Pressure ulcers: a bid to standardise care

Every year millions of people across the globe experience pressure ulcers, representing a global challenge to healthcare providers. Although pressure ulcers are largely preventable, they affect around 20% of people in hospital across Europe and can affect anyone who is immobile or unable to feel the pain and discomfort that results from sitting or lying too long in one position.1 The European Pressure Ulcer Advisory Panel (EPUAP) was established over 15 years ago to bring together clinicians and researchers with an interest in pressure ulcer prevention and management. Professor Michael Clark, president of EPUAP, explained that the organisation was set up with the goal of raising the profile of pressure ulcers and is constantly looking to identify partnership opportunities and to identify synergies in research, relating to pressure ulcers. “One important piece of work we have undertaken, in association with the American National Pressure Ulcer Advisory Panel (NPUAP), has been the creation of a set of guidelines for health professionals,” he said. “Our eventual aim is that these guidelines will globally standardise the care received by people at risk of, or with pressure ulcers.” Prof. Clark explained the difficulty in evaluating the extent of people suffering from pressure ulcers. He said: “It is very difficult to gain accurate figures for the number of people that suffer from pressure ulcers as there is very limited comparable data. Everyone that has counted pressure ulcers over the years has done so in a slightly different way, so it is impossible to compare or to say whether incidences of pressure ulcers are increasing or decreasing. My own belief, however, is that numbers are currently static or increasing. “Any figures that do exist also need to be considered in conjunction with changes in the patient population over the years – in general, the hospital population today is more acutely ill than it has been in the past. Early surveys which I was involved with in the 1980s, for example, included hospitalised people who would not be inpatients today – their care is now much more likely be managed within the primary care system.” One piece of work which Prof. Clark does believe is worth a closer look comes from Peter and Kath Vowden, the founders and leaders of Bradford’s Wound Healing Unit, who, several years ago, counted all the instances of pressure ulcers in the Bradford population – both acute and non acute. “They found that there were more pressure ulcers in the community setting than in the acute sector, and I see no reason why these findings should not be typical across the country,” he said. Vowdens’ 2009 audit2 across acute and community services in Bradford reported that the prevalence of pressure ulceration within the population receiving healthcare was 0.74 people with a pressure ulcer per 1,000 population. Of the people with pressure ulcers few (11%) were located in hospital, suggesting that current pressure ulcer epidemiology and costs may be understated, given their reliance on hospital-based surveys of pressure ulcers.

Recognising the issue P

rof. Clark believes that, in the UK, there has now been recognition of the issue and that the right steps are starting to be taken. “The challenge has been that the 2005 National Institute for Health and Clinical Excellence (NICE) guidelines require mandatory reporting for categories 2, 3 and 4 pressure ulcers, which has resulted in a great deal of paperwork. However, it has also generated a greater awareness of the scale of the pressure ulcer problem and has resulted in some laudible attempts around the country to reduce the instances of people getting pressure ulcers. “There has also been a great deal of technology introduced in a bid to prevent pressure ulcers over the years,” said Prof. Clark. “This can probably best be seen in the sophisticated beds and cushions that have been brought to market, which have gone a long way to help control the problem in addition to a greater attempt by carers to encourage those at risk to move, and not to remain static or immobile for long periods.” Prof. Clark also believes that telemedicine will have an increasingly important role to play in the management of pressure ulcers. He said: “This technology is being used to good advantage, particularly in remote regions. Telemedicine can offer a way to bring professional expertise to communities which may be spread across a wide geographical area. I believe that telemedicine services will become much more widely adopted in the future.” The result of the collaborative effort between the EPUAP and NPUAP, mentioned earlier in this article, was a set of guidelines, published in 2009,3 which summarise evidence-based guidelines on pressure ulcer prevention and treatment. Although this is due to be updated in 2014, it still offers a very useful guide for healthcare professionals involved in the care of patients and vulnerable people who are at risk of developing pressure ulcers, whether they are in a hospital, long-term care, assisted living at home or any other setting and regardless of their diagnosis or healthcare needs. It could also offer help to guide patients and carers on the range of prevention strategies available. As part of the guideline development process, NPUAP and EPUAP developed a common international definition and classification system for pressure ulcers. It agreed on four levels of injury. These include: