Professor Carol Dealey presented on three international projects involving pressure ulcers that she has been involved in. The first was developing the 2009 International Pressure Ulcer Guidelines over 5 years with a committee from the European Pressure Ulcer Advisory Panel and the National Pressure Ulcer Advisory Panel. The second was a consensus document on pressure ulcer aetiology factors like pressure, shear, friction, and microclimate. The third, ongoing project is developing global evidence-based recommendations for using wound dressings to prevent pressure ulcers with an international expert group. The projects highlighted the benefits and challenges of international collaboration across disciplines and distances.

1. International Projects to
Prevent Chronic Wounds
Professor Carol Dealey

2. In this presentation
• I will be talking about 3 different international
projects in which I have been involved as useful
examples
• They have all been undertaken in a slightly
different way
• They all involve pressure ulcers

3. International Pressure Ulcer
Guidelines
• This project took over my life for 5 years!
• It was very hard work, but very satisfying.
• I made some good friends during this time
• So – here is the story of how the guidelines were
developed.

4. The Two Societies
.
EPUAP = European Pressure Ulcer NPUAP = National Pressure Ulcer
Advisory Panel, founded in 1996 it Advisory Panel and it is an
is a Pan-European Society American society founded in 1987

5. • Both associations had produced pressure ulcer
guidelines:
NPUAP in 1992 (Prevention) and 1994
(Treatment)
EPUAP in 1997 (Prevention, 1998 (Treatment)
and 2003 (Nutrition)
There was an urgent need for these
guidelines to be updated

6. When in doubt – form a committee!
• Guideline development
Group (GDG)– from both
EPUAP and NPUAP
• Carol Dealey – Chair
EPUAP GDG
• Janet Cuddigan & Diane
Langemo – Co-Chairs of
NPUAP GDG
• 5 members from each
society

7. Guideline Development Group
European Pressure Ulcer Advisory Panel
Dr. Carol Dealey
Dr. Michael Clark,
Dr. Lisette Schoonhoven,
Anne Witherow,
Prof. Dr. Tom Defloor,
Dr. Katrien Vanderwee
National Pressure Ulcer
Advisory Panel
Dr. Janet Cuddigan
Dr. Diane K. Langemo
Dr. Mona M. Baharestani
Mary Ellen Posthauer
Dr. Joyce Black
Evan Call

8. • The full GDG (NPUAP and EPUAP) defined a
search strategy for both guidelines.
• Evidence was limited to papers published in
peer-reviewed journals and cited on PubMed,
CINAHL, EMBASE, AHMED or the Cochrane
and HTA databases. Quantitative studies were
included if they were laboratory-based studies,
controlled or cohort studies.
• The full GDG developed a template for all the
evidence tables

9. • The full GDG agreed the hierarchy of evidence
to be used in both guidelines
• Each guideline was divided into a series of
topics, recognising that there will be some
overlap between the two.
• The treatment guideline does not include all
possible topics, but has assessed those most
clinically useful

10. Strength of Evidence Rating for
Strength of Evidence
Recommendations
• A – Recommendation supported by direct scientific
evidence from properly designed & implemented controlled
trials on PU in humans providing statistical results that
consistently support the guideline statement. (Level I
studies)
• B – Recommendation supported by direct scientific
evidence from properly designed & implemented clinical
series on PU in humans providing statistical results that
consistently support the recommendation. (Level II, III, IV, V
studies)
• C – The recommendation is supported by expert opinion or
indirect evidence (e.g. surrogate outcomes, studies in
animal models & other types of chronic wounds).

11. Reviewing the Evidence
Small Working Groups (SWGs)
• Sub-groups, each with a sub-group leader,
reviewed the literature for specific topics
• Evidence tables were produced, allowing the
SWG to develop guideline statements and a
summary of the evidence
• Guideline statements and supporting text sent to
GDG for review

12. • Draft recommendations then circulated to full
GDG (NPUAP and EPUAP) for comments
• The GDG met to agree format for the guideline
document and review the draft
recommendations in order to develop the 1st
draft of the guideline topics
• The topics were then made available for
stakeholder review

13. 146 Representatives from 32
Countries

14. And 903 individuals from 53
countries

15. Review
• Every stakeholder was informed when the
statements were available for review and given
the opportunity to comment on the statements
both by suggesting literature that might have
been missed and commenting on the text
• The full GDG met to discuss each comment and
review the suggested literature
• The guideline text was then revised in the
light of the literature/comments as
appropriate

16. Final Draft Stage
• This stage was all about
ensuring there were no
anomalies between
treatment and prevention
• Checking the text for
typos
• Ensuring we had all the
evidence tables
• Checking and rechecking
the references

