EUROPEAN PRESSURE ULCER ADVISORY PANEL

Pressure Ulcers Rapidly Heal When Treated With Comprehensive Wound Care Protocol
Harold Brem, MD; Nidhi Kapil-Pair; David Kaplan; Miriam Cadot; and *James Zoller

Mount Sinai School of Medicine, 5 East 98th Street, Box 1259, New York, NY 10029
* Medical University of South Carolina, 19 Hagwood Avenue, PO Box 250807, Charleston, SC 25087, USA

Introduction: The rate at which wounds heal is of primary importance to the clinician as a means of determining the patient’s expected healing time. Prevention of pressure ulcers is the ideal, but not always achievable in the Respiratory Care Unit (RCI) population, many of whom have already developed pressure ulcers in the acute stage of their illness. We postulate, however, that aggressive, ongoing surveillance and early intervention in the context of a comprehensive treatment paradigm will help to halt the progression of pressure ulcers and promote healing, even in the hospital bedbound population.

Chronic wounds may not heal at all if left untreated. Because of an underlying physiologic impairment, chronic wounds fail to heal in an timely manner, with consequent compromise of anatomical and functional integrity.1,2 All pressure ulcers are chronic wounds.

While observational evidence indicates that the inability to move in response to pressure correlates with the development of pressure ulcers, other factors also contribute. Among these, intriguing evidence indicates that ‘pressure’ ulcers reflect an underlying physiological impairment of vascular flow and angiogenesis. For example, Auerbach and colleagues experimentally established that angiogenic response is dependent on anatomical location.3,4 Experimentally, the angiogenic (new blood vessel growth) response is significantly less in the lower dorsum than in the upper dorsum.3–5

This might help explain the distribution of nonhealing wounds in the lower back (e.g., the sacrum), as compared to the upper back over bony prominences. Evidence demonstrates that wound healing is slowed in the lumbosacral area. In addition to an inability to move in response to pressure, chronically critically ill patients may also have impaired blood flow or impaired angiogenic responses in areas where pressure ulcers commonly develop.

While clinicians may be unable to change underlying physiology, we propose that aggressive surveillance for and early treatment of pressure ulcers can help avoid their occurrence or reduce their intensity and duration. This report describes a strategy that seeks to prevent the formation and progression of pressure ulcers in a hospitalized patient.

Methods: 63 consecutive hospitalized patients with Stage II, III, and IV pressure ulcers were analyzed over a 7-month period. These patients received a standard protocol consisting of pressure relief with alternating air therapy (Pegasus Renaissance, Arjo Pegasus Inc. USA), debridement of all nonviable tissue, a moist wound healing environment, and maximized nutrition. Of the patients who healed, 8/10 were always bedbound and 9/10 had respiratory failure.

Results: Of the 63 patients analyzed, 10 patients who had Stage II or III pressure ulcers completely healed (defined as 100% epithelialization with no drainage). The average size of these wounds at study entrance was 2.18 cm2 and the average time to healing was 4.6 weeks. The wounds healed at a rate of 0.53 cm2/week and their average albumin was 2.54 g/dl. 20 other patients with Stage II or III pressure ulcers who were enrolled in the study during the same time period with an average initial area of 15.37 cm2 healed at a rate of 1.53 cm2/week. However, these patients exited the study prior to complete healing.
Summary: Pressure ulcers can heal at a rate greater than 5mm2/week. We speculate that patients with significant comorbidities can heal their pressure ulcers with the above stated protocol. If the ulcer is failing to heal, the clinician may be advised to choose alternate methods of treatment until the healing rate of at least 5 mm2/week is achieved.

References:
1. Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol. 1994; 130: 489–493.
2. Mostow EN. Diagnosis and Classification of Chronic Wounds. Clin Dermatol. 1994; 12: 3–9.
3. Auerbach R, Auerbach W. Regional differences in the growth of normal and neoplastic cells. Science. 1982; 215: 127–34.
4. Auerbach R, Morrissey LW, Kubai L, et al. Regional differences in tumor growth: studies of the vascular system. Int J Cancer 1978; 22: 40–46.
5. Kubai L, Auerbach R. Regional differences in the growth of skin transplants. Transplantation 1980; 30: 128–131.

Wound healing in Hungary compared to European countries
Istvan Sugar (Hungarian Wound Healing Society)
Zsolt Jobai (AMDM)

Authors, on the basis on disposal data – give a review the position of wound-healing in Hungary. It can be concluded the rate of use of traditional bandages more higher – compared to modern bandages – as in West-European countries as well.

The primary places of wound-healing treatment are the hospitals in Hungary, but in other countries the outpatient-clinics and the home care are preference.

