Editor's note: The 20th anniversary ofAdvances in Skin & Wound Careis also the 20th anniversary of the National Pressure Ulcer Advisory Panel. In this article, current and alumni members highlight the group's achievements.
Although pressure ulcers had existed for centuries, their prevalence was high enough in the 1980s to warrant national professional and public concern. Thus, 20 years ago, a small group of health care professionals joined key visionaries from Gaymar Industries (Orchard Park, NY) who had conceived the idea of a national organization to address issues related to pressure ulcers and to increase public awareness of this problem. The key individuals were the late John Whitney, Jack TerBeek, Louise Colburn, and Tom Stewart. They established a national multidisciplinary health care advocacy organization dedicated to preventing and improving the care of individuals with pressure ulcers-the National Pressure Ulcer Advisory Panel (NPUAP). The NPUAP was born in Orchard Park, NY, in August 1987, sponsored largely at that time by Gaymar Industries.
Today, the NPUAP is an independent, not-for-profit, professional organization dedicated to advancing the scientific knowledge base in the prevention and management of pressure ulcers. It remains a multidisciplinary team of leading experts from a variety of health care disciplines, including nursing, medicine, physical therapy, occupational therapy, dietetics, and engineering. The NPUAP consists of a Board of Directors, a Corporate Advisory Council, a Collaborating Organizations Council, a Providers Advisory Council, and an Alumni Council of past board members. Three committees-education, public policy, and research-work toward meeting the NPUAP's goal of providing multidisciplinary leadership for improved patient outcomes in pressure ulcer prevention and management.
* The Education Committee coordinates all educational programs, including conferences and publication of educational videos, monographs, and CDs.
* The Public Policy Committee endeavors to strengthen legislative liaisons by creating and advancing a legislative agenda that presents a unified national approach to the prevention and management of pressure ulcers.
* The Research Committee is responsible for identifying the gaps in current knowledge, identifying research-funding sources, and assisting in the development and dissemination of research data related to pressure ulcers.
The following is a closer look at the NPUAP's achievements in these areas.
Education
Education of providers and patients has been and continues to be a primary focus of the NPUAP. Toward this end, the NPUAP has held a consensus conference every 2 years since 1989 to enhance awareness of the seriousness of the national pressure ulcer problem and to strive to reach consensus among health care providers and researchers on approaches to the prevention, diagnosis, and management of these chronic wounds. Accomplishments to date include the following:
In 1989, the NPUAP presented a nationally, and eventually internationally, accepted definition for pressure ulcers; published a pressure ulcer staging system; and recommended methods for tracking pressure ulcer prevalence and incidence.
* In 1991 and 1993, the NPUAP's conferences focused on the prediction, prevention, and treatment of pressure ulcers. The Agency for Healthcare Policy and Research (AHCPR), now the Agency for Healthcare Research and Quality (AHRQ), developed guidelines on the prediction, prevention, and treatment of pressure ulcers, which were influenced by peer review provided at these conferences. The NPUAP's panel members provided some of the leadership for the development and critique of these guidelines.
* The 1995 NPUAP Consensus Conference focused on pressure ulcer healing and the staging system.
* The 1997 consensus conference focused on the histological inappropriateness of reverse staging of pressure ulcers to document healing. The Pressure Ulcer Scale for Healing(PUSH) Tool, a scientifically developed tool for monitoring pressure ulcer healing, was presented at the conference.
* In 1999, the NPUAP provided guidance on the issue of early identification of pressure-induced damage in individuals with darkly pigmented skin. The definition of a Stage I pressure ulcer was revised to incorporate this information.
* In 2000, the NPUAP addressed the issue of avoidable versus unavoidable pressure ulcers.
* In 2001, NPUAP published a monograph that summarized all pressure ulcer prevalence and incidence data from 1990 to 2000. The monograph, titled, "Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future," has been widely disseminated and extensively cited.
* The 2003 consensus conference focused on the state of pressure ulcers in America, including best practices for prevention, risk assessment, quality indicators, pain management, adjuvant therapies, and seamless delivery of care.
* The 2005 consensus conference addressed the pathogenesis and evolution of deep tissue injury (DTI) and established consensus on how to best integrate DTI into the current staging system. This conference brought national and international attention to a very important pressure ulcer etiology and treatment issue.
Other NPUAP accomplishments in the areas of education include:
* The development and wide distribution of 3 educational CDs for health care providers. These topics include "Pressure Ulcer Prevalence and Incidence," "Pressure Ulcer Prevention," and "Pressure Ulcer Treatment." Over the years, the NPUAP has also developed a slide series for the same purpose.
* The development and dissemination of a video on "Pressure Ulcer Prevention and Treatment," designed primarily for use in long-term care.
* A multitude of educational conferences on pressure ulcers have been held throughout the United States.
Public Policy
After the original NPUAP board of directors developed an organizational plan and wrote the tenets for the NPUAP, the members searched for ways to make a difference. In 1987, several Public Policy Committee members went to Washington, DC, to meet with congressional members about the requirements for hired caregivers in long-term care. The group succeeded in adding language to a bill passed in 1988 that upgraded the criteria for long-term-care nursing assistants.
