EPUAP Review 5/2 RIP - European Pressure Ulcer Advisory Panel

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64 epuap News EUROPEAN PRESSURE ULCER ADVISORY PANEL from the Netherlands A NEW EVIDENCE-BASED PRACTICE GUIDELINE ON PRESSURE ULCER PREVENTION AND MANAGEMENT IN 2002 new guidelines on pressure ulcer prevention and management were released in the Netherlands. These evidence-based guidelines built upon the literature review conducted during the development of the United States Agency for Health Care Policy and Research (AHCPR) pressure ulcer guidelines issued in the early 1990s. As such the new Dutch guidelines offer new insights into the management of pressure ulcer prevention and management given their foundation upon new research studies and an awareness of literature published in languages other than English. The European Pressure Ulcer Advisory Panel would like to acknowledge CBO, Dutch Institute for Quality in Health Care (Kwaliteitsinstituut voor de Gezondheidszorg) CBO, PO Box 20064, 3502 LB Utrecht, the Netherlands for their kind permission to present an edited version of these new guidelines within the EPUAP Review. In this issue we cover the methodological issues related to the development of the new guidelines. Why was the new guideline developed? Recent years have seen greater focus upon the problem of pressure ulcers in the Netherlands at a political and economic level. For example political initiatives have included a report on pressure ulceration to the Secretary of Health and the Health Council. 1 This report was followed by a written reply to the report’s conclusions submitted by the Health Minister to the Dutch House of Commons. In parallel with these political issues there has been a growth in the availability of national epidemiological data 2 along with a stronger awareness of the economic impact of pressure ulcers. 3–18 In the Netherlands approximately 13% of all patients in teaching hospitals have pressure ulcers, the prevalence then rises in home care (17%), general hospitals (23%) and to about 30% in nursing homes 2 while the annual spend on pressure ulcer care is about 600 million Euros with a total population of 16 million. 16–17 These developments have not occurred in a vacuum; Dutch demography has changed over the past ten years with greater numbers of elderly people, while the scientific basis for pressure ulcer prevention and management has also advanced. Taken together there was perceived to be a need to revise earlier consensus texts developed in the Netherlands during the mid 1980s, and to update the US AHCPR guidelines that date from 1992. This update of the guideline was commissioned by the CBO (Dutch quality organization for health care) with all relevant interest groups represented in the working group established to direct the guideline update. What is the purpose of the new guideline? Essentially the guideline must be appropriate for use in daily medical, nursing and paramedical practice giving sound recommendations and practical advice. All patient groups and care settings are to be covered by the guideline’s recommendations – both those with an elevated risk of developing pressure ulcers and those with established pressure ulcers. One important consideration was that the guideline should seek to facilitate the co-ordination of care both within and between institutions. Definition of pressure ulceration used throughout the guideline In this guideline, ‘pressure ulcer’ should be considered to refer to any tissue damage caused by mechanical loading (pressure, shear and friction alone or in combination). Developing the guideline In 2000 a Working Group was formed to lead the development of the new guideline (See Appendix 1 for composition of the group) formed of society representatives and active researchers. In particular this latter group comprised of post-doctoral fellows drawn from the Netherlands and Belgium and collectively known as the European Pressure Ulcer Research Interest Group (EPURIG). The working group first met on 11 May 2000 and separated the guideline development into two phases – development of the recommendations, and commentary from appropriate stake-holders. The EPURIG members were tasked to identify the relevant literature, review it and form draft recommendations. The primary role of the scientific society representatives was to provide comment upon these draft recommendations. Studies to be included in the review were to have been published since the AHCPR pressure ulcer prevention guideline issued in 1992. Initially it was anticipated that the latest date of publication to be covered by the review was Summer 2000 but this process extended to include new publications for a further twelve months (Summer 2001). Throughout the review process close co-operation was sought with relevant Dutch steering committees and European and North American pressure ulcer organizations (EPUAP and NPUAP). During the initial meeting, the chair of the working group proposed the guideline be divided into five sections covering: Volume 5, Number 2, 2003
