br />
(11%) used it in practice.<br />
Implementation stage<br />
As the stages typically follow each other in a time-ordered<br />
manner, only responses from participants who used this<br />
guideline in their daily practice were analysed. As only two<br />
used the guideline in Germany, these were not taken in<strong>to</strong><br />
account in the later stages as this sample was <strong>to</strong>o small for<br />
further analysis.<br />
18<br />
• Screening Every participant screened patients; screening<br />
was most likely <strong>to</strong> take place ‘sometimes’, followed by ‘always’<br />
and then ‘rarely’, although this percentage was much<br />
lower for patients with pressure ulcers. Full results for this<br />
and other aspects relating <strong>to</strong> the implementation stage are<br />
given in Table 2.<br />
• Assessment Weight and weight his<strong>to</strong>ry were most frequently<br />
mentioned in responses. Health-care organisations<br />
in the Netherlands mentioned weight his<strong>to</strong>ry significantly<br />
more often than those in the UK (p = 0.03). In the UK, body<br />
mass index (BMI) and use of a nutritional screening <strong>to</strong>ol<br />
were mentioned sig-nificantly more frequently than in the<br />
Netherlands (p = 0.01).<br />
• Intervention When a nutritional problem was identified,<br />
the most commonly identified intervention was oral<br />
supplements, followed by normal feeding, particularly in<br />
the UK, where this was significantly more frequent than<br />
in the Netherlands (p = 0.01). Parenteral feeding was also<br />
mentioned less frequently in the Netherlands than in the<br />
UK (p = 0.01).<br />
• Evaluation Weight gain was the outcome measure most<br />
frequently used <strong>to</strong> evaluate the success or failure of nutritional<br />
intervention, followed by pressure ulcer healing.<br />
Biochemical parameters were mentioned significantly more<br />
frequently in the UK than in the Netherlands (p = 0.01).<br />
Thirteen per cent of health-care organisations in both countries<br />
still used none of these outcome measures.<br />
• Follow-up In the Netherlands and UK patients were<br />
most likely <strong>to</strong> be screened regularly or more often if their<br />
condition indicated. Patients were screened at first contact<br />
in fewer than one in ten organisations. No one stated that<br />
they never screened patients.<br />
Confirmation stage<br />
Here, the individual looks for support for his or her decision<br />
<strong>to</strong> use the guideline. The individual could reverse their<br />
decision if exposed <strong>to</strong> barriers <strong>to</strong> implementation. Figure 1<br />
shows the most important barriers <strong>to</strong> nutritional support.<br />
Discussion<br />
The goal of this study was <strong>to</strong> investigate the degree <strong>to</strong><br />
which the <strong>EPUAP</strong> nutritional guideline on pressure ulcer<br />
prevention and management had been disseminated and<br />
implemented in clinical health-care organisations within<br />
the Netherlands, Germany and UK.<br />
Sixty-one per cent of the study participants were aware<br />
of the <strong>EPUAP</strong> nutritional guideline, and of these 99% had a<br />
positive attitude <strong>to</strong>wards it. Moreover, 25% of those who were<br />
aware of the guideline had used it in their daily practice.<br />
However, it is important <strong>to</strong> note that, due <strong>to</strong> the low<br />
response rate, the questionnaire might present a skewed<br />
view of the current state of implementation across the three<br />
countries.<br />
The guideline was launched in 2004 with no specific<br />
strategy for its dissemination and implementation. One year<br />
later a relatively large number of the participating organisations<br />
already knew of it, especially in the Netherlands (59%)<br />
