A Means of Identifying and Dealing with a Major Health Problem with a European Initiative
George W. Cherry
Introduction: The Problem
Pressure ulcers are a major health problem worldwide. Historically and even today they have not had a high profile when compared to other medical conditions such as cardiovascular disease and cancer. However, awareness of the extent and cost of the problem is growing. Factors contributing to this are an increase in the aging population in developed countries as well as in developing countries, immuno- compromising diseases such as HIV and AIDS, and trauma such as burns leading to an increased susceptibility of pressure-related wounds.1Figure 20.1 (see color section) illustrates how pressure ulcers particularly affect the elderly population.
The financial burden on healthcare systems is also increasing due to treatment costs, up to £1.4–2.1 billion (4% annual NHS expenditure) per year in the National Health Service in the United Kingdom, and in the USA it has been estimated to be even higher, particularly with the indirect effect of litigation.2
Pressure ulcers have been a major medical problem since the beginning of civ- ilization. In the nineteenth century.3William Heberdeen in a presentation to the College of Physicians in London in 1815 gave a description of a bed frame that would aid in the treatment of these wounds (Figure 20.2). He summarized his pre- sentation by stating:
As the ultimate object of the medical art is the removal or alleviation of those evils to which the human body is exposed, I make no scruple of laying before the College of Physicians some account of a contrivance from which I have lately experienced great benefit; though strictly speaking the calamity be no disease and the remedy no medicine. There is no-one in the habit of attending the sick but must have had reason to deplore the wretched condition of those who, being bedridden through accident or infirmity, have contracted sores of a very painful and dangerous kind by long pres- sure. Especially if the patient lie in the wet and filth of his own body which he is unable to restrain.
Development of the European Pressure Ulcer Advisory Panel (EPUAP)
The organization of the EPUAP began in Amsterdam at the 6th European Con- ference of the Wound Management Association in October 1996 when a few of the participants were approached by Dr Willi Jung of Germany to meet with
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representatives of the National Pressure Ulcer Advisory Panel (NPUAP) from the USA to determine if a similar organization could be established in Europe. Fol- lowing this meeting an inaugural meeting of the EPUAP was held in London in December 1996 with representatives from more than 13 European countries who had an interest in pressure ulcers. Though it was thought that many of the orga- nizational aspects of the NPUAP were relevant, it was generally agreed that the EPUAP should be unique in its structure, reflecting the differences in the health- care systems between the USA and Europe.
The EPUAP was formally established after that meeting and a public announce- ment was published in the Lancet at the beginning of 1997.4The advisory panel was registered as a charity in the UK but with activities throughout Europe with the following mission statement:
The European Pressure Ulcer Advisory Panel’s objective is to provide the relief of persons suffering from or at risk of pressure ulcers, in particular through research and the education of the public.
Development of EPUAP Through Annual Open Meetings
The publicity of the launch of the EPUAP in the Lancet was followed by the first open meeting, which was held in Oxford in September 1997. This first meeting was well attended by delegates from throughout Europe and other parts of the world and led to a number of important initiatives, in particular the formation of the EPUAP’s pressure ulcer prevention guidelines through the interactive input led by our first president, Professor Keith Harding (Figure 20.3—see color section). This interaction was particularly useful in having participants openly debate statements which would become part of the guidelines. A working committee came up with the final guidelines based on levels of evidence similar to those used by the NPUAP (Table 20.1).
The success of the panel was also ensured by the support of our annual meet- ings by the EPUAP corporate sponsors. In addition, the content of the first meeting and those that followed was ensured by the late Professor Gerry Bennett who was the first Recorder and a major contributor to the inaugural meeting held in London in 1996.
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Figure 20.2 Bed frame designed by William Heberdeen Jr in 1815 for the treatment and pre- vention of pressure sores.
The second annual open meeting was held in Oxford with its theme “Learning from each other—the European experience.” Again this was well attended and a major outcome was the publication of the EPUAP pressure ulcer treatment guide- lines (Figure 20.3—see color section). Ownership of both of the guideline docu- ments was established with the input from the delegates attending these meetings.
Recently nutritional guidelines for pressure ulcer prevention and treatment were published and presented at the 2nd World Union of Wound Healing Societies Meeting in Paris in July 2004. Again the formation of these guidelines followed the same protocols as the prevention and treatment guidelines in their development (Figure 20.4—see color section).
The EPUAP guidelines have been translated into a number of European languages and more than 100,000 individual brochures have been distributed to clinicians throughout Europe. They are also available on the EPUAP website (www.epuap.org).
An early achievement of the EPUAP led by Professor Jeen Haalboom, our second president, was highlighted in another article published in the Lancet in 1998 on the need for establishing a uniform method in Europe to deal with the prevention and treatment of pressure ulcers.5From the answers to question- naires sent to EPUAP representatives in different countries, he was able to high- light how information concerning such items as basic registration of pressure ulcers and related aspects of management was lacking (Figure 20.5a and b—see color section).
