Prevention and Treatment of Pressure Ulcers : Clinical Practice Guideline

This guideline is the result of a collaborative effort among the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). A comprehensive literature review was conducted on pressure ulcer prevention and treatment. A rigorous scientific methodology was used to appraise available research and make evidence-based recommendations for the prevention and treatment of pressure ulcers. Draft guidelines were made available to 986 invited stakeholder individuals and organizations/societies and stakeholder feedback was considered by the guideline developers. In the final development process, the guideline development team used a consensus voting process (GRADE) to assign strengths of recommendation. Strength of recommendations indicate the extent to which one can be confident that adherence to a recommendation will do more good than harm, and are indented to assist the health professional to prioritize interventions. The guideline includes 575 explicit recommendations and/or research summaries for the following pressure ulcer topics: etiology; prevalence and incidence; risk assessment; skin and tissue assessment; preventive skin care; prophylactic dressings; microclimate control; fabrics and textiles; nutrition; repositioning and early mobilization; support surfaces; medical device related pressure ulcers; pressure ulcer classification; wound assessment; monitoring of healing; pain assessment and treatment; cleansing; debridement; wound dressings (including growth factors and biological wound dressings); assessment and treatment of infection and biofilms; biophysical agents (e.g. electrical stimulation, negative pressure wound therapy, electromagnetic field treatment); and surgery. Additional sections address the specific needs of special populations including bariatric individuals, critically ill individuals, older adults, pediatric individuals, individuals in palliative care and individuals in the operating room setting. The guideline includes sections to assist in implementing the guideline within organizations, including quality improvement strategies, quality indicators, health professional education and recommendations to assist patient consumers. The guideline also includes the NPUAP/EPUAP International Pressure Ulcer Classification system, complete with full Category/Stage descriptions and illustrative photography. CLINICAL PRACTICE GUIDELINE INTRODUCTION 3 Strengths of Evidence and Strengths of Recommendations Full explanation of the methodology is available in Appendix 1: Guideline Methodology. Individual studies were assigned a ‘level of evidence’ based on study design and quality. The body of evidence supporting each recommendation was given a ‘strength of evidence’. A consensus voting process (GRADE) involving all the experts formally engaged in the guideline development was used to assign a ‘strength of recommendation’ that indicates the confidence the health professional can have that the recommended practice will improve patient outcomes (i.e., do more good than harm). The overall aim of the ‘strength of recommendation’ is to help health professionals to prioritize interventions. Strengths of Evidence A The recommendation is supported by direct scientific evidence from properly designed and implemented controlled trials on pressure ulcers in humans (or humans at risk for pressure ulcers), providing statistical results that consistently support the recommendation (Level 1 studies required). B The recommendation is supported by direct scientific evidence from properly designed and implemented clinical series on pressure ulcers in humans (or humans at risk for pressure ulcers) providing statistical results that consistently support the recommendation. (Level 2, 3, 4, 5 studies) C The recommendation is supported by indirect evidence (e.g., studies in healthy humans, humans with other types of chronic wounds, animal models) and/or expert opinion Strengths of Recommendation  Strong positive recommendation: definitely do it  Weak positive recommendation: probably do it  No specific recommendation  Weak negative recommendation: probably don’t do it  Strong negative recommendation: definitely don’t it