The NPUAP serves as a resource to health care professionals, government, the public, and health care agencies.  The three mission committees of the NPUAP (Public Policy, Education, and Research) are active in a variety of endeavors including webinars, creation of a reference database, and a number of public policy initiatives.

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NPUAP announces the conclusion of its summer meeting, August 23-24 in Baltimore, MD

Over 60 people participated, representing all facets of patient care and advocacy. Attendees were hopeful but guarded about the present healthcare environment. Following a review of the Strategic Plan, recent accomplishments and project status reports, the group hosted a representative from the Centers for Medicare and Medicaid Services (CMS). The ensuing dialog established the basis for a memorandum of understanding with both short and long term goals.

At his meeting NPUAP welcomed new Corporate Advisory Council (CAC) members Wellsense USA, Inc. and Wound Care Education Institute as well as new Provider Organization Council (POC) member Ernest Health to the Panel. Other meeting highlights were a review of the newly redesigned website ( ) that launched in early July, a drafting of a new position statement regarding pressure ulcers in which cartilage is evident and continuing plans for the 2013 Biennial Conference being held in the Woodlands, TX, February 22-23, 2013.

NPUAP Announces Release of Newly Developed Cartilage Position Statement

NPUAP has a new position statement entitled Pressure Ulcers with Exposed Cartilage are Stage IV Pressure Ulcers. In this position statement, staging for ulcers absent of soft tissue, such as skin over cartilage, is examined. To read this position statement in its entirety please go to:

NPUAP Call for Poster Abstracts: Deadline October 1, 2012

The National Pressure Ulcer Advisory Panel (NPUAP) invites you to submit an abstract for a poster presentation at our 13th National Biennial Conference scheduled for February 22-23, 2013 in The Woodlands (Houston), Texas.  The top 4 poster presenters will be asked to provide a brief oral presentation during the conference’s general session.

The deadline to submit abstracts is October 1, 2012.  Applicants will be notified of the status of their abstract’s acceptance by November 1, 2012.

Please click on the link below to learn more and to submit your abstract:

Have Your Patients Been Asking About “Bedsores”?

Consumer Reports discussed “Bedsores” along with 7 other “things that should never happen in a hospital” in the August 2012 issue of the magazine. The reader is told that “while there is never an excuse of operating on the wrong body part, there are several less dramatic events that also should never occur” including pressure ulcers. “Bedsores”,  as they are called in the article, is number one on the list. Here is what they said… “These painful wounds, usually on the ankles, back, buttocks, hips or other bony areas, can develop if a patient is left in one position too long. Frequent repositioning and special pads, cushions and mattresses can prevent them. If you see early signs, including patches of skin that have reddened, let the nursing staff know.”

The majority of the article focused on medical harm telling the reader that 1.4 million Medicare recipients  a year are seriously hurt by their hospital care and “what happens to other people is less clear because most hospital errors go unreported and hospitals only report on a fraction of things that can go wrong”.  Ratings of hospital safety are included, provided for the various regions of the US. The full article is at

Pressure Ulcer Treatment Strategies: A Comparative Effectiveness Review

The National Pressure Ulcer Advisory Panel (NPUAP) would like to commend AHRQ for the enormous undertaking of synthesizing available information regarding the treatment of pressure ulcers (PU). In particular, the sources for information were broader than are usually undertaken including soliciting unpublished information from stakeholders. The population of patients with pressure ulcers is very diverse; unlike renal failure or congestive heart failure, there are no reliable lab tests for skin failure and the outcome of a treatment for any individual is also dependent on multiple co-morbidities. The difficulty of this technology assessment is compounded by the fact that healing is a continuum and no one modality is likely to be appropriate from initiation of treatment to wound closure.

This review provides an excellent platform to call for the implementation of certain basic approaches [eg methodology for wound measurement, clinical endpoints, use of consistent staging terminology and perhaps partitioning healing research to partial thickness (Stages I & II) and full thickness (Stages III & IV)] which would allow more accurate comparisons and meta-analyses in the future.