17. The Guidelines were
published in 2009
They are available as a
Clinical Practice Guide
and as Quick Reference
Guides
The QRG is available in
18 different languages
including Portuguese
The translations are
freely available for
download at
www.epuap.org

18. What did I learn about International
collaboration?
• It is really important to talk to
each other – emails are not
enough!
• When we started the
guidelines the 2 societies did
not know each other well and
there were misunderstandings
at first. American English and
English English are not the
same!
• Be prepared to compromise

19. THE NEXT EXAMPLE

20. A project to produce a
consensus document on
pressure ulcer aetiology.
It aimed to expand on the
information in the
International Pressure
Ulcer Guidelines.
Unlike the Guidelines
which were funded by
EPUAP and NPUAP, this
was funded by an
unrestricted educational
grant from KCI Europe
Holding BV

21. Expert working group
• Mona Baharestani*, (USA) • Maarten Lubbers*, (The
• Netherlands)
Joyce Black*, (USA)
• Courtney Lyder*, (USA)
• Keryln Carville, (Australia)
• Takehiko Ohura, (Japan)
• Michael Clark*, (UK)
• Heather Orsted, (Canada)
• Janet Cuddigan*, (USA)
• Vinoth Ranganathan, (USA)
• Carol Dealey*, (UK)
• Steven Reger*, (USA)
• Tom Defloor*, (Belgium)
• Marco Romanelli*, (Italy)
• Amit Gefen*, (Israel)
• Hiromi Sanada, (Japan)
• Keith Harding, (UK)
• Makoto Takahashi, (Japan)
• Nils Lahmann*, Berlin
(Germany)
* = worked on EPUAP/NPUAP Guidelines

22. Pressure, shear, friction and
microclimate – why needed?
• Pressure has long been viewed as the most
important extrinsic factor in pressure ulcer
development
• Increasing interest in the roles of shear, friction
and microclimate
• Emerging awareness of the synergistic links
between pressure, shear, friction and
microclimate

23. Pressure, shear, friction and
microclimate
Groundbreaking initiative:
• Fulfilled a need for educational materials that aid
understanding of the basic physics involved in
pressure, shear, friction and microclimate
• Demonstrated how the physics involved
underpins best clinical practice in the prevention
(and treatment) of pressure ulcers

24. Pressure, shear, friction and
microclimate
The technical section of each paper:
• Defined the relevant extrinsic factor
• Clearly described basic physics involved
• Explained the contribution of the extrinsic factor
to pressure ulcer aetiology
• Described the links between the factors

25. Pressure, shear, friction and
microclimate
The clinical practice section of each paper:
• Described how to identify patients at risk from the
extrinsic factor
• Explained the types of and rationale for the clinical
interventions that aim to prevent or ameliorate the
effects of the extrinsic factor
Note: Pressure ulcer prevention involves much more than
extrinsic factor modification: this document was not
intended to provide a comprehensive discussion of
pressure ulcer prevention protocols

26. How did this project work?
• This work was undertaken
with a mixture of
teleconferences and emails
• The scientists wrote the
physics part and some of
the clinicians (mostly
nurses) wrote the clinical
application
• It went out for review to the
rest of the expert group

27. The Outcome
A useful document
freely available to
download from the
Wounds International
website:
http://www.woundsinte
rnational.com/pdf/cont
ent_8925.pdf

28. What did I learn from this project?
• We need scientists to explain the
physics
• But they cannot apply this
knowledge to clinical practice –
that is where nurses come in.
• So we need multi-professional
working – and to respect each
others’ expertise

29. There’s more
• When you know each
other it is easier to
work at long distance
• This project involved
writing, reviewing and
judicious editing and
formatting (by Wounds
International)
• There did not need to
be a lot of debate on
the content

30. MY LATEST PROJECT

31. Global Evidence Based
Practice Recommendations
for the Use of Wound
Dressings to Augment
Pressure Ulcer Prevention
Protocols - August 2012
This is very new and not
totally completed, so I am
going to tell you quite a bit
about it
It has been funded by an
educational grant from
Molnlycke Healthcare

