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The NPUAP/EPUAP Unveils
The NEW International Guidelines for Pressure Ulcer Prevention and Treatment
By Jeri Ann Lundgren, RN, CWS, CWCN
March 25, 2009
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I attended the National Pressure Ulcer Advisory Panel’s (NPUAP) 11th National biennial conference that was held on February 27-28, 2009. The objective of the conference was to introduce the newly revised evidence-based International Guidelines for the Prevention and Treatment of Pressure Ulcers: Public Policy and Clinical Practice. The guidelines were developed by the NPUAP in conjunction with the European Pressure Ulcer Advisory Panel (EPUAP).
At the conference, the NPUAP and EPUAP unveiled the draft version of the Prevention Clinical Practice Guideline and the final version of the Treatment Clinical Practice Guideline. The NPUAP/EPUAP’s plan is to roll out both final versions in May 2009. Currently, in the Prevention Clinical Practice Guideline the etiology of pressure ulcers, nutrition, support surfaces and repositioning sections are complete. The skin care section, risk assessment and the operating room statements are in the process of being finalized.
The NPUAP/EPUAP emphasized that these guidelines were developed after extensive research of the literature to ensure they promote evidenced-based practices. Overall, many of the current standard practices for the prevention and treatment of pressure ulcers remain the same, however, there were several new areas of interest worth noting. The follow is a brief overview of those areas.
Overall highlights or areas of interest of the DRAFT version of the Prevention Clinical Guidelines (EPAUP-NPUAP, 2009) are:
- Repositioning frequency is influenced by the individual and the support surface in use. It sites two randomized controlled trails in nursing homes (Defloor et al., 2005; Venderwee et al., 2007) showing that patients on a visco-elastic foam mattresses could be turned every four hours and did not result in an increase in pressure ulcer formation. There was no difference between turning a patient every two hours as opposed to four. Please note that they stress the importance of an appropriate support surface. Overall, you should assess the individual’s skin and general level of comfort. If the individual is not responding to the repositioning regime, reconsider the frequency and method of repositioning.
- Having a pressure redistribution support surface, however studies are still deficient on what type of surface to use when. They note that there is no evidence that one high specification foam mattress is superior over an alternative high specification foam mattress. In addition, overlay or mattress-replacement alternating pressure active support surfaces have a similar efficacy in terms of pressure ulcer incidence.
- Active support surfaces are encouraged in the care of individuals who are unable to be repositioned due to their underlying medical or physical condition.
- Use a pressure-redistribution seat cushion for individuals sitting in a chair whose mobility is reduced. Defloor & Grypdonck (2000) found that air cushions produced the lowest interface pressure after one hour of immobilization. Reposition seated individuals more frequently than in a lying position.
- Use of small-cell alternating pressure air mattress or overlays are not recommended.
The following are some overall highlights or areas of interest of the Treatment Clinical Practice Guideline (EPUAP-NPUAP, 2009):
- Endorses the new NPUAP staging system that includes suspected deep tissue injury and unstageable for the use in the US. Reinforces to use the staging system for pressure ulcers only.
- Do not stage/classify pressure ulcers on mucous membranes.
- Observe the pressure ulcer for changes with each dressing change that may indicate the need for a modification in treatment.
- Assess the pressure ulcer initially and at least weekly, documenting findings. Revaluate the pressure ulcer care and the individual if the pressure ulcer does not show progress toward healing within 2 weeks, when the goal is healing.
- To measure length and width it’s recommended that the longest length head-to-toe, and longest width side-to-side, perpendicular (at 90 degrees) to the length.
- Reinforces that care should be taken to avoid causing injury when probing the depth of a wound bed or the extent of undermining or tunneling.
- Emphasizes to evaluate the progress of the wound and recommends utilizing a validated tool such as the Pressure Ulcer Scale for Healing Tool (PUSH) or the Bates-Jensen Wound Assessment Tool (BWAT).
- The Pain Assessment and Management section is new to the guidelines and recommends utilizing a validated pain scale to assess for pain.
- Recommends to replace the existing mattress with an “upgrade” support surface if the individual:
- Cannot be turned off of the ulcer
- Has pressure ulcers on two or more turning surfaces, limiting turning options
- Fails to heal or demonstrates ulcer deterioration despite appropriate comprehensive care
- Is at high-risk for additional ulcers;
- “Bottoms out” on the existing support surface.
- Continue to turn/reposition the individual regardless of the support surface. Turning and repositioning should be based on the characteristics of the support surface and the individual’s response.
- Do not turn the individual onto a body surface that is damaged or still reddened from a previous episode of pressure loading.
- Continues to recommend that heels be floated regardless of the support surface.
- The guideline gives guidance on the use of support surfaces by the stage of the pressure ulcer.
- The guidelines also addresses spinal cord injured individuals and bariatric individuals.
- The guideline has a section on wound bed preparation and biofilms in pressure ulcers.
- It details different types of dressings and when to utilize them. Areas of interest include the recommendation of medical-prepared honey dressings, cadexomer iodine dressings and silicone dressings (see guidelines for specifics). It also concluded that there is no evidence to support or refute the use of collagen dressings.
- The guideline supports the use of adjunctive modalities such as negative pressure wound therapy, electromagnetic agents (i.e., electrical stimulation or electromagnetic fields), ultraviolet-based phototherapy, acoustic ultrasound, low frequency ultrasound and hydrotherapy. Please refer to the guideline for indications of use.
- The panel found insufficient peer reviewed published evidence to recommend the use of hyperbaric oxygen therapy, topical oxygen therapy, biological dressings and growth factors at this time.
- Consider systemic antibiotics for individuals with clinical evidence of infection verses topically applied agents.
- Consider the use of silver or manuka honey for ulcers infected with multiple organisms (see guidelines for indications of use).
- The guidelines have a section on nutrition. It notes no research has demonstrated an effect of zinc supplementation on pressure ulcer healing. If there are clinical signs of a zinc deficiency, then zinc should be supplemented at no more then 40mg per day and for only 2-3 weeks. High doses of zinc can affect copper production and lead to anemia.
- The guidelines continue to provide guidance for debridement options. It continues to support the practice to not debride stable, dry, hard uninfected eschar on heels.
- The guidelines state that wounds debrided with papain-urea verses collagenase showed a reduction of the devitalized tissue and the amount of granulation was greater for those receiving papain-urea, however the healing rates were the same. I found this interesting as the papain-urea based products are no longer available in the United States.
Once the guidelines are finalized and officially rolled out, hopefully in May, I will outline their contents for use and highlight those areas of change or of stressed interest. You can also receive more information at www.npuap.org.
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Jeri Ann Lundgren
RN, CWS, CWCN, Director of Wound and Continence
Pathway Health Services, Inc.
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References
1. NPUAP-EPUAP Prevention Clinical Practice Guideline – Draft, (2009). NPUAP, Washington, DC.
NPUAP-EPUAP Treatment Clinical Practice Guideline, (2009). NPUAP, Washington, DC
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