Because of modern bandages can be reached in Hungary also, the questions are:
• Why do not use the modern bandages the panel doctors?
• Is it good the financial support?
• Who knows to brush-up of knowledge-material?

Authors try to reply, try to find explanations to above questions.

The Scientific Board of Hungarian Wound Healing Society regularly keeps lectures about the most modern instruments in everywhere in Hungary.

Working together across Europe
Deborah Thompson, RGN, DipHE
Senior Nurse Tissue Viability and Practice Development Weston Area Health NHS Trust.

The aim of this presentation is to share the experience of working with nurses in Eastern Europe. Following my application to be involved in some overseas voluntary work, I was selected as part of a team to modernise healthcare in Croatia earlier this year. My specialist area of the project involved the implementation and audit of pressure ulcer prevention guidelines.

To modernise and standardise pressure ulcer prevention, the EPUAP pressure ulcer prevention guidelines were proposed and it was agreed that they should be implemented across the pilot site. To enable this to happen key nurses were identified to be trained in the theory and practical implementation of the EPUAP guidelines. It was evident that changes in practice were required to meet the expectations of the guidelines.

The pilot brief included education of staff in the importance of monitoring practice. To assist audit of pressure ulcer prevention on the pilot site the group used the ‘Essence of Care’ benchmark. The pressure ulcer benchmark was ideal to assess current practice in line with the EPUAP guidelines. An action plan was devised in order that the nurses could continue to develop and continually evaluate practice, to achieve the standard set by the EPUAP guidelines.

Photographs taken throughout the project and an account of my personal experience support the presentation.

Quality in North America views of the NPUAP
Courtney H. Lyder, ND, GNP, FAAN
Associate Professor and Director, Program for the Advancement of Chronic Wound Care, Yale University School of Nursing

The National Pressure Ulcer Advisory Panel was established in1987 to serve as a resource to health care professionals, government, the public, and health care agencies. Through various activities within the NPUAP, we have championed the use of pressure ulcers as a quality indicator. Because pressure ulcers requires a multidisciplinary approach to both prevent and treat, it potentially can be a good indicator of how well the multidisciplinary team is working. This presentation will focus on the use of pressure ulcers as a quality indicator. Moreover, this presentation will review how the U.S. federal government uses pressure ulcers as a quality indicator.

Latest concept and treatments of pressure ulcers in Japan
Takehiko Ohura
General Secretary of Japanese Society of Pressure Ulcers

1. Introduction
The Japanese Society of Pressure Ulcers (JSPU) was established in 1999 and the fourth annual meeting will take place this August. The number of members has increased from 1300 in 1999 to approximately 2050 today. This includes 750 medical doctors, 1200 nurses, and 100 researchers including biomedical system engineers.

2. Identification of the risk factors for pressure ulcers in Japan
Purpose With the introduction of the new Medicare system, a nation-wide study 0was conducted to identify the risk factors for pressure ulcers that anyone can measure.
Subject 132 patients were selected from this study based on the criteria that the onset day of the pressure ulcer and the medical condition and nursing care given for one month prior to this onset were both known. Eighty-one questions relating to pressure ulcer development were included in the protocol.

Result and discussion
1. Decreased consciousness, morbid bony prominence, oedema and articulator contracture are identified as the risk factors for pressure ulcers in the aged group. 21.6 % of this group develop a pressure ulcer when their consciousness status is inbetween clear and coma with mild or moderate morbid bony prominence. 91.0 % of the group develop a pressure ulcer when their consciousness status is coma with severe morbid bony prominence, oedema and articulator contracture.
2. The importance of a pressure relief mattress is demonstrated in the bed-ridden aged group. There is a 27–32 % difference in pressure ulcer development, in this group, depending on whether they use a pressure relief mattress (mattress) or not.

Clinical application of the risk factors
1. These findings can be used, as a guideline, to decide on how many or what kind of mattress should be introduced.
2. If a study is conducted, using each category of risk factors, it shows significance in the wound healing process. Therefore a clinical trial should be conducted, considering these risk factors.
3. Definition of morbid bony prominence – The bone in the sacral region becomes abnormally prominent due to disused muscle atrophy. This can be distinguished from a normal anatomical bony prominence. Morbid bony prominence demonstrates a strong relationship with pressure ulcer development. It also contributes to increased pressure as well as shear force.
4. The use of a new electrical device in clinical settings for the measurement of shear force. This device has allowed us to obtain new evidence. It should be noted that the dislocation caused by shear force and the shear force itself should be considered as different factors. When the upper body is tilted up, the shear force on the sacral region differs depending on whether both knees are elevated or not. Residual shear force can also be detected after the upper body is lowered down again.