• risk assessment • prevention • pressure ulcer assessment • treatment and complications • organizational issues and specific care-setting situations This structure was subsequently adopted during the development of the guideline. Search strategy Relevant literature was identified through a combination of searches of electronic data bases and hand-searching of reference lists and other available evidence-based guidelines. The electronic search covered four key data-bases – the Cochrane Library, CINAHL, EMBASE and MEDLINE. Each data-base was searched using the following key-words; pressure ulcer, pressure ulcers, pressure sore, pressure sores and decubitus. Studies retrieved with the last key-word were rejected from the review if they referred to the decubitus position. The search was refined using a variety of study designs as additional key-words; randomized clinical trials, cohort studies, retrospective studies, prospective studies, case control studies and case studies. Eligible studies had to be published between 1992 until July 2001. Members of the working group also submitted publications out with those included on the electronic data-bases while further publications were identified from reference lists and other evidence-based guidelines. In total over 400 publications were considered in this review. Each publication was then reviewed and graded using the following criteria: Where publications reported the use of interventions for either pressure ulcer prevention or treatment; A1 systematic reviews that included some studies of A2 level, with consistent results across the individual studies, A2 appropriately designed and conducted randomized controlled trials, B low quality randomized controlled trials or nonrandomized comparative cohort studies or patient-controlled studies, C non-comparative studies, D expert opinion. And in cases where publications reported upon diagnostic procedures for example risk assessment; A1 several prospective studies (including some at A2 level) with minimal loss to follow-up within specified patient groups that reported clinical outcomes achieved after implementing a specified diagnostic procedure, A2 studies comparing the results from a diagnostic procedure against previously agreed ‘gold standard’ reference procedure, with appropriate statistical analyses, B studies comparing the results from a diagnostic procedure against a reference procedure, may not have appropriate statistical analyses, C non comparative studies, D expert opinion. Throughout the process of reviewing and grading studies the working group would like to thank the Belgian Pressure Ulcer Guideline Committee for the assistance they provided. Having graded the sources of evidence, the recommendations in the new guideline were also weighted as follows: 1 Recommendation based on one systematic review (A1), or at least two independent studies on level A1 or A2, 2 Based on at least two independently executed studies on level B, 3 Based on one study at level A2 or B, or studies on level C, 4 Based on expert opinion. Each recommendation is supported by its scientific basis, representing a summary of the studies that underpin the recommendation. The key studies and weighting (level 1 to 4) are illustrated for each of the given recommendations. Where recommendations were in part based on information outside the scientific studies (for example patient preferences, cost, equitable access throughout all care settings) the non-scientific aspects are listed as ‘other considerations’. Adopting this procedure for presenting recommendations was considered to increase the transparency and implementation of the guideline while also facilitating discussion within the working group! Legal implications of the guideline Clinical guidelines are not laws, but rather offer insights based on the available evidence that would assist caregivers to deliver ‘good’ care. These insights are based on the average or typical patient and when faced with a heterogeneous patient population it is likely that caregivers may exercise their professional judgement and decide to deviate from the guideline. Such deviations should be noted in the patients medical record. Updating the guideline NEWS FROM THE NETHERLANDS The CBO will update the guideline no later than 2007 although earlier review may be required dependent upon advancves in scientific knowledge and clinical practices. References 1. Gezondheidsraad: Decubitus.Den Haag: Gezondheidsraad, 1999. Publicatie nr 1999/23, blz.13. 2. Bours, G. and Halfens R. ‘Decubitus komt nog veel te veel voor.’ TVZ 1999; (20): 608–611. 3. Hey, S. Pressure sores care and cure (letter). Lancet 1996; 348: 1511.D 4. Haalboom JRE. Pressure Ulcers. Lancet 1998; 352: 581. 5. Hu TW, Stotts NA, Fogarty TE and Bergstrom B. Cost analysis for guideline implementation in prevention and early treatment of pressure ulcers. Decubitus 1993; 6: 42–46. 6. Frantz R, Bergquist S and Specht J. The cost of treating pressure ulcers following implementation of a research-based skin care protocol in a long term Volume 5, Number 2, 2003 65
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