Janet Cuddigan

National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System

The National Pressure Ulcer Advisory Panel has updated the definition of a pressure ulcer and the stages of pressure ulcers based on current research and expert opinion solicited from hundreds of clinicians, educators, and researchers across the country. The amount of anatomical tissue loss described with each stage has not changed. New definitions were drafted to achieve accuracy, clarity, succinctness, clinical utility, and discrimination between and among the definitions of other pressure ulcer stages and other types of wounds. Deep tissue injury was also added as a distinct pressure ulcer in this updated system.

Medical device related pressure ulcers in hospitalized patients

Most pressure ulcers occur over bony prominences such as heels and the sacrum. However, the National Pressure Ulcer Advisory Panel recognises that pressure ulcers can also occur on any tissue under pressure and thereby can develop beneath medical devices. This article reports on results from a secondary analysis of existing data collected by The Nebraska Medical Center on pressure ulcer quality improvement initiatives and outcomes. The purpose of this study was to quantify the extent of the problem and identify risk factors for medical device related (MDR) pressure ulcer development in hospitalised patients. A subset of data collected during eight quarterly pressure ulcer incidence and prevalence studies (N = 2178) was created and analysed. The overall rate of hospital‐acquired pressure ulcers was 5·4% (113 of 2079). The proportion of patients with hospital‐acquired ulcers related to medical devices was 34·5% (39 of 113). Findings indicate that if a patient had a medical device, they were 2·4 times more likely to develop a pressure ulcer of any kind. Numerous risk factors for pressure ulcer development were identified; however, none differentiated between those with MDR and traditional pressure ulcers.

Debridement: controlling the necrotic/cellular burden.

PURPOSE:To provide physicians and nurses with an overview of the options for debriding a chronic wound to improve wound healing. TARGET AUDIENCE:This continuing education activity is intended for physicians and nurses with an interest in learning about methods for debriding chronic wounds to promote wound healing. LEARNING OBJECTIVES:After reading the article and taking the test, the participant will be able to:1. Describe the 4 types of debridement most commonly used in clinical practice.2. Describe when to debride a wound and how to determine which method to use.

A new pressure ulcer conceptual framework.

Aim This paper discusses the critical determinants of pressure ulcer development and proposes a new pressure ulcer conceptual framework. Background Recent work to develop and validate a new evidence-based pressure ulcer risk assessment framework was undertaken. This formed part of a Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research. The foundation for the risk assessment component incorporated a systematic review and a consensus study that highlighted the need to propose a new conceptual framework. Design Discussion Paper. Data Sources The new conceptual framework links evidence from biomechanical, physiological and epidemiological evidence, through use of data from a systematic review (search conducted March 2010), a consensus study (conducted December 2010–2011) and an international expert group meeting (conducted December 2011). Implications for Nursing A new pressure ulcer conceptual framework incorporating key physiological and biomechanical components and their impact on internal strains, stresses and damage thresholds is proposed. Direct and key indirect causal factors suggested in a theoretical causal pathway are mapped to the physiological and biomechanical components of the framework. The new proposed conceptual framework provides the basis for understanding the critical determinants of pressure ulcer development and has the potential to influence risk assessment guidance and practice. It could also be used to underpin future research to explore the role of individual risk factors conceptually and operationally. Conclusion By integrating existing knowledge from epidemiological, physiological and biomechanical evidence, a theoretical causal pathway and new conceptual framework are proposed with potential implications for practice and research.

Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus

Pressure ulcer prevalence and incidence data are increasingly being used as indicators of quality of care and the efficacy of pressure ulcer prevention protocols. In some health care systems, the occurrence of pressure ulcers is also being linked to reimbursement. The wider use of these epidemiological analyses necessitates that all those involved in pressure ulcer care and prevention have a clear understanding of the definitions and implications of prevalence and incidence rates. In addition, an appreciation of the potential difficulties in conducting prevalence and incidence studies and the possible explanations for differences between studies are important. An international group of experts has worked to produce a consensus document that aims to delineate and discuss the important issues involved, and to provide guidance on approaches to conducting and interpreting pressure ulcer prevalence and incidence studies. The groups main findings are summarised in this paper.