and UK (75%), and a smaller number had actually applied<br />
it <strong>to</strong> practice (26% and 26% respectively).<br />
In Germany, only 22% of health-care organisations were<br />
aware of the guideline and 9% had used it in daily practice.<br />
However, these results may be influenced by selection bias<br />
Volume 8, Number 1, <strong>2007</strong>
Figure 1. Barriers <strong>to</strong> nutritional<br />
support in pressure ulcer patients<br />
(n = 61).<br />
Netherlands Germany UK Total<br />
Total sample 146 50 167 363<br />
GUIDELINE EVALUATION, IMPLEMENTATION AND DISSEMINATION<br />
Incomplete questionnaires<br />
Knowledge stage<br />
4 1 9 14<br />
No. of people who responded 142 49 158 349<br />
No. of respondents who used<br />
dissemination channels (%)<br />
Dissemination channel:<br />
85 (60)*† 11 (22)‡ 119 (75) 215 (62)<br />
• <strong>EPUAP</strong> review 4%† 0%‡ 18% 11%<br />
• <strong>EPUAP</strong> internet site 3%*† 38% 28% 19%<br />
• Other professional journal 17% 31% 15% 17%<br />
• Industry 28%*† 0% 0% 11%<br />
• <strong>EPUAP</strong> conference 13%* 0% 15% 14%<br />
• Other conference 22%*† 6% 13% 16%<br />
• Colleagues 10%*† 0% 5% 7%<br />
• Other<br />
Persuasion stage<br />
2%* 25% 6% 6%<br />
No. of people who responded 85<br />
Consequence of knowing:<br />
11 119 215<br />
• Positive attitude 90% 99% 100% 99%<br />
• Negative attitude<br />
Decision stage<br />
1% 0% 0% 1%<br />
No. of people who responded 85 11 119 215<br />
% who used guideline<br />
in their daily practice<br />
26%* 9%‡ 26% 25%<br />
* Significant (p
EUROPEAN PRESSURE ULCER ADVISORY PANEL<br />
20<br />
Netherlands UK Total<br />
Number of respondents 22 31 53<br />
Should nutritional screening be undertaken<br />
on every patient?<br />
• At risk of pressure ulceration?<br />
— Always 19% 38% 31%<br />
— Sometimes 67% 55% 59%<br />
— Rarely 14% 7% 10%<br />
— Never<br />
• With pressure ulcers?<br />
0% 0% 0%<br />
— Always 38% 47% 44%<br />
— Sometimes 57% 53% 54%<br />
— Rarely 5% 0% 2%<br />
— Never 0% 0% 0%<br />
Assessment includes:<br />
• Weight 86% 61% 72%<br />
• Body mass index 18%* 68% 48%<br />
• Weight his<strong>to</strong>ry 96%* 52% 70%<br />
• Clinical judgement 46% 65% 57%<br />
• Nutritional screening <strong>to</strong>ol 23%* 81% 57%<br />
Nutritional interventions:<br />
• Normal feeding 32%* 71% 56%<br />
• Oral supplements 96% 99% 96%<br />
• Tube feeding 36%* 52% 46%<br />
• Parenteral feeding 5%* 39% 26%<br />
Evaluation — outcome measures <strong>to</strong> record<br />
success or failure of intervention:<br />
• No measurement 5% 19% 13%<br />
• Weight gain 86% 74% 77%<br />
• Development of PU 68% 52% 59%<br />
• Improvement in PU healing 82%* 65% 72%<br />
• Biochemical parameters 18%* 51% 43%<br />
Follow up — how frequently screened?<br />
• At first contact only 5% 10% 8%<br />
• At regular intervals 57%* 33% 44%<br />
• When condition indicates 29% 43% 37%<br />
• Never 0% 0% 0%<br />
• Don’t know 10% 13% 12%<br />
* Significant (p < 0.005) differences between<br />
the Netherlands and UK<br />
Table 2. Results for the implementation stage<br />
as most German participants were not aware of the <strong>EPUAP</strong>,<br />
which has few German members and communicates mainly<br />
in English, which may be a barrier for German-speaking<br />
countries. Furthermore, in Germany there is a national<br />
expert standard which professionals are expected <strong>to</strong> use as<br />
the guideline for pressure ulcer prevention and treatment.<br />
Lastly, the German addresses were randomly selected from<br />
a general database, whereas in the UK all NHS trusts were<br />
selected and in the Netherlands addresses were taken from<br />
a targeted database. Any of these fac<strong>to</strong>rs could have influenced<br />
the results.<br />
Interestingly, of the 61% of respondents who were aware<br />
of the guideline, 99% had a positive attitude <strong>to</strong>wards it, yet<br />
