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EPUAP Guidelines update 2019 – What it means for your organisation

Having reviewed the updated quick reference guidelines (below) and from what I have seen from clinical discussion forums there are only a few small changes to the 2014 version.

The main difference as far as I can see are in the strengths of evidence to some of the statements. I have listed the ones that stand out relevant to long term care and hospices below.

The updated EPUAP full copy is now available if you want to read in full, it costs £120 including shipping.

However the electronic copy if you want to purchase is 50 euros, see Link:

The main points I want to highlight you to are below:

Page 27 Pressure Ulcer assessment –

Use a wound assessment chart that prompts action if no improvement in 2 weeks. Ideally this can be used for a category 1 or 2 pressure ulcer initially to add identification of early ‘Root causes’ and potential solutions. Always involving the parent in this process by explaining risks and trying to find solutions together.

Wound photography is something that is still not standard in long term care settings. Implementing a wound photography standard operating procedure or policy will be a great action this year if not already in place. If you would like some guidance on this or copy of other policies in place, ask the Facebook group or look under the files section on the Facebook page where I have uploaded an example.

Page 20 Repositioning:

I wanted to highlight this section as I know from my champion facebook group discussions and training that assessing for preventing seating acquired pressure ulcers can be a challenge as well as when repositioning in bed is difficult. This has been especially an issue for end of life patients and those with contractors or even where your patient has full capacity but declines a full turn in the bed.

Although we look for alternatives and discuss risks with the patients and/or the next of kin there are some circumstances where a full 30% tilt is impossible. There is increased guidance to refer to on page 20, with a strength of agreement within the EPUAP guidelines for micro-movements for critical unwell.

Equally the evaluation of a patient with a sacral or coccyx deep tissue injury not always being nursed in supine position, but can individually asses as may be offloaded more appropriately for example in a tilt chair than in bed. 

These recommendations should offer the assessing clinician further guidance on what to consider in a holistic assessment and in more complex case involving a wider Multi-Disciplinary team may be beneficial.

Page 22 Support Services:

  • For treatment of category 2-4 there seems to be increased support indicating a specialist LAL (immersion) system rather than standardised dynamic pumped AIR. Most TVNs may go to low air loss mattresses for treating deep tissue injuries (SDTI) especially for microclimate support, comfort and if patient unable to reposition.
  • For the prevention of pressure ulcers for high risk patients the use of a high specification foam mattress over pumped system comes on the back of further research. The over use of traditional pumped AIR mattresses for use in prevention has less evidence basis support over a high risk static mattress with adequate offloading such as repositioning or independent turning by the resident, along with the other aSSKINg risk assessment care planning tools.
  • Increased support in not nursing all Sacral/Coccyx in the bed if unable to offload from affected area. Enhanced and MDT care plan may assess for this. Not all residents with a sacral or coccyx pressure ulcer will be better off in bed. If they only are able to lie in the supine position, this may not be offloading the pressure off the affected ares. Where available reclining chairs with tilts may offer more adequate offloading. Otherwise tilts while on bed may be more achievable than the full 30% turn. This needs to be agreed between the care provider, TVN and where possible the occupational and/or physiotherapists. Care plans and reposting documentation must fully match the care the provider is able to give.

Page 38 Table for the classifications of pressure ulcers:

For the 6 classifications of pressure ulcers, has not changed in physiological depth and clinical indicator. However the update of “Grade’ of pressure ulcer has been changed to ‘Category’ or ‘Stage’.

For organisations only reporting multiple Category 2s, 3 or 4 to CQC and local authorities, should be documenting and consider reporting serious deep tissue injuries and potential unstageable that look like they may be a deep tissue injury. At the very least organisations should be following their own internal investigation process or ‘RCAs’ for these types of wounds as often indicative of deep tissue injury and may result in wider investigation or safeguarding.

For those of you that are Tissue Viability Links or champions I would recommend going through the guidelines and highlighting any sections that you may want to feed back to your organisation or take actions on.

To benchmark yourself or use an organisational self assessment guide for compliance to the recommendations page 37 offers a quality indicator breakdown guide.

For any further questions or guidance on implementing any of these recommendations in your organisation come on to the Facebook discussion group below or contact me.