NPUAP recognizes that this document is still in draft format-some of the comments are likely editing-related. There is a concern, however, that the results in the Structured Abstract/Executive Summary will be highlighted without the significant caveats that are presented regarding strength of evidence. For example, if there is only low strength evidence that wound healing is similar with collagen compared to standard care dressings, AHRQ’s own definition suggests that there is low confidence that this evidence reflects the true effect and that further research is likely to change the confidence in the estimate of the effect. A conclusion of further research is warranted’ for the areas with low confidence might convey the message more accurately.

Other selected areas of concern are:

  • The 2007 NPUAP staging system is a six stage system which includes Unstageable and Suspected Deep Tissue Injury (Executive Summary and Introduction). Research on PU healing is typically limited to Stages I-IV but the NPUAP-EPUAP Clinical Practice Guidelines, 2009 reaffirmed the six stage system.
  • Use of the term vacuum-assisted closure (ES-2) instead of Negative Pressure Wound Therapy (NPWT) is confusing.
  • ES-5 Population and Interventions sections seem to imply that direct research was undertaken rather than that these were selection criteria for the documents that were reviewed.
  • ES-13 Table A Key Outcome is listed as Alternating pressure beds but the conclusion relates to alternating pressure chair cushions.
  • ES-19 and the Key Points (p. 78) related to surgery for pressure ulcers cite independent variables-for example ‘Sacral ulcers have lower recurrence rates after surgery than ischial pressure ulcers.’ The location of the ulcer, whether or not the patient has a spinal cord injury, and whether or not bone debridement is done during surgery are defining characteristics of the patient’s wound.
  • ES-22 cites the review by Reddy (2008) as being the most current, comprehensive evidence about the effectiveness of pressure ulcer treatments. This analysis and recommendations had a concerning degree of selection bias created by limiting reviewed studies to randomized, controlled trials. Not all treatments or interventions are appropriate for this type of study.
  • Page 18 (Results) discusses a study of Air Fluidized beds which apparently backstaged the ulcers. Stage III and IV ulcers do not heal to Stage II. This ‘study’ also failed to provide data for the control group.
  • The Adjunctive Therapy Tables (13-15) starting on page 87 lack the ‘quality’ evaluation in the first column. In addition, the methodology for selecting documents led to a rating of ‘insufficient evidence’ of harm (p 108) for NPWT despite warnings from the FDA in 2009, 2011 and 2012. This should not be construed to imply that NPWT should not be used but rather that it warrants attention and monitoring unlike most topical dressings.

Evaluating the effectiveness of support surfaces for treating pressure ulcers by combining results from distinct studies is hindered by a number of factors including variability among products with similar features (e.g. Low air-loss). Mechanistically, support surfaces affect pressure ulcer treatment by redistributing pressure away from the injured site and creating a microclimate that does not adversely affect the healing process. Low air-loss is a feature of a support surface “that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin.” (NPUAP-EPUAP Clinical Practice Guidelines, 2009). Notice that the term “low air-loss” refers to a feature and not a category of product. Clearly, if a bed only provided flow of air to the skin without redistributing pressure it would not be an effective support surface. Therefore, the extent to which a surface with low air-loss affects healing is almost certainly also related to how the surface redistributes pressure. A study to isolate the effect of the low airloss feature would need to be conducted on the same mattress with and without the air escaping through the cover. There is no such study in the literature.

The statement in the structured abstract on page v that reads, “there is no overall benefit to low air-loss beds compared to standard foam mattresses” is potentially misleading because the small number of studies conducted did not control for the additional factor of pressure redistribution. Therefore, there is insufficient evidence in the literature to compare surfaces with low air-loss features to foam mattresses without low air-loss features.

The statement in the structured abstract on page v that reads, “different mattress brands are comparable in performance “ is unclear. Does “different mattress brands” refer to only support surfaces with air-fluidized features or all support surfaces? Or, does it follow from the second key point on page 17 referring to alternating pressure beds? If it is the latter, this is a potentially misleading broad generalization.

