Pressure injury guidelines: a look back and review of what’s new

Go behind-the-scenes of the revised NPIAP guideline and discover how it might affect your daily practice

The news had been out for months. An update to the International Clinical Practice Guideline for Prevention and Treatment of Pressure Ulcers/Injuries was close to completion. Thousands of volunteer hours had been dedicated to its creation, with contribution from hundreds of industry experts and over a dozen wound care associations.

The National Pressure Injury Advisory Panel emailed on Nov. 13, 2019, announcing the guideline’s official release date. But everyone involved was sworn to secrecy regarding the content until Nov. 15-16, 2019, at the guideline launch event.

The big debut

Arriving at the University of Southern California Hotel in Los Angeles, there was a palpable buzz as attendees gathered for an introduction and welcome speech by NPIAP President Janet Cuddigan, PhD, RN, CWCN, FAAN. To the sold-out crowd of wound care experts, administrators, public policy makers, researchers and educators, Dr. Cuddigan described the history of the international pressure injury guideline, as well as the cross-continent collaborative that produced the latest update.

Throughout the two days, esteemed speakers revealed the guideline’s key evidence and recommendation changes, the rigorous methodology used to develop them and how they fit into the broader wound care practice. As a surprise bonus, attendees were among the very first to receive a hard copy of the 405-page guideline.

The 2019 Clinical Practice Guideline is available for purchase through NPIAP, while a free, 43-page Quick Reference Guide is downloadable and presents an abridged version of every recommendation and good practice statement.

Looking back

Although clinical practice guidelines (CPG) have been commonplace for decades in most areas of healthcare—the National Guideline Clearinghouse lists more than 2,000 such guidelines1 — it culminated four years of work to publish the first international CPG for the prevention and treatment of pressure injuries. The goal was to provide guidance to caregivers and individuals and to develop evidence-based recommendations that could be implemented by healthcare professionals around the world.2

“Through trial, error and intense research, evidence-based practice guidelines have been developed to advance wound care management.”

Jackie Todd, MBA, BS, BSN, RN, CWCN, DAPWCA, Medline National Clinical Education Specialist and NPIAP panel member

What was the seed that led to the guideline? Simply, the prevalence of pressure injuries. “Every day, there are thousands of patients in hospitals, long-term care centers and home care environments who are either at risk for skin breakdown, or who have already developed wounds,” says Jackie Todd, MBA, BS, BSN, RN, CWCN, DAPWCA, Medline National Clinical Education Specialist and NPIAP panel member. “Through trial, error and intense research, evidence-based practice guidelines have been developed to advance wound care management.”

To work out the practical details of the guideline and develop valuable recommendations, a specific scientific methodology was used to identify and appraise the available research, then combine it with expert opinions and reviews from nearly 1,000 stakeholders.

For the second edition, published in 2014, the Pan Pacific Pressure Injury Alliance (PPPIA) joined the discussion and deliberation. In addition to expanding its coverage of pressure injury-related topics to include emerging fields of interest such as prevention and treatment of biofilms, and medical device-related injuries, the 2014 CPG assigned a strength to each recommendation.

“The strength of recommendation identifies the importance of the recommendation statement based on potential to improve patient outcomes,” the NPIAP website explains. “It provides an indication to the professional of the confidence one can have that the recommendation will do more good than harm and can be used to assist in prioritizing pressure ulcer related interventions.”

The 2014 edition sold more than
6,000 copies and was downloaded over 200,000 times.

The latest and greatest

The 2019 guideline continues to complement and enhance coverage of pressure injuries. To prepare for its development, a joint Guideline Governance Group (GGG) was formed in 2017, with four representatives each from NPIAP, EPUAP and PPPIA. Steered by Guideline Methodologist Emily Haesler, PhD, the 12-member group drove the process and reviewed all documentation, occasionally meeting in person but more often coordinating multi-time-zone conference calls.

“The international guideline truly is an international labor of love,” says Todd.

2019 Guideline by the numbers
3,500 abstracts
reviewed to drive the new guideline
1,233 patients
who participated in the online survey
699 registered
stakeholders who provided key feedback
181 researchers
and clinicians who read and developed the guideline
140 recommendations
in the guideline
62 good practice
statements to address gaps in care
14 associate
wound care-related organizations from around the world involved in the guideline
12 members
of the Guideline Governance Group from the NPIAP, EPUAP and PPPIA
1 methodologist
to make sure it all comes together

Every chapter of the guideline covers a topic, listing the clinical questions that are addressed. Then, after each recommendation, there is an evidence summary, implementation considerations and evidence discussion. To put all this together, more than 3,500 research studies were considered under the leadership of the NPIAP, EPUAP and PPPIA, with the support of numerous international wound care organizations. Each study was evaluated for efficacy and relevancy, as well as bias and the quality of the study; those that met the criteria were used to inform the guidelines.