Further annual open meetings were held in Amsterdam (the Netherlands), Pisa (Italy), Le Mans (France), Budapest (Hungary), Tampere (Finland), and Aberdeen (Scotland), each with a specific theme ranging from “Technology in the new mil- lennium” to “Pressure ulcers; back to basics—the fundamental principles.” The annual meetings are a major educational opportunity and the Recorder and the scientific committee play an important role in the success of these events. Dr Michael Clark has been Recorder since the Budapest meeting in 2002, where the theme was “Pressure ulcers—a quality of care indicator.” At this meeting a major focus of the program was dedicated to work that the EPUAP itself had carried out, with the results of the Prevalence of Pressure Ulcers in Europe study being an important aspect of the Budapest program.
Additional Education Activities
The EPUAP has been producing its own journal, the EPUAP Review, three times per year, under the editorship of Dr Michael Clark published through the EPUAP Business Office (Figure 20.6—see color section). The Review has served as a forum
Table 20.1. Levels of evidence
A Results of two or more randomized, controlled trials in pressure ulcers in humans
B Results of two or more controlled clinical trials in humans or, where appropriate, results in two or more controlled trials in an animal model provide indirect support
C This rating requires one or more of the following:
(1) results of one controlled trial
(2) results of at least two case series/descriptive studies on pressure ulcers in humans, or (3) expert opinion
for debates on issues about pressure ulcers. One item that stimulated considerable discussion was an article written by Professor Joe Barbenel and S. Hagisawa: “The limits of pressure sore prevention.”6The Review is also published on our website www.epuap.org, which was established shortly after the Panel was established.
A major recent educational project has been carried out under the leadership of Professor Tom Defloor of the University of Ghent, Belgium, who produced the computer CD PUCLAS (pressure ulcer classification system), which is available in nine languages (Figure 20.7a, b, and c—see color section).
Educational grants have been set up through contributions from industry, which have led to a number of studies including the major European pressure ulcer preva- lence study as well as the development of the nutritional guidelines.
In addition to ascertaining the extent of the problem of pressure ulcers through- out Europe, we thought that it would be important to determine the effectiveness and impact of our guidelines and a baseline of the problem was necessary. The importance of having such information has recently been emphasized in the work of the NPUAP in the USA, where shortly after the panel was established in 1989 they set as a national goal to reduce the incidence of pressure ulcers by 50% by the year 2000.7This organization has recently published its progress in reaching that goal in “Pressure ulcers in America: Prevalence, incidence and implications for the future,” where they state that the major problem in assessing this goal has been inconsistency in the initial figures presented on incidence and inconsistencies in methodology. The EPUAP prevalence study was designed to reduce or eliminate these obstacles in order to assess the problem as well as benefits from interven- tions that arise from the work of the EPUAP.
Education of the Public and Government
Education is a major part of our mission statement and educating the public as to the extent of pressure ulcers and their cost to health budgets is extremely impor- tant. The role of litigation following pressure ulcers, although not as extensive as in the USA, is beginning to be publicized in European countries. This awareness has been further highlighted in popular television medical dramas where the development of pressure ulcers and their consequences have been emphasized.
The EPUAP has made a major effort in pointing out the problem of pressure ulcers to government, though not to the same successful extent as has been done in the Netherlands where economic studies revealed that the costs of prevention and treatment of pressure ulcers approach those of cardiovascular disease and cancer.5 To make governments aware of the problem the EPUAP has written to Members of Parliament in the UK as well as to the European Parliament empha- sizing the extent and cost of pressure ulcers.
Summary
The European Pressure Ulcer Advisory Panel (EPUAP) is an example of how a ded- icated organization from a number of countries can approach a major chronic wound healing problem such as pressure ulcers through education, research, and dissemination through a cooperative program.
References
1. Romanelli M. Pressure ulcer prevention and management in Italy. In: Cherry GW (ed) Concepts in pressure relief – importance in the prevention and treatment of pressure ulcers. Oxford: Positif Press; 2004: 18–19.
2. Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age Ageing 2004; 33(3):
230–235.
3. Bedsores over the centuries. In: Parish LC, Witkowski JA, Crissey JT (eds) The decubitus ulcer in clinical practice. Berlin, Heidelberg: Springer-Verlag; 1997: 3–8.
4. EPUAP. European Pressure Ulcer Panel launched. Lancet 1997; 349:262.
5. Haalboom JRS. Pressure ulcers. Lancet 1998; 352(15 August): 581.
6. Barbenel J, Hagisawa S. The limits of pressure sore prevention. J R Soc Med 1999; 92:576–578;
reviewed in the EPUAP Review 2000; 2(2):43–44.
7. National Pressure Ulcer Panel. Cuddingan J, Ayello EA, Sussman C (eds) Pressure ulcers in America:
Prevalence, incidence and implications for the future. Reston, VA: NPUAP; 2001.
8. Clark M, Bours G, Defloor T. The prevalence of pressure ulcers. in Europe. Hospital Decisions 2003/2004; Winter: 123–129.