A comment on page 17 reads, “Currently there is no universally accepted classification of support surfaces.” While this technically correct, there has been broad consensus reached between the US, European, Japanese, and others that the general (nonmutually exclusive) categories of support surfaces are reactive support surface, active support surface, integrated bed system, non-powered, powered, overlay, and mattress. (NPUAP-EPUAP Clinical Practice Guidelines, 2009)

The information contained in the Structured Abstract , Executive Summary and body of the paper is very similar-perhaps it could be condensed to create a less formidable, more useable document. Even the studies rated as ‘good’ frequently have low numbers of patients and many sites; many of the studies resemble pilot studies-further complicating the task. NPUAP would be honored to collaborate with AHRQ in addressing some of the above cited concerns in greater detail than is permitted by the limited commentary section.

This document can serve as a scaffolding on which to build improved information regarding comparative effectiveness of PU treatments through continuous literature review as better quality studies become available.

In summary, we do not find any factual errors or significant oversights. Our comments and suggestions are meant to provide consistency and cohesion to the document. The above correction  will produce a valuable document for clinician and academicians. Thank you for the opportunity to participate in the comment period for ARHQ’s Pressure Ulcer Treatment Strategies: A Comparative Effectiveness Review.

Proposed rule from CMS for Stage 2 Meaningful Use of Certified Electronic Health Records (EHR) Technology

The NPUAP Public Policy Committee would like to make the following comments on the proposed rule from CMS for Stage 2 Meaningful Use of Certified Electronic Health Records (HER) Technology. While we commend the inclusion of the current clinical quality measures proposed for eligible hospital and critical access hospitals (CAHs), we recommend the addition of quality measures of pressure ulcer risk and prevention.

The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research. NPUAP is an independent not-for-profit professional organization dedicated to the prevention and management of pressure ulcers. Formed in 1987, the NPUAP Board of Directors is composed of leading experts from different health care disciplines— all of whom share a commitment to the prevention and management of pressure ulcers. The NPUAP serves as a resource to health care professionals, government, the public and health care agencies, provides educational materials, conducts national conferences, and support of efforts in public policy, education and research.

NPUAP defines prevalence as “a proportion of persons who have a pressure ulcer at a specific point in time”.(1) It is estimated that the prevalence of pressure ulcers varies from 10% to 18% in acute care, 2.3% to 28% in long term care, and 0% to 29% in home care. Approximately 2.5 million patients are treated for pressure ulcers in U.S. acute care facilities each year and as many as 60,000 U.S. hospital patients die each year from pressure ulcer complications.(2) Development of a stage 3 or 4 pressure ulcer during a hospital stay is considered a Serious Reportable Event.(3)

Another serious concern is the increased incidence of pressure ulcers in hospitals. From 1993 to 2006, there was a 78.9% increase in the number of hospital stays during which pressure ulcers were noted. Stays with a secondary diagnosis of pressure ulcers increased by 86.4% during this period, while stays principally for pressure ulcers increased by 27.2%. Adult hospital stays noting a diagnosis of pressure ulcers totaled $11.0 billion in 2006.(4) Since Medicare was the most common payer of adult stays related to pressure ulcers, this represents a great financial burden on the US health care system.

The following initiatives and programs have listed pressure ulcer prevention and treatment as a priority concern:

• Partnership for Patients Areas of Focus(5)
• National Quality Forum’s Serious Reportable Events (SREs)(6)
• Joint Commission Pressure Ulcer Prevention Project(7)
• Center for Medicare and Medicaid serious Hospital Acquired Conditions(HACs)(8)
• Agency for Healthcare Research and Quality: Preventing Pressure Ulcers in Hospitals—A Toolkit for Improving Quality of Care(9)
• HL7 Patient Care Work Group Pressure Ulcer Standards for Assessment and Prevention(10)
• The 2010 National Patient Safety Goals (11) Goal 14: Prevent health-care associated pressure ulcers (decubitus ulcers)
• National Pressure Ulcer Advisory Council(12) Pressure Ulcer Stages
• Academy of Nutrition and Dietetics Evidence Analysis Library: Unintended Weight Loss (UWL) in Older Adults(13)