At the same time, the NPUAP asked the National Institutes of Health (NIH) to organize a consensus development conference on pressure ulcer prevention. The NIH was supportive and candid: It would take 6 years for this concept to be placed on the NIH conference agenda, so the NIH encouraged the NPUAP to develop its own consensus development conference.
In March 1989, the NPUAP held its first consensus conference in Washington, DC. The NIH provided 3 conference speakers, with 2 members of the US Congress in attendance. The resulting consensus development conference statement "Pressure Ulcers: Incidence, Economics and Risk Assessment" was widely published and frequently cited.
In 1989, the chairperson of the Public Policy Committee testified at regional hearings for Healthy People 2000: The Health Care Objectives for the Nation. The NPUAP consensus statement was used to document the importance of pressure ulcer prevention. An NPUAP goal to reduce the incidence of pressure ulcers 50% by the year 2000 was presented and was initially included in the Healthy People 2000 objectives. It was later eliminated in the final version to limit the overall number of objectives. However, this goal became the driving force for many NPUAP long-term objectives.
Because of testimony at Healthy People 2000 hearings, the NPUAP was designated as a liaison organization and continued to receive annual updates from the US Public Health Service. In 1999, the NPUAP was invited to submit a pressure ulcer objective for Healthy People 2010. This time, the NPUAP objective was included in the final document.
In 1993, impending budget cuts threatened Medicare beneficiaries with loss of support surfaces and dressing materials for chronic wounds. The NPUAP's trips to Capitol Hill intensified with a campaign for coverage and payment of dressing materials to be retained under Section 2079 of the Social Security Act and the Medicare Policy Manual. The NPUAP worked tirelessly to retain the chronic wound care dressing benefit for the American public. The work of the NPUAP was rewarded with a positive outcome after a successful meeting with Dr Helen Smits, Deputy Administrator of the Health Care Financing Administration.
Meetings also were held with the Medical Directors of the Durable Medical Equipment Regional Carriers (DMERCs) to review criteria for support surfaces and categorize them for coverage and payment.
Research and Public Policy
In many cases, the work of the NPUAP has been a joint collaboration between the Public Policy and Research Committees, as their missions have overlapped to some degree. Among the achievements of the NPUAP in the public and research arenas are:
* An ongoing collaboration with other professional organizations to ensure policymakers' recognition of pressure ulcers as a prevalent, costly, and morbid condition. Most recently, the NPUAP worked with the Centers for Medicare and Medicaid Services (CMS) on Tag F314 to develop the part of the document, implemented in 1993, that provides guidance to long-term-care surveyors.
* The NPUAP developed and disseminated its white paper opposing the reverse staging of a pressure ulcer.
* In 1995, the NPUAP provided expert guidance for refinement of the assessment instrument used in home care, specifically the Outcome and Assessment Information Set (OASIS). In addition, the NPUAP has offered expert testimony to CMS, formerly known as the Health Care Financing Administration, on issues such as policies for dressing reimbursement, classification of support surfaces, and new technologies for pressure ulcer care.
Research
The NPUAP Board and, on occasion, members of the various advisory councils, have developed and published a wide array of manuscripts, monographs, an assessment tool, and other publications in nationally refereed journals. To date, the NPUAP has about 20 such publications to its credit.
In 2001, the NPUAP assumed the responsibility of coordinating the Support Surface Standards Initiative (S3I). This 3-year initiative with clinicians, support surface manufacturers, consumers, and researchers with worldwide representation led to the completion in June 2006 of a standardized support surface nomenclature. The availability of standardized terminology affords an objective means for evaluation and comparison of support surfaces, ultimately making support surface selection more consistent and understandable for health care providers. This will also impact research, industry, and reimbursement for support surfaces. The terms and definitions have been posted on the NPUAP Web site.
Guideline Revisions
Clinical practice guidelines are systematically developed statements to assist practitioners in making patient decisions about appropriate health care for specific clinical conditions. Appropriately developed guidelines can serve as authoritative statements about best practice for providers and patients, as an important educational tool, and as a benchmark in assessing care delivered. Current pressure ulcer guidelines developed by the AHCPR, the European Pressure Ulcer Advisory Panel (EPUAP), and the Singapore Ministry of Health, for example, are dated in terms of content, having been developed in 1992 and 1998, respectively, thus they do not address significant advances in the research and product arenas, and the processes for guideline development.
The NPUAP, in a collaborative effort with the EPUAP, has been working for more than a year to conduct a thorough literature search and analysis in an effort to develop international pressure ulcer guidelines. A goal to complete the guidelines has been set for early 2008. This initiative is part of the NPUAP's joint collaboration with the EPUAP of the pressure ulcer stream for the 2008 World Union of Wound Healing Societies meeting in Toronto, Ontario, Canada. Drs Diane Langemo and Janet Cuddigan, are the co-chairpersons of the NPUAP initiative, and Dr Carol Dealey, is the EPUAP's chairperson.
Twenty years is a relatively short time to make major changes in policy at the federal government level. It was apparent, however, that such policy changes were crucial for the health of the nation. The NPUAP has truly been a pioneer in the pressure ulcer arena. Today, NPUAP panel members continue to work with policymakers to improve the quality of life for all patients at risk for pressure ulcers and for all patients living with a pressure ulcer.