The Development, Dissemination, and Use of Pressure Ulcer Guidelines

Abstract

Clinical guidelines have been defined as “systematically developed statement(s) to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” In this definition the use of “assist” clearly indicates that a successful guideline does not seek to compel practitioners to practice in a rigid, inflexible manner but rather that evidence-based or evidence-linked recommendations are offered to help reduce inequities in healthcare provision. While clinical guidelines are a relatively recent phenomenon, there are now a wide range of national and international clinical guidelines that address pressure ulcer prevention and/or management beginning with the consensus guidelines developed in the Netherlands in 1985, through the US Agency for Health Care Policy and Research guidance issued in the early 1990s (on prevention and treatment) to European guidelines developed by the European Pressure Ulcer Advisory Panel (EPUAP). Recently the wheel has turned full circle with the development of new national guidelines in both the Netherlands and the UK under the respective auspices of the Dutch Institute for Healthcare Improvement (CBO), and the National Institute for Clinical Excellence (NICE). The CBO is an independent, not-for-profit organization advising on clinical guideline development across the whole spectrum of healthcare, while NICE was established as a Special Health Authority within England and Wales in April 1999. Working within the UK National Health Service, NICE seeks to deliver “authoritative, robust and reliable guidance” (www.nice.org.uk) regarding what constitutes best practice, with this information available to all consumers, be they patients, the public, or the health professionals. The wealth of pressure ulcer guidelines has been developed using a variety of methods that seek to synthesize the available scientific and clinical knowledge available during each guideline’s development. Early national guidelines, for example the Dutch guidelines of 1985 (prevention) and 1986 (treatment), were developed using informal consensus techniques. Later guidelines such as those of the US Agency for Health Care Policy and Research (AHCPR) were based on formal consensus techniques, with more recent guidelines seeking to be based solely upon the best practices of evidence-based medicine. This chapter discusses the evolution of pressure ulcer guideline development using the new Dutch guidelines as examples of evidence-based national guidelines. Beyond guideline evolution aspects of their dissemination, implementation, and appraisal will also be considered.