Click here for the Wounds UK Home Page November 2005

Two new books on pressure ulcers.	One month on from the launch of the latest NICE guideline on pressure ulcers and a growing sense of unease over some of the recommendations of this clinical practice guideline appears to be emerging. Two specific issues appear to be raising concern. The first of these concerns touches upon the recording of Grade 2 pressure ulcers as critical incidents. This advice is contradicted by the European Pressure Ulcer Advisory Panel who this summer recommended that only Grades 3 and 4 should be considered as clinical incidents. NICE considered that the economic impact of reporting Grade 2 pressure ulcers as clinical incidents would require the equivalent of 73 full time staff just to document these wounds as clinical incidents. This additional burden was considered to have a negligible impact on total costs of pressure ulcer care given that nurses would incorporate this recording within their day-to-day practice! There are potentially two consequences of this decision to treat Grade 2 pressure ulcers as clinical incidents - either these wounds will go unreported or they will be classified as not being pressure ulcers - this perhaps being justified given the EPUAP's recent focus upon discriminating between superficial pressure ulcers and wounds caused by abrasion exacerbated through prolonged exposure to moisture. There is now an urgent need to address the consequences of reporting Grade 2 pressure ulcers as clinical incidents -not least the risk that by 'crying wolf' through including superficial wounds as clinical incidents then the concept of clinical incident reporting may itself be devalued. Other emerging concerns from the new NICE guideline touch upon support surface provision. It is recommended in the guideline that decisions on the selection of support surfaces should be based on 'cost considerations and an overall assessment of the individual'. While no-one would disagree that support surface use must be cost-effective simply looking at cost may lead purchasers to select the cheapest option regardless of its effectiveness. This recommendation appears at best to be simplistic and in hindsight greater emphasis should have been placed on clarifying concepts of cost and cost-effectiveness to prevent a movement towards the lowest cost intervention supplanting more cost effective alternatives. No single clinical practice guideline will be considered by all to be ideal but these early concerns over the potential impact of the new NICE pressure ulcer guideline may be significant with marked and potentially negative changes in practice following their uncritical implementation. There clearly needs to be further discussion between NICE and concerned clinicians if these emerging issues are not to detract from the successful implementation of the guideline to the benefit of all, and especially those individuals with or vulnerable to pressure ulcers. Michael Clark Editor	Keeping up to date with pressure area care Recent publications

Two new books on pressure ulcers. Like buses you wait for new books on pressure ulcers without joy then two come almost at once! This autumn sees the publication of new texts on pressure ulcers from the same publisher (Springer) and sharing editors and contributors. The first book Pressure Ulcer Research: Current and Future Perspectives is edited by Dan Bader and colleagues, (Carlijn Bouten, Denis Colin and Cees Oomens). The table of contents for this title (taken from the Springer website (http://www.springer.com/sgw/cda/frontpage/0,11855,5-10061-22-45362244-detailsPage%253Dppmmedia%257Ctoc%257Ctoc,00.htm) linclude the aetiopathology of pressure ulcers: A hierarchical approach.- Medical perspectives in the 21st century.- Medico-legal implications.- Patients at risk for pressure ulcers and evidence based care for pressure ulcer prevention.- The measurement of interface pressure.- Susceptibility of spinal cord injured individuals to pressure ulcers.- Prevention and treatment of pressure ulcers using electrical stimulation.- Biochemical status of soft tissues subjected to sustained pressure.- Stump-socket interface conditions.- Perspectives of numerical modelling in pressure ulcer research.- Skin morphology and its mechanical properties associated with loading.- Compression-induced tissue damage: animal models.-The role of oxidative stress in the development and persistence of pressure ulcers.- Transport of fluid and solutes in tissues.- Skin model studies.- In vitro muscle model studies.- Imaging tissues for pressure ulcer prevention.- Magnetic resonance imaging and spectroscopy of pressure ulcers.- Microelectrodes and biocompatible sensors for skin p02 measurements.- New tissue repair strategies. The second new book has been compiled by the EPUAP titled 'Science and Practice of Pressure Ulcer Management' and edited by Marco Romanelli, Michael Clark, George Cherry, Denis Colin and Tom Defloor. This book will be published in December 2005 and the table of contents again reproduced from the Springer web-site (http://www.springer.com/sgw/cda/frontpage/0,11855,4-10061-22-45788278-detailsPage%253Dppmmedia%257Ctoc%257Ctoc,00.html) covers the scale of the Problem (Epidemiology).- Social Impact.- Recent Advances in Pressure Ulcer Research.- Aetiology and Risk Factors.- Pressure Ulcer Classification.- Risk Assessment.- Prevention Management of Pressure: Equipment Selection.- Prevention Management of Pressure: Manual Repositioning.- Skin Care.- Nutrition: EPUAP Guidelines.- Wound Assessment.- Wound Bed Preparation in Pressure Ulcers.- Conservative Management of Pressure Ulcers.- Surgical Management of Pressure Ulcers.- Debridement of Pressure Ulcers.- Bacterial Balance.- Litigation on Pressure Ulcers.- Development and Implementation of Guidelines.