32. Consensus group
Joyce Black RN PhD Michael Clark PhD Paulo Alves RN MSc Tod Brindle RN MSc
(Co-Chair) (Co-Chair) Paulo Alves is an Assistant Professor Tod Brindle is a wound and ostomy
Dr Black is an Associate Professor of Dr Clark is a Visiting Professor in of Nursing and Tissue Viability at the consultant for the Virginia
Nursing at the University of Nebraska Tissue Viability, Birmingham City Catholic University of Portugal and Commonweath University Medical
in the USA. She is a Fellow of the US University, UK and Manager of the researcher of the Portuguese Wound Center, Richmond, in the USA. His
Academy of Nursing and currently on Welsh Wound Network. He is also Management Association. Pressure clinical specialty area includes
the Board of the National Pressure President of the European Pressure Ulcers are his main research. He is pressure ulcer prevention in high risk
Ulcer Advisory Panel. Ulcer Advisory Panel currently a board member of the populations.
European Pressure Ulcer Advisory
Panel and the European Wound
Management Association.
Evan Call MS, CSM (NRM) Carol Dealey RN PhD Nick Santamaria RN PhD
Evan Call is Adjunct Faculty in the Dr Dealey is Senior Research Fellow Dr Santamaria is Professor of
Microbiology Department at Weber at University Hospital Birmingham Nursing Research, Translational
State University, USA, and NHS Foundation Trust and Honorary Research at The University of
undertakes research in relation to Professor in Tissue Viability at Melbourne and The Royal Melbourne
medical devices for pressure ulcer University of Birmingham in the UK. Hospital, Australia. His research
prevention. He is currently on the Her main research programme is the involves the prevention of pressure
Board of the National Pressure Ulcer prevention of pressure ulcers. She is ulcers in critically ill trauma patients
Advisory Panel. a Past President of the European in ICU.
Pressure Ulcer Advisory Panel.

33. What have we been doing?
1. A literature review of current evidence which included both clinical
and laboratory studies relating to the use of dressings for pressure
ulcer prevention
2. This improved our understanding of their role in reducing the
impact of pressure, shear and microclimate
3. This information provided the evidence we needed to develop Best
Practice Statements of the likely effectiveness of dressing when
used in pressure ulcer prevention alongside other prevention
methods. These statements were presented at the WUWHS
Conference in Japan in a Quick Reference Guide
4. We are planning a full document with all the evidence to be
submitted for publication in a wound journal

34. • So what do dressings
do in pressure ulcer
prevention?

35. Shear redistribution
The dressing translates shear force to
the skin outside the area of concern.
Without a dressing Within the dressing the interface of
multiple layers aids in the absorption of
shear

36. Friction reduction
If the surface of the dressing is slippery
Without a dressing it will reduce friction, conversely if it is
not it will increase friction.

37. Pressure
• redistribution
Without a dressing A dressing with adequate thickness distributes
forces over a larger area thus accomplishing
pressure re-distribution

38. Balance of Skin Microclimate
With a basic dressing With a multi layer silicone foam dressing

39. Balance of Microclimate
A dressing that maintains relative humidity of
between 40 and 80% at the skin surface helps
maximise the resilience of the skin.
Dressings that trap moisture at the skin surface
reduce the strength of the skin and lead to
maceration.
Dressings that withdraw too much moisture can
predispose skin to stiffness and cracking.
This can be identified by obvious signs of
maceration or dryness.

40. Do some dressings outperform others?
• Laboratory tests
found a multilayer
silicone dressing out-
performed others
• But need clinical
confirmation – there
are some cohort
studies + awaiting the
results of an
Australian RCT

41. In the meantime….
Based on what we
know so far we
have produced a
dressing selection
guide

42. Part of the Dressing Selection Guide for Pressure
Ulcer Prevention in the Sacrum and Buttocks
Mechanism of Injury Mechanisms of Dressing Selection
Pressure, Friction, Protection
Shear & Microclimate
Elevating the head of the The dressings used for Structure:
bed increases pressure and pressure ulcer prevention
shear on the pelvic region, should: A multi layer silicone foam
note the percent of body 1. Redistribute pressure dressing
mass that is focused on the 2. Minimise shear with the ability to redistribute
pelvic region as the head of 3. Balance micro-climate pressure, redistribute and
bed is raised. 4. Reduce friction absorb shear, and
0° = 30% of body mass 5. Prevent mechanical effectively manage
30° = 44% of body mass stripping of skin when microclimate.
45° = 52% of body mass removing the dressing to
90° = 70% of body mass inspect the skin
6. Provide barrier protection
to the skin
7. Have an atraumatic
contact layer

43. You can get a copy
From the Neve
Stand in the
Exhibition

44. So what have I learnt from this project?
• We had an initial meeting followed by
teleconferences. This worked when we were
assembling the evidence.
• It did not work for writing the Best Practice
Statements and we ended up meeting for 2 days
to write them
• Meetings are essential for writing guidelines or
best practice statements

45. Overall Conclusions
• It is good to work with colleagues from other
countries – people are the same everywhere, we
just need to get better at talking to each other
• Nurses can make an important contribution – but
we need to work in multi-professional groups in
order to produce really significant outcomes

46. Any Questions?