Also providing crucial input were international stakeholders and multiple small working groups. One small working group was composed of consumers who reviewed each chapter for cultural sensitivity and relevance to individuals with or at risk for pressure injuries. With more emphasis this time focused on the needs and desires of patients and informal caregivers, an online survey was created to collect the thoughts of patients from around the world.

Todd notes that, although research studies cited in the guideline may be sponsored by healthcare-related companies, their influence is prohibited from being part of the decision-making process on the recommendations. In addition, anyone with a conflict of interest is asked to leave the room when necessary. At all times, and for everyone, corporate association is left at the door to ensure a nonbiased publication and that the data provide thorough and thoughtful evidence. “We are patient advocates first,” Todd stresses.

Always looking forward

As the research on pressure injury prevention and treatment continues, so do these patient advocates who will soon start to plan for the next guideline update, due out in 2024. “We’ll go through the guideline with a fine-tooth comb, and every piece that is old and antiquated or no longer applicable to best practice as it stands currently will be revised or eliminated and replaced,” Todd says.

What’s new and improved?

Here, we highlight the primary changes of note in the 2019 Guideline.

  1. Implementation considerations. Based on the evidence and research, these are real-time recommendations for real-life situations.
  2. Patient voice. By surveying patients and informal caregivers, this guideline represents more patient-centered standards. It helps guide clinicians on what to do and how to do it so that treatment best meets the patient’s needs.
  3. Consolidation of recommendations. By delineating evidence-based recommendations versus good practices, the 2019 recommendations have been pared down to 140 from 550. The recommendations also integrate special populations, such as pediatric patients, rather than separating them into distinct chapters.
  4. Strength of evidence. Each recommendation indicates what kind of studies led to the recommendation. Based on that, each recommendation is accompanied by a strength rating.

What to do right now

The 2019 CPG for Prevention and Treatment of Pressure Ulcers/Injuries is yours to use and share with your colleagues. As NPIAP Treasurer William Padula, PhD, Assistant Professor, Department of Pharmaceutical and Health Economics, USC School of Pharmacy, suggests, take baby steps to implementing the guideline. Figure out what works for you. Maybe each month or quarter you focus on different protocols or different components, always adding a new one. Measure both the process and the outcomes until you’ve reached your goal of zero percent pressure injuries, and you’ve found something worth standardizing within your healthcare setting.

The guideline is just that, a guideline. Now it’s up to you to make it a valuable resource that has a positive impact on your patients.

Learn more about how to prevent and treat pressure injuries and download our shareable poster set.

Special thanks to contributor Jackie Todd MBA, BS, BSN, RN CWCN, DAPWCA, National Support Surface and Heel Protection Clinical Education Specialist in Medline’s Advanced Skin and Wound Care Division. Todd develops and supports education and clinical programs related to support surfaces and heel protection/offloading devices. She has also been a member of the NPIAP Corporate Advisory Council for 20 years.

What’s in a name

In 1986, in a small town near Buffalo, New York, Thomas P. Stewart, PhD, enlisted the help of 14 other doctors, educators, authors and frontline clinicians to establish the National Pressure Ulcer Advisory Panel.3 Since then, it has become an internationally recognized leader in the field. It has also continued to evolve with the times—including its recent name change. It is now the National Pressure Injury Advisory Panel (NPIAP). In a press release, Executive Director Pamela H. McKenna, CAE, stated, “The new name reflects the future direction of the organization and a reaffirming of our commitment to adopt the internationally preferred term, pressure injury, in place of pressure ulcer.” In conjunction with the new name comes a reenergized logo. The large, green circle symbolizes the patient who, McKenna says, “will always be at the center of what we do.” She goes on to describe, “The sunrays emanating from the core represent NPIAP’s work in reaching out to improve outcomes for patients with education, research and public policy.” The new name and renewed logo convey NPIAP’s eye the future, but its focus remains constant: the prevention and treatment of pressure injuries.

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  1. “The Emergence of Clinical Practice Guidelines,” George Weisz, Alberto Cambrosio, Peter Keating, Loes Knaapen, Thomas Schlich, Virginie J Tournay Milbank Q. 2007 Dec; 85(4): 691–727. doi: 10.1111/j.1468-0009.2007.00505.x; Accessed February 14, 2020
  2. www.npiap.com
  3. Nursing Center, https://www.nursingcenter.com/journalarticle?Article_ID=4625843&Journal_ID=54015&Issue_ID=4625828; Accessed February 14, 2020