- Setting a Research Agenda.- The Development and Role of EPUAP.- Management of Pressure Ulcers in Developing Countries.- Innovation in Pressure Ulcer Prevention and Management. It will be interesting to see how reviewers and readers judge the merits of these two books with overlapping editors and authors given that both will appear on our shelves at the same time! Keep reading for: Keeping up to date with pressure area care Download this newsletter in PDF format Pressure Ulcer References This month the reference list covers issues related to superficial pressure ulcers - their causes and treatment. This is not an exhaustive list but reflects the diversity of thought surrounding their aetiology, and the several actions taken to manage the early stages of pressure damage. Butcher M. Prevention and management of superficial pressure ulcers. British Journal of Community Nursing 2005;Suppl:S16. Di Giulio P, Saiani L, Laquintana D, Palese A, Perli S, Andreatta M, et al. [A double blind randomised clinical trial to assess the efficacy of the treatments of the superficial pressure sores]. Assistenza Infermieristica e Ricerca:Air 2004;23(4):201-8. Blumel JE, Tirado K, Schiele C, Schonffeldt G, Sarra S. [Prediction of the pressure ulcer development in elderly women using the Braden scale]. Revista Medica de Chile 2004;132(5):595-600. Defloor T, Schoonhoven L. Inter-rater reliability of the EPUAP pressure ulcer classification system using photographs. Journal of Clinical Nursing 2004;13(8):952-9. Clever K, Smith G, Bowser C, Monroe K. Evaluating the efficacy of a uniquely delivered skin protectant and its effect on the formation of sacral/buttock pressure ulcers. Ostomy Wound Management 2002;48(12):60-7. Galvin J. An audit of pressure ulcer incidence in a palliative care setting. International Journal of Palliative Nursing 2002;8(5):214-21. Conzut L, Bin A, Toneatto M, Quattrin R. [The surveillance system of decubital lesions of the University Polyclinic in Udine: results of an incidence study].[see comment]. Assistenza Infermieristica e Ricerca:Air 2002;21(1):17-21. Russell L, Reynolds T, Carr J, Evans A, Holmes M. A comparison of healing rates on two pressure-relieving systems. British Journal of Nursing 2000;9(22):2270-80. Phillips L. Cost-effective strategy for managing pressure ulcers in critical care: a prospective, non-randomised, cohort study. Journal of Tissue Viability 2000;10(3 su):2-6. Kolnaar BG, Chel VG. [Summary of 'Decubitus' guideline of the Dutch College of Family Practitioners].[see comment]. Nederlands Tijdschrift voor Geneeskunde 2000;144(14):646-9. Bourdel-Marchasson I, Barateau M, Rondeau V, Dequae-Merchadou L, Salles-Montaudon N, Emeriau JP, et al. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Groupe Aquitain Geriatrique d'Evaluation. Nutrition 2000;16(1):1-5. Berlowitz DR, Brand HK, Perkins C. Geriatric syndromes as outcome measures of hospital care: can administrative data be used? Journal of the American Geriatrics Society 1999;47(6):692-6. Watret L. Using a case-mix-adjusted pressure sore incidence study in a surgical directorate to improve patient outcomes in pressure ulcer prevention. Journal of Tissue Viability 1999;9(4):121-5. Arao H, Obata M, Shimada T, Hagisawa S. Morphological characteristics of the dermal papillae in the development of pressure sores. Journal of Tissue Viability 1998;8(3):17-23. Escobar Bravo MA. [Primary care of bedsores. Frequency and characteristics]. Revista de Enfermeria 1998;21(237):55-8. Barczak CA, Barnett RI, Childs EJ, Bosley LM. Fourth national pressure ulcer prevalence survey. Advances in Wound Care 1997;10(4):18-26. Kokate JY, Leland KJ, Held AM, Hansen GL, Kveen GL, Johnson BA, et al. Temperature-modulated pressure ulcers: a porcine model. Archives of Physical Medicine & Rehabilitation 1995;76(7):666-73. Hagisawa S, Ferguson-Pell M, Cardi M, Miller SD. Assessment of skin blood content and oxygenation in spinal cord injured subjects during reactive hyperemia.[erratum appears in J Rehabil Res Dev 1994;31(2):178]. Journal of Rehabilitation Research & Development 1994;31(1):1-14. Barnett RI, Ablarde JA. Skin vascular reaction to standard patient positioning on a hospital mattress. Advances in Wound Care 1994;7(1):58-65. Holmes JHt, Guileyardo JM, Barnard JJ, DiMaio VJ. Pressure sores in a Christian Science sanatorium. American Journal of Forensic Medicine & Pathology 1993;14(1):10-1. Silver FH, Wang MC. A review of the etiology and treatment of skin ulcers with wound dressings: comparison of the effects of occlusive and nonocclusive dressings. Journal of Long-Term Effects of Medical Implants 1992;2(4):267-88. Haalboom JR, Bakker H. [Revision consensus prevention and treatment decubitus].[see comment]. Nederlands Tijdschrift voor Geneeskunde 1992;136(27):1306-8. LeVasseur SA, Helme RD. A double-blind clinical trial to compare the efficacy of an active based cream F14001 against a placebo non-active based cream for the treatment of pressure ulcers in a population of elderly subjects. Journal of Advanced Nursing 1991;16(8):952-6. Clark M, Rowland LB, Wood HA, Crow RA. Measurement of soft tissue thickness over the sacrum of elderly hospital patients using B-mode ultrasound. Journal of Biomedical Engineering 1989;11(3):200-2. Lingner C, Rolstad BS, Wetherill K, Danielson S. Clinical trial of a moisture vapor-permeable dressing on superficial pressure sores. Journal of Enterostomal Therapy 1984;11(4):147-9. Wills EE, Anderson TW, Beattie BL, Scott A. A randomized placebo-controlled trial of ultraviolet light in the treatment of superficial pressure sores. Journal of the American Geriatrics Society 1983;31(3):131-3. Braverman AM, Nasar MA. The treatment of superficial decubitus ulcers. Practitioner 1981;225(1362):1842-3.   Download this newsletter in PDF format