Clinical Practice Guidelines for Pressure Ulcer/ Injury Prevention and Treatment

September - October 2022

Clinical Practice Guidelines for Pressure Ulcer/ Injury Prevention and Treatment: Opportunities and Challenges Editorial Summary The cost associated with pressure ulceration are escalating, both in personal cost to quality of life and the financial burden of costs that need to be met by each healthcare system. The cost associated with the management of injury due to pressure ulcers are considered to be very significant in many countries. Education and training remain an area of focus to reduce the incidence of this condition. This article explores the clinical practice guidelines for pressure ulcer/ injury prevention.

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vidence-based practice is a fundamental approach to healthcare that helps patients to receive high quality, efficient, safe, and individualized care.

Evidence-based medicine (or healthcare) can be defined as “…the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”.1 Clinical Practice Guidelines (CPGs) are particularly useful tools to translate this evidence into practice and to support these individual patient focused decisions.

Prof Jan Kottner Professor of Nursing Science, Charité - Berlin University of Medicine Berlin, Germany

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One of the first CPGs on the prevention of pressure ulcers/ injuries was published by the Agency for Health Care Policy and Research in the United States 30 years ago.2 It contained 25 recommendations including pressure ulcer/ injury risk assessment, regular repositioning, use of special support surfaces, and educational programs. Since then, numerous CPGs have been published and are regularly updated.

For more than 10 years the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA), have worked successfully together to develop, update, disseminate and implement international CPGs for the prevention and treatment of pressure ulcers/ injuries. These three organisations published their third and latest international edition in 2019.3 The expansion of CPGs indicates an increased interest in and the use of evidence-based pressure ulcer/ injury management on a national and international level. The international CPG alone was cited more than 2000 times in international literature, indicating wide

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However, successful dissemination.4 dissemination is different from implementation in practice, and evidence indicates that pressure ulcer/ injury prevention and treatment must be improved. Although it is widely accepted that not all pressure ulcers/ injuries are preventable, a substantial proportion are. Clinicians are in charge, but much of the responsibility lies within structures and processes of organizations and their management. This also includes managing information overload and balancing conflicting recommendations, and the requirements of numerous policies at the same time.5 Developing national and international CPGs in parallel may also result in unnecessary duplication of efforts, which is problematic in times of limited resources and funding. Low quality pressure ulcer/ injury guidelines6 are unlikely to improve care.

Finally, in the field of pressure ulcer/ injury prevention and treatment are many areas of missing evidence. There is an urgent need for well-designed trials in the field.7 This is a particular challenge for guideline developers because guideline recommendations must be based on evidence, while practitioners expect guidance irrespective of the availability of evidence.8 Interestingly, basic pressure ulcer/ injury preventive approaches such as systematic skin inspection, using support surfaces, or raising heels, have not changed significantly over decades2, and are cornerstones of state-ofthe-art pressure management today.

Conclusion Despite these well-known challenges, there are a number of opportunities. Strong and

Clinical Practice Guidelines for Pressure Ulcer/ Injury Prevention and Treatment: Opportunities and Challenges

“Worldwide, there is an increasing acceptance of the standards for trustworthy guidelines and up-to-date guideline development methods.”

established relations between the EPUAP, NPIAP and PPPIA are an excellent basis for further efficient international collaboration.

Worldwide, there is an increasing acceptance of the standards for trustworthy guidelines and up-to-date guideline development methods, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. There is also an increasing number of low-risk of bias confirmatory trials and high quality systematic reviews and metaanalysis, including the latest series of Cochrane support surface reviews.9 This strengthens a growing body of evidence in pressure ulcer/ injury prevention and treatment to be employed in high quality CPGs in the future.

References 1. Sackett DL, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312(7023):71–2.https://doi.org/10.1136/bmj.312.7023.71 2. U.S. Department of Health and Human Services, Agency for Health Care Policy. Pressure Ulcers in Adults: Prediction and Prevention – Clinical Practice Guideline Number 3. Rockville, Maryland, United States of America, 1992.

3. Kottner J et al. A closer look at the 2019 International Guideline on the prevention and treatment of pressure ulcers/injuries. J Tissue Viability. 2020;29(4):225-226.https://doi. org/10.1016/j.jtv.2020.09.003 4. Kottner J, El Genedy-Kalyoncu M. The uptake of the international pressure ulcer/injury prevention and treatment guidelines in the scientific literature: A systematic analysis of two major citation databases. J Tissue Viability. 2022 Aug 7 (Online ahead of print).https://doi. org/10.1016/j.jtv.2022.07.011 5. Carthey J et al. Breaking the rules: understanding non-compliance with policies and guidelines. BMJ 2011;343:d5283.https://doi.org/10.1136/bmj.d5283 6. Gillespie BM et al. The quality and clinical applicability of recommendations in pressure injury guidelines: A systematic review of clinical practice guidelines. Int J Nurs Stud.

2021;115:103857.https://doi.org/10.1016/j.ijnurstu.2020.103857 7. Walker RM et al. Prevention and treatment of pressure injuries: A meta-synthesis of Cochrane Reviews. J Tissue Viability. 2020;29(4):227-243.

8. Haesler E, Kottner J, Cuddigan J; 2014 International Guideline Development Group.

The 2014 International Pressure Ulcer Guideline: methods and development. J AdvNurs.

2017;73(6):1515-1530.https://doi.org/10.1111/jan.13241 9. Shi C et al. Beds, overlays and mattresses for preventing and treating pressure ulcers: an overview of Cochrane Reviews and network meta-analysis. Cochrane Database Syst Rev. 2021;8(8):CD013761.

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