only one in four of the organisations used it. One reason<br />
for this could be that implementation of guidelines is a time<br />
consuming process, 20 and this study <strong>to</strong>ok place <strong>to</strong>o soon<br />
after the launch.<br />
Another reason may be that if implementation strategies<br />
are not treated as an integral part of the development<br />
process of clinical guidelines, then implementation in<br />
daily practice may be hampered. 20 While dissemination of<br />
a guideline may increase awareness among the target audience,<br />
it is not sufficient <strong>to</strong> bring behavioural change in the<br />
absence of an active implementation strategy. 22 One year,<br />
therefore, may be <strong>to</strong>o short a time in which <strong>to</strong> measure the<br />
effects on daily practice of guidelines disseminated without<br />
an implementation strategy.<br />
Moreover, practitioners struggle when implementing<br />
guidelines, despite their enthusiasm. This seems <strong>to</strong> be because<br />
they experience a number of barriers. Understanding<br />
these barriers will enable the development of strategies for<br />
increasing the use of guidelines in daily practice. 23,24<br />
This study showed that the most important barrier <strong>to</strong><br />
implementation of the guideline was lack of knowledge and<br />
skills, followed by lack of clarity about who is responsible<br />
for nutritional support, and inability <strong>to</strong> access nutritional<br />
support.<br />
These barriers were also identified in previous studies.<br />
24–26 They were not explored further, so no extra information<br />
was available on which skills and knowledge were<br />
lacking. An insight in<strong>to</strong> why these barriers exist will improve<br />
guideline implementation in clinical practice.<br />
As discussed, individual studies have indicated that<br />
adequate nutritional status has a positive effect on pressure<br />
ulcer prevention and healing. It is important that this<br />
relationship is made more explicit, and strong scientific evidence<br />
from robust RCTs is therefore needed. This will help<br />
<strong>to</strong> increase our understanding of the relationship between<br />
pressure ulceration and nutrition, and provide a stronger<br />
evidence base on which <strong>to</strong> implement new guidelines.<br />
Conclusion<br />
This study demonstrates that the <strong>EPUAP</strong> guideline on nutrition<br />
in pressure ulcer prevention and management was quite<br />
well disseminated in the Netherlands and UK.<br />
After only one year, two-thirds of participating healthcare<br />
organisations were aware of the guideline and one<br />
quarter had it in place.<br />
The main barrier <strong>to</strong> implementing nutritional support<br />
in pressure ulcer care was lack of knowledge and skills.<br />
Recommendations<br />
• A larger multi-country controlled study is needed on the<br />
dissemination and implementation of this European<br />
guideline.<br />
• There should be a greater focus on the barriers <strong>to</strong> implementing<br />
nutritional support in pressure ulcer care, with<br />
a view <strong>to</strong> creating an effective implementation strategy.<br />
• We should learn from examples of best practice relating <strong>to</strong><br />
guideline implementation in different countries.<br />
• More robust RCTs are needed <strong>to</strong> strengthen the scientific<br />
evidence on the relationship between poor nutrition and<br />
the development of pressure ulcers and their healing.<br />
Volume 8, Number 1, <strong>2007</strong>
References<br />
1. Bours, G.J., Halfens, R.J., Lubbers, M. and Haalboom, J.R.<br />
The development of a national registration form <strong>to</strong> measure<br />
the prevalence of malnutrition in the Netherlands. Os<strong>to</strong>my<br />
Wound Manage 1999; 45: 28–40.<br />
2. Tannen, A., Dassen, T., Bours, G. and Halfens, R. A comparison<br />
of pressure ulcer prevalence: concerted data collection<br />
in the Netherlands and Germany. Int J Nurs Stud 2004; 41: 6,<br />
607–612.<br />
3. Severens, J.L.A. Kosten van decubitus in Nederland. Afdeling<br />
MTA, Univesitair Medisch Centrum Radboud, Nijmegen,<br />
1999.<br />
4. Strat<strong>to</strong>n, R.J., Green, C.J., Elia, M. Disease-related Malnutrition:<br />
An evidence-based approach <strong>to</strong> treatment (1st edn). CABI, 2003.<br />
5. <strong>EPUAP</strong>, Pressure Ulcer Treatment Guidelines, 2003.<br />
www.epuap.org/gltreatment.html<br />
6. Bouten, C.V., Oomens, C.W., Baaijens, F.P. and Bader, D.L.<br />
The etiology of pressure ulcers: skin deep or muscle bound?<br />
Arch Phys Med Rehabil 2003; 84: 616–619.<br />
7. Bours, G.J., De Laat, E., Halfens, R.J. and Lubbers, M.<br />
Prevalence, risk fac<strong>to</strong>rs and prevention of pressure ulcers in<br />
Dutch intensive care units: results of a cross-sectional survey.<br />
Intensive Care Med 2001; 27: 10, 1599–1605.<br />
8. Bergquist, S. and Frantz, R. Pressure ulcers in communitybased<br />
older adults receiving home health care: prevalence,<br />
incidence and associated risk fac<strong>to</strong>rs. Adv Wound Care 1999;<br />
12: 7, 339–351.<br />
9. Green, S.M., Winterberg, H., Franks, P.J. et al. Nutritional<br />
intake in community patients with pressure ulcers. J Wound<br />
Care 1999; 8: 325–3<strong>30</strong>.<br />
10. Langer, G., Schloemer, G., Knerr, A. et al. Nutritional interventions<br />
for preventing and treating pressure ulcers.<br />
In: Cochrane Library, issue 4, 2003.<br />
11. Benati, G. and Pedone, V. Impact on pressure ulcer healing<br />
of an arginine-enriched nutritional solution in patients with<br />
severe cognitive impairment. Arch Geron<strong>to</strong>l Geriatr 2001; 33:<br />
1, 43–47.<br />
12. Bourdel-Marchasson, I., Barateau, M., Rondeau, V. et al. A<br />
multi-center trial of the effects of oral nutritional supplementation<br />
in critically ill older patients. Nutrition 2000; 16:<br />
1, 1–5.<br />
13. Chernoff, R.S., Mil<strong>to</strong>n, K.Y. and Lipschitz, D.A. The effect<br />
of a very high protein liquid formula on decubitus ulcer<br />
healing in long-term tube-fed institutionalised patients.<br />
J Am Diet Assoc 1990; 90: A-1<strong>30</strong>–A-139.<br />
GUIDELINE EVALUATION, IMPLEMENTATION AND DISSEMINATION<br />
14. Houwing, R., Rozendaal, M., Wouters-Wesseling, W. et al.<br />
A randomised, double-blind assessment of the effect of<br />
nutritional supplementation on the prevention of pressure<br />
ulcers in hip-fracture patients. Clin Nutr 2003; 22: 4,<br />
401–405.<br />
15. Strat<strong>to</strong>n, R.J., Ek, A.C., Engfer, M. et al. Enteral nutritional<br />
support in prevention and treatment of pressure ulcers: a<br />
systematic literature review and meta-analysis. Ageing Res Rev<br />
2005; 4: 422–450.<br />
16. Curry, S. Organzational interventions <strong>to</strong> encourage guideline<br />
implementation. Chest 2000; 118: (2 Suppl), 40S–46S.<br />
17. Grimshaw, J., Russell, I.T. Effects of clinical guidelines on<br />
medical practice: a systematic review of rigorous evaluations.<br />
Lancet 1993; 342: 1317–1322.<br />
18. Schols, J.M.G.A, Jager, de-van den Ende, M.A. Nutritional<br />
intervention in pressure ulcer guidelines: an inven<strong>to</strong>ry.<br />
Nutrition 2004; 20: 548–553.<br />
19. Clark, M., Schols, J.M., Benati, G. et al. Pressure ulcers and<br />
nutrition: a new European guideline. J Wound Care 2004; 13:<br />
7, 267–273.<br />
20. Greenhalgh, T., Robert, G., Bate, D. et al. How <strong>to</strong> Spread<br />
Good Ideas: A systematic review of the literature on diffusion,<br />
dissemination and sustainability of innovations in<br />
health care service delivery and organisation. Report for the<br />
