The Expert Working Group who put the document together comes from a variety of countries from across the world. They are a mixture of nurses, doctors and bioengineers, all with a special interest in pressure ulcers. Some have considerable practical experience which is reflected in the text. The authors have also been able to take advantage of information in the International Pressure Ulcer Guidelines recently published by the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel.

Dr Carol Dealey PhD MA BSc (Hons) RN RCNT
University Hospital Birmingham NHS Trust,
University of Birmingham
Carol Dealey is Senior Research Fellow at University Hospital Birmingham NHS Trust, Birmingham, UK
and University of Birmingham, UK.
Carol has worked and researched in the field of Tissue Viability for over 20 years and was one of the first Clinical Nurse Specialists in Tissue Viability (1987-97). Carol has undertaken a considerable body of research in the subject and has presented at national and international conferences as well as having numerous publications. The 4th edition of her textbook the Care of Wounds is in preparation.
She is Immediate Past President of the European Pressure Ulcer Advisory Panel and was one of their representatives on a joint working party with the USA National Pressure Ulcer Advisory Panel to develop international pressure ulcer guidelines. She was President of the European Wound Management Association 1993/4 and is currently a Council member. She was also Chairman of the Tissue Viability Society from 1996-98. Carol is Editor of the EWMA Journal and on the editorial boards of the Journal of Tissue Viability and International Wound Journal.

This paper will discuss implementation of the information provided in the document into everyday practice. For example, repositioning and the use of pressure redistributing devices are widely used across Europe for the prevention of pressure ulcers. The link between the theoretical information on pressure and the practical application in practice will be discussed for these strategies and for others used in the document. 

New insights in pressure ulcer prevention:

Pressure, Shear, Friction and Microclimate in context

The overall goal of clinical practice is to restore or maintain health. Iatrogenic injuries, such as pressure ulcers, sometimes occur. Inappropriate care methods often remain in practice long after evidence has shown them to be harmful or ineffective. Education is critical in ensuring that all members of a clinical team act to prevent pressure ulcers according to the best evidence available.

Pressure has long been viewed as the most important extrinsic factor in pressure ulcer development. However, recent and ongoing research is revealing that shear, friction and microclimate also have important roles. For example, pressure and shear are closely linked, friction has a role in the development of shear, and microclimate influences the susceptibility of skin and soft tissues to the effects of pressure, shear and friction.
In addition to a direct effect, pressure also acts indirectly through the generation of shear stresses to produce pressure ulcers.

Clinical recommendations from the recent NPUAP and EPUAP guidelines that particularly relate to shear, friction and microclimate are reviewed in practice steps.
This scientific symposium will focus on new insight in pressure ulcer prevention and translate these in practice. But clinical judgement is always required for all who have the knowledge, skills and understanding to implement these new insights in their daily practice for effective and safe use.
Best clinical practice begins with identification of those at risk and ends with an evaluation of the impact, ie the effect on incidence and prevalence of pressure ulcers. 

Speakers: 

Michael Clark PhD
Welsh Wound Network
Cardiff, UK
Roles & memberships
Cardiff University
Cardiff University School of Medicine
Department of Dermatology & Wound Healing
Senior Research Fellow

Dr. Maarten Lubbers
Surgeon – intensivist
AMC – UvA, Amsterdam, Holland
1981: Surgeon
University of Amsterdam, Holland
1983: Chief Surgical Intensive Care Unit
University of Amsterdam, Holland
1983 - now: Academic Medical Center, Amsterdam
2007 also: Chief Hyperbaric Oxygen Unit AMC
Main interests:

- inflammation
- wounds
- transplantation
- infection
- sepsis
- MOF
Wounds: Healing, infection, dressings, tissue engineering;
antiseptics, evidence, health economics, guidelines.

Member

- ESCMID
- EPUAP
- EWMA
- ETRS
Author - more than 100 papers
- co-author several books
Lectures - more than 300

An international group of experts, who produced a consensus document on measuring the prevalence and incidence of pressure ulcers in 2009, recognised the need for an educational resource that takes a fresh approach to the extrinsic factors involved in pressure ulceration. The resultant consensus document – Pressure ulcer prevention: pressure, shear, friction and microclimate in context – consists of three papers: Pressure in context, Shear and friction in context, and Microclimate in context.

Each paper clearly defines and explains the science behind the extrinsic factor under examination and clarifies the synergistic links that exist between the factors. The papers build on the basic science to describe how the extrinsic factors contribute to pressure ulcer development, and discuss the types of and rationale for relevant clinical interventions that aim to prevent or ameliorate the effects of the extrinsic factor.

Biography speaker:

Prof. Keith Harding
Cardiff University, Cardiff, UK
Professor Keith Harding is currenty a Professor of Rehabilitation Medicine (Wound Healing) and the Director of the Wound Healing Research Unit at the University of Wales, College of Medicine.
He has worked in clinical research in Cardiff, and spent many years in General Practice. He has a long-standing interest in wound healing and has provided clinical supervision of a part-time outpatient clinic.
He also has a long-standing interest in continuing medical education and has acted in various capacities including GP CME Tutor for Wales and Postraduate Organiser for the University Hospital of Wales, as well as establishing further education courses in wound healing.
He is a member of the Royal College of Genral Practitioners and a Fellow of the Royal College of Surgeons, England.
Research interests include inflammatory cells in wound healing, aspects of measurement, the diabetic foot and quality of life evaluation. 

In 2007 the Federal Center for Medicare and Medicaid Services (ref 3) announced that it would no longer reimburse US hospitals for NPUAP stage 3 and 4 hospital-acquired PUs. Hospitals in the US therefore need to develop a prevention model that uses proven interventions. This presentation describes how implementation of one such model resulted in zero prevalence of hospital-acquired PUs. Central to its success is that the programme was a management priority.

3 Center for Medicare and Medicaid Services, 2008

Isabel Bales, RN, MSN, CWON, AGNP
694 West Fort Street • Farmington, Illinois 61531 • USA 

Professional Objective:
To practice as an adult/geriatric nurse practitioner to provide care,
especially to those afflicted with wounds, diabetes, and patients in need of palliative care.
To conduct research that will result in the improvement of patient care.

Credentials:
Professional Registered Nurse       
Certified Wound and Ostomy Nurse  

Certifications:
Wound Care
Ostomy Care

Education:
MSN, University of Illinois at Chicago, May 2009
BSN, Southern Illinois University at Edwardsville, December 2000

Research:
Reaching for the Moon: Achieving Zero Pressure Ulcer Prevalence, 2009
The Development of a Computer-Based Ostomy Care Training Resource for Staff Nurses, 2008
A Comparison Between the use of  Intravenous Bags and the Heelift Suspension Boot to Prevent Pressure Ulcers – 2007

Publications:
Reaching for the Moon: Achieving Zero Pressure Ulcer Prevalence, Journal of Wound Care, 18(4), April 2009
The Development of a Computer-Based Ostomy Care Training Resource for Staff Nurses, 2008,
Publication Pending on the Ostomy and Wound Management Journal

Professional Experience:

2003-Present
WOUND AND OSTOMY NURSE, Methodist Medical Center of Illinois.
• Clinical resource for the acute and rehabilitative care of patients with  selected disorders
of the gastrointestinal, genitourinary, and integumentary systems,  such as complex draining wounds,
ostomies, fistulae, dermal ulcers, tubes, and  incontinence.  Main wound care educator for the nursing
staff.  Primary wound care and ostomy care patient educator. Participate in the development and
implementation of procedures and  protocols.  Recommend standards for cost-effective supplies/equipment
related to wound, ostomy, and incontinence care to be utilized in the hospital through product evaluation.
Chairperson of the wound committee.

 
2002-2003
STAFF NURSE, Methodist Medical Center of Illinois, Transitional Care Unit.
•Assessment of patients, medication administration, treat wounds, implement interventions  following
hospital protocols.  Preceptor and mentor for the unit’s new staff.  Member of  QI committee.  Functioned
as the charge nurse when assigned.

2000-2002
ASSISTANT DIRECTOR OF NURSING, HCR-Manor Care, Canton, Illinois

1998-2000
ASSISTANT DIRECTOR OF NURSING, HCR-Manor Care At Riverview, East Peoria, Illinois

1996-1998
STAFF NURSE, Graham Hospital, Canton, Illinois

Methods: A BIM was developed to investigate the use of different hospital surfaces; standard foam, constant low pressure and alternating pressure surfaces. The model summarizes the cost of PU treatment for patients with existing ulcers and demonstrates whether prevention strategies using pressure relieving surfaces can save hospitals money as a result of preventing PUs in the ‘at risk’ population. The model also provides information on the optimal way in which to adopt appropriate surfaces.  A hypothetical scenario is presented for a typical medium-sized hospital, with more patients placed on pressure relieving surfaces than on standard foam surfaces as previously was the case.

Results: The findings from the hypothetical scenario indicate that when more pressure relieving devices were adopted, there was a reduction in PU development. The associated PU treatment costs reduced substantially, which offset the increased outlay for the surfaces themselves, resulting in substantial cost savings.

Conclusions/Discussion: Our model demonstrates that the implementation of pressure relieving surfaces will reduce the incidence of PUs and generate cost savings. Hence, in order to reduce the strain on hospital budgets that PUs can cause, adopting a planned approach to PU prevention and treatment using pressure relie¬ving surfaces is vitally important.

However, quantification of the problem is complex. Therefore international pressure ulcer guidelines on performing prevalence and incidence studies were (recently) published. The information available in those guidelines will be addressed.
When interpreting prevalence or incidence data, it is important to understand what incidence and prevalence is, which factors influence those figures, and how to interpret and report the data. Also practical issues related to the collection of prevalence and incidence data will be covered.

Method: A BIM was developed to investigate the use of different hospital surfaces; standard foam, constant low pressure and alternating pressure surfaces. The model summarises the cost of PU treatment for patients with existing ulcers and demonstrates whether prevention strategies using pressure relieving surfaces can save hospitals money as a result of preventing PUs in the ”at risk“ population. The model also provides information on the optimal way in which to adopt appropriate surfaces. A hypothetical scenario is presented for a typical medium-sized hospital, with more patients placed on pressure relieving surfaces than on standard foam surfaces as previously was the case.

Results: The findings from the hypothetical scenario indicate that when more pressure relieving devices were adopted, there was a reduction in PU development. The associated PU treatment costs reduced substantially, which offset the increased outlay for the surfaces themselves, resulting in substantial cost savings.

Conclusions: Our model demonstrates that the implementation of pressure relieving surfaces will reduce the incidence of PUs and generate cost savings. Hence, in order to reduce the strain on hospital budgets that PUs can cause, adopting a planned approach to PU prevention and treatment using pressure relieving surfaces is vitally important.

The document draws on the significant clinical research evidence available and the consensus opinion of the expert working group. Many of these experts met in February 2008 to examine the role of epidemiological studies in the development and evaluation of pressure ulcer prevention programmes. Following this meeting, consensus recommendations were developed to provide guidance on performing prevalence and incidence studies and how to use the data collected to improve standards of care for pressure ulcers. In particular it outlines a systematic approach to evaluating, interpreting and comparing studies. In this presentation, Dr Nils Lahmann will outline the key sections of the document, using his clinical experience in Germany to highlight the issues surrounding prevalence and incidence and how implemen-tation of effective PU prevention strategies can help to reduce PU occurrence.

The focus will be upon the impact of bariatric patients and pressure ulcer care that is becoming more prevalent within health organisations with the increasing challenges of the obese patient. With the specialty of caring for the larger, heavier individuals evolves, it becomes increasingly important to recognise the need for adequate consideration for pressure ulcer prevention for these individuals with weight issues. When these two areas are combined it escalates what is already recognised as a major health challenge worldwide. It is now common knowledge that obesity has enormous detrimental consequences for health and the economy. The rise of obesity is widely accepted as a major public health problem and often perceived as resulting in considerable health system expenditure.
There are many implications both for health and for the moving and handling of patients, therefore risk assessment, adequate and suitable equipment provision, and training are essential in bariatric handling. The increased strain on the patient’s joints, cardiovascular system, range of movement and posture all make it more difficult for them to move and be moved. This potential from enforced immobility heightens susceptibility to pressure ulcer development; every organisation must strive to deliver the best service for their patients and in particular with this group prevention of pressure ulcers are of significant importance. 

The need for pressure ulcer prevention strategies is well recognised in clinical guidelines. The appropriate use of pressure-relieving surfaces during hospitalisations is central to the prevention of pressure ulcers. Pressure-relieving surfaces fall into three broad categories: standard foam surfaces, continuous low-pressure surfaces and alternating pressure surfaces. The costs of these surfaces differ substantially. As such, it is vital that healthcare planners and providers ensure that patients are allocated to appropriate surfaces to ensure that prevention strategies are effective and healthcare resources are allocated efficiently. By following best practice guidelines on the appropriate use of pressure-relieving surfaces, hospitals can reduce the pressure ulcer prevalence, while saving money as a result of more efficient use of surfaces and reduced treatment costs.

1 Kaltenhaler, E., Whitfield, M.D., Walters, S.J., Akehurst, R.L., Paisley, S. UK, USA and Canada: How Do Their Pressure Ulcer Prevalence and Incidence Data
Compare. Journal of Wound Care. Jan 2001; 10(1): 530-5.

The measurement and interpretation of pressure ulcer occurrence data has long been problematic in pressure ulcer research, with different definitions of pressure ulceration, differing clinical populations and different data collection methods among some of the challenges faced. This presentation will consider the measurement of pressure ulcer occurrence given that this is a key foundation to achieving evidence of the implementation of successful pressure ulcer prevention strategies. The evidence for changes in pressure ulcer occurrence following the introduction of pressure ulcer preventive strategies will be reviewed. In this section, the focus will be placed upon the impact of the introduction of pressure-redistributing support surfaces as a common tactic to reduce pressure ulcer occurrence. The problems that can arise when attempting to uncover the value of any single tactic used to prevent pressure ulcers will be highlighted and related back to the challenge of correctly measuring pressure ulcer occurrence. The presentation will conclude with recommendations for future pressure ulcer occurrence data collection that should help standardise data allowing more meaningful comparisons between health care providers and trends in pressure ulcer occurrence over time to be made.