Conquer chronic wounds with wound bed preparation.

Acute wound healing follows an orderly sequence of biologic events requiring little intervention from the primary care provider. Chronic wounds fail to follow this progression and require wound bed preparation for healing. To manage chronic wounds, clinicians must understand and apply the biology of chronic wound healing. This article provides an evidence-based approach to guide clinicians in prescribing interventions to minimize, eliminate, or balance factors known to impair wound healing.

The PUSH tool: a survey to determine its perceived usefulness.

OBJECTIVE: To determine the perceived usefulness of the Pressure Ulcer Scale for Healing (PUSH). PARTICIPANTS: A convenience sample identified through the National Pressure Ulcer Advisory Panel Web site as users or registered users of the PUSH tool. MAIN OUTCOME MEASURE: A survey instrument was developed to capture experience, ease of use, and perceived utility and weakness of the PUSH tool. RESULTS: Of 103 respondents, most (79) agreed or strongly agreed that PUSH required an appropriate amount of time to complete. It was also found to be reliable and easy to use and teach to others. Respondents were not as positive regarding usefulness, with 75% indicating that increased PUSH scores prompt patient and treatment reassessment. Respondents agreed or strongly agreed that improvement is possible in the size subscale (59%), the tissue type subscale (49%), and the exudate amount subscale (32%). Most commonly indicated for improvement was the addition of wound depth information. CONCLUSION: Respondents generally found PUSH easy to use and helpful in pressure ulcer management. Specific areas of improvement were also identified.

Developing a pressure ulcer risk factor minimum data set and risk assessment framework

Aim To agree a draft pressure ulcer risk factor Minimum Data Set to underpin the development of a new evidenced-based Risk Assessment Framework. Background A recent systematic review identified the need for a pressure ulcer risk factor Minimum Data Set and development and validation of an evidenced-based pressure ulcer Risk Assessment Framework. This was undertaken through the Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research and incorporates five phases. This article reports phase two, a consensus study. Design Consensus study. Method A modified nominal group technique based on the Research and Development/University of California at Los Angeles appropriateness method. This incorporated an expert group, review of the evidence and the views of a Patient and Public Involvement service user group. Data were collected December 2010–December 2011. Findings The risk factors and assessment items of the Minimum Data Set (including immobility, pressure ulcer and skin status, perfusion, diabetes, skin moisture, sensory perception and nutrition) were agreed. In addition, a draft Risk Assessment Framework incorporating all Minimum Data Set items was developed, comprising a two stage assessment process (screening and detailed full assessment) and decision pathways. Conclusion The draft Risk Assessment Framework will undergo further design and pre-testing with clinical nurses to assess and improve its usability. It will then be evaluated in clinical practice to assess its validity and reliability. The Minimum Data Set could be used in future for large scale risk factor studies informing refinement of the Risk Assessment Framework.

Skip the knife: debriding wounds without surgery.

You can remove dead tissue from a wound in many ways. Find out your options—and how to choose which one to use.

Pressure Ulcer Guidelines: ''Minding the Gaps'' When Developing New Guidelines

Since the early 1990s, clinical practice guidelines have become an increasingly integral part of clinical practice. Health care professionals possess an intrinsic desire to provide the best care possible. As such, guidelines influence patients, providers, and payers. Practice guidelines based on the best scientific evidence available have the potential to enhance consistency of care, reduce morbidity and mortality, and improve quality of life, at least for some conditions. Much of the seminal work in guideline development methodology occurred in the 1990s. Since that time, a number of pressure ulcer guidelines have been developed by the industry, governmental agencies, and professional organizations. The methodological rigor involved in developing these guidelines varies, as does the currency of evidence supporting guideline recommendations. An analysis of existing pressure ulcer guidelines was undertaken by a task force of the National Pressure Ulcer Advisory Panel (NPUAP) in preparation for its collaborative venture with the European Pressure Ulcer Advisory Panel (EPUAP) to develop evidence-based international guidelines on pressure ulcer prevention and treatment. The results of this gap analysis are described below.