Pressure ulcers: new international guidelines provide evidence-based recommendations for healthcare professionals

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Pressure ulcers represent a growing medical and financial burden to society. Even though several preventive and therapeutic approaches are available, their treatment remains difficult and time-consuming. The 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline gives healthcare providers and wound specialists evidence-based recommendations for improving the management of patients with pressure ulcers.

They can affect people of any age, from premature babies to the elderly: Pressure ulcers or ‘bedsores’ are a very common and painful skin injury with profound effects on quality of life. Defined as “localised damage to the skin or/and underlying tissue, primarily caused by prolonged pressure on the skin,”1 pressure ulcers pose a serious threat to patients’ safety and have a significant economic impact on healthcare systems. It is estimated that approximately 4% of annual healthcare budgets in Europe are spent in the management of these chronic wounds, with nursing time accounting for 41% of these costs2.

Despite new therapeutic approaches and advances in dressing technologies, approximately 10% of hospital patients and 5% of community nursing patients still suffer from pressure ulcers. Patients with reduced mobility, impaired circulation and poor skin health are especially at risk of developing these injuries, which are usually caused by sitting or lying in one position without movement for a long time or by medical devices pressing on the skin. Treatment of pressure ulcers is time consuming, expensive and painful for the patients. Ulcers can become infected, leave scars, reopen easily and can even have fatal consequences3. Therefore, the early detection of risk factors and the implementation of effective preventive measures are crucial for reducing their incidence and avoiding patient suffering.

Clinical practice guidelines: a joint effort of organisations around the world

In order to give global health professionals much needed evidence-based recommendations, in 2009 the National Pressure Injury Advisory Panel (NPIAP) in the United States and the European Pressure Ulcer Advisory Panel (EPUAP) published the first international Clinical Practical Guidelines (CPG) for the prevention and treatment of pressure ulcers. In 2014, the Pan Pacific Pressure Injury Alliance (PPPIA) joined this consortium, and all three organisations published the first update of the guidelines. Since then, cooperation between research groups and clinicians has contributed to a better understanding of the aetiology and development of pressure ulcers. Therefore, the three organisations, supported by 14 international associate institutions, decided to review the guidelines in compliance with rigorous methodological standards. Small working groups with almost 200 international pressure injury experts were formed to review the evidence and draft recommendations. Stakeholders as well as over 1200 patients and their caregivers were also part of the development process4.

This concerted effort led to the publication of the second update of the guidelines in 20195 6. Commenting on the release of the guidelines, Janet Cuddigan, PhD, RN, FAAN, President of NPIAP stated, "The NPIAP is pleased to join our international partners, the EPUAP and PPPIA, in releasing this international guideline. The guideline critically analyses and summarises a large body of international research to develop evidence-based clinical recommendations. The guideline bridges a critical gap by accelerating the translation of research into practice to improve patient outcomes."7

Starting from current insights to develop evidence-based recommendations

The first step in the evaluation process was reviewing the most recent research evidence and recommendations. Data were discussed to formulate more than 100 evidence-based recommendations, good practice statements and quality indicators. The current investigations shed new light on the pathological processes leading to the formation of pressure ulcers. According to the “damage cascade” model, pressure ulcers occur, primarily, due to the deformation and distortion of cells and tissues rather than, as previously thought, because of inadequate blood flow. Subsequent inflammation and ischemia also contribute to the damage8. This clearer understanding of pressure ulcer development has significant consequences for their prevention and treatment, building the base for the new recommendations.

The guidelines also identify risk factors and cover prevention and treatment of pressure ulcers for all age groups, in all healthcare settings, irrespective of the medical diagnoses, comorbidities and/or other health characteristics. The CPG address not only healthcare professionals but also caregivers and individuals, who are at risk of developing, or already suffer from, pressure ulcers. In addition to the general recommendations, the guidelines make specific recommendations for infants and children, as well as for patients with underlying pathologies such as spinal cord injuries and obesity.

A wide implementation of these updated guidelines will result in a more targeted and improved approach to the issue of pressure ulcers. Prevention remains a crucial step in the management of these wounds as it can avoid patients’ suffering and save substantial resources.



  1. Pressure ulcers (pressure sores), NHS website
  2. Pressure Ulcers: A Population Health Issue, Fact Sheet, EWMA
  3. Pressure ulcers: Just the facts!, Fact Sheet, EPUAP
  4. EPUAP Guidelines, NPIAP – EPUAP – PPPIA
  5. Review of the Current Management of Pressure Ulcers, Tatiana V. Boyko et al, Wound Healing Society
  6. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, NPIAP – EPUAP – PPPIA
  7. News and Statements, NPIAP – EPUAP – PPPIA
  8. Updated international guidelines highlight new “damage cascade” for why pressure ulcers develop, iWounds news
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