National Co-ordination Centre for the NHS Service Delivery<br />
and Organisation R&D, 2004.<br />
21. Rogers, E.M. Diffusion of innovations. Free Press, 2003.<br />
22. Conroy, M. and Shannon, W. Clinical guidelines:<br />
their implementation in general practice.<br />
Br J Gen Pract 1995; 45: 396, 371–375.<br />
23. Grol, R. Successes and failures in the implementation of<br />
evidence-based guidelines for clinical practice. Med Care 2001;<br />
39: 8 (Suppl 2), 46–54.<br />
24. Parahoo, K. Barriers <strong>to</strong>, and facilita<strong>to</strong>rs of, research utilization<br />
among nurses in Northern Ireland. J Adv Nurs 2000; 31;<br />
1, 89–98.<br />
25. Meijers, J.M.M., Janssen, M.A.P., Cummings, G., Wallin, L. et<br />
al. Assessing the relationships between contextual fac<strong>to</strong>rs and<br />
research utilization in nursing: systematic literature review. J<br />
Adv Nurs 2006; 55: 5, 622–635.<br />
26. Kajermo, K., Nordstrom, G., Krusebrant, A. et al. Barriers<br />
<strong>to</strong> and facilita<strong>to</strong>rs of research utilization, as perceived by a<br />
group of registered nurses in Sweden. J Adv Nurs 1998; 27: 4,<br />
798–807.<br />
This recent publication from the <strong>EPUAP</strong> Nutrition and Pressure Ulcers Working Group<br />
is reprinted with thanks <strong>to</strong> the Journal of Wound Care.<br />
Volume 8, Number 1, <strong>2007</strong> 21
22<br />
epuap<br />
Future Meetings<br />
AUGUST / SEPTEMBER <strong>2007</strong><br />
<strong>30</strong> – 1 10th European Pressure Ulcer Advisory Panel<br />
Open Meeting<br />
Pressure Ulcers:<br />
putting knowledge in<strong>to</strong> practice<br />
Academic Centre<br />
John Radcliffe Hospital, <strong>Oxford</strong>, UK<br />
Contact: <strong>EPUAP</strong> Business Office<br />
14 As<strong>to</strong>n Street<br />
<strong>Oxford</strong>, OX4 1EP, UK<br />
Tel: +44 (0)1865 791725<br />
Fax: +44 (0)1865 791725<br />
E-mail: oxfordwound@aol.com<br />
Website: www.epuap.org<br />
SEPTEMBER <strong>2007</strong><br />
26 – 28 17th Annual Meeting of the European<br />
Tissue Repair Society (ETRS)<br />
Measurements in Wound Healing – the conduit<br />
between the labora<strong>to</strong>ry and the clinic<br />
Botley Park Country Club<br />
Southamp<strong>to</strong>n, UK<br />
www.etrs<strong>2007</strong>so<strong>to</strong>n.com<br />
For further information contact:<br />
The ETRS Business Office<br />
14 As<strong>to</strong>n Street, <strong>Oxford</strong>, OX4 4EF, UK<br />
Tel: +44 (0)1865 791725<br />
Fax: +44 (0)1865 791725<br />
E-mail: oxfordwound@aol.com<br />
ETRS Website: www.etrs.org<br />
E-mail for Raj Mani: rm1@so<strong>to</strong>n,ac.uk<br />
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<br />
JUNE 2008<br />
4 – 8 Third Congress of World Union of Wound<br />
Healing Societies<br />
Toron<strong>to</strong>, Canada<br />
Abstract submissions <strong>to</strong>:<br />
www.worldunion2008.com<br />
Abstract submissions by 15 <strong>September</strong> <strong>2007</strong><br />
Notification by 15 December <strong>2007</strong><br />
Confirm your attendance by 15 January 2008<br />
SEPTEMBER 2008<br />
3 – 6 11th European Pressure Ulcer Advisory Panel<br />
Open Meeting<br />
Site Oud Sint-Jan<br />
Bruges, Belgium<br />
For further information contact:<br />
The <strong>EPUAP</strong> Business Office<br />
14 As<strong>to</strong>n Street, <strong>Oxford</strong>, OX4 4EF, UK<br />
Tel: +44 (0)1865 791725<br />
Fax: +44 (0)1865 791725<br />
E-mail: oxfordwound@aol.com<br />
Website: www.epuap.org<br />
SEPTEMBER 2008<br />
24 – 26 18th Annual Meeting of the European<br />
Tissue Repair Society (ETRS)<br />
Malta<br />
For further information contact:<br />
The ETRS Business Office<br />
14 As<strong>to</strong>n Street, <strong>Oxford</strong>, OX4 4EF, UK<br />
Tel: +44 (0)1865 791725<br />
Fax: +44 (0)1865 791725<br />
E-mail: oxfordwound@aol.com<br />
Volume 8, Number 1, <strong>2007</strong>