The Agency for Healthcare Research and Quality (AHRQ) and the National Quality Forum (NQF) have endorsed numerous quality measures relating to pressure ulcer prevention and treatment.(14,15)

Screening for pressure ulcer risk and appropriate intervention for treatment of pressure ulcers are important components in wound healing and maintenance of tissue integrity. It is important that the skin integrity and interventions are communicated as patients move across the continuum of care. Standardization of patient information exchange has the potential for improving patient safety and clinical outcomes

NPUAP recommends the addition of Clinical Quality Measures (CQM) for both prevention and treatment of pressure ulcers in the Stage 2 regulations under the domains of Patient Safety, Care Coordination, Efficient Use of Healthcare Resources and Clinical Process/Effectiveness.

NPUAP requests the following objectives:

1. Inclusion of interdisciplinary assessment and treatment goals for pressure ulcers as mandatory for both Eligible Professionals (EP) and Eligible Hospitals (EH).
2. The EP, EH or CAH that transitions a patient to another setting of care or provider of care or refers that patient to another provider of care should provide summary care records for each transition of care or referral.
3. EP: Provide clinical summaries for patients for each office visit.
4. Generate lists of patients who have documented pressure ulcers on admission to EH or CAH.
5. Documentation of appropriate stage of existing pressure ulcers, at admission and on discharge, using a formal wound classification guideline.
6. Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP or for the EH. Provide patients the ability to view online, download, and transmit information about a hospital admission.
7. Use clinically relevant information from Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient.
8. Document treatment plan of care for patients with existing pressure ulcers and those at high risk for developing pressure ulcers.
9. Document pressure ulcer risk assessment.

In summation, patient care suffers from incomplete, inaccessible and inconsistent use of pressure ulcer assessment and treatment plans. Inclusion of these as a component of the next iteration of EHRs will serve to improve patient care and communication among health care providers. This can also provide transparency and needed information for patients and caregivers once they are given access to the EHR. An additional benefit to the health system is an avenue to develop quality surveillance and initiatives. Thank you for the opportunity to offer comments on the CMS proposed regulations for Stage 2 Meaningful Use of Certified Electronic Health Records (EHR) Technology.

NPUAP Upcoming Webinar – Pressure Ulcer Documentation: Telling a Complete, Accurate and Legally Defensible Story

Stay tuned for more information for NPUAP’s Live webinar entitled Pressure Ulcer Documentation: Telling a Complete, Accurate and Legally Defensible Story presented by Dr. Joyce Black and Dr. Diane Langemo on July 19 at 2:00 PM EDT.

Save the Date for the 2013 NPUAP Biennial Conference

Please save the date for the National Pressure Ulcer Advisory Panel’s (NPUAP) 2013 Biennial Conference scheduled for February 22-23 (Fri-Sat), 2013, at The Woodlands Waterway Marriott in The Woodlands (Houston), Texas. Make plans now to attend this important pressure ulcer conference focused on DEEP TISSUE INJURY: The State of the Science. Stay tuned for more details and registration information in the next few months.

Dr. Barbara Braden’s Repositioning Webinar a Huge Success!

On April 12, 2012 more than 500 people tuned in to Dr. Barbara Braden’s webinar entitled Q 2 Hour Turning & 30 Degree Lateral Positioning – Science or Tradition?.  NPUAP was able to offer CEUs for this immensely popular webinar!  If you were unable to attend the webinar and would like to purchase the recording please click HERE to be redirected to our online store.

NPUAP announced the successful completion of its biannual meeting held in Tampa, Florida

Over 60 representatives from all facets of patient care and advocacy were represented. Participants were hopeful but guarded about the present healthcare environment. All were excited about recent accomplishments including new objective ways to test and compare specialty pressure redistribution mattresses, upcoming sponsored national and international meetings and successful outreach via webinars.