Assessing the Need for Developing a Comprehensive Content-Validated Pressure Ulcer Guideline

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Laura Bolton, PhD, Adjunct Associate Professor; Sue Girolami, RN, BSN, CWOCN; Stephanie Slayton, PT, DPT, CWS; Teri M. Berger, RN, BSN, CWCN; Linda Foster, RN, BSN, CWCN; Kathy T. Whittington, MS, RN, ET, CWCN; Diane Merkle, APRN, CWOCN; and the Association for the Advancement of Wound Care Guideline Subcommittee

Evaluating the clinical relevance of PUCI items will serve as preparation for the final construct validation step of the process — ie, determining the level of best available evidence supporting each item. Participants also are invited to share Level A evidence with the authors for any aspect of PU care. The final validated guideline will be updated regularly to incorporate new evidence, offering a benchmark for professional PU care and reimbursement.


     Guideline quality is characterized by clear, precise, unambiguous language with logical easy-to-follow recommendations annotated with the best available evidence. 12 In addition to previously published differences in existing PU guidelines, 11 the authors review of 11 published guidelines, including 10 on the NGC website and two draft guidelines, showed important variations in definitions, procedures, content, professional focus, evidence basis, and degree or methods of validation. By crafting and content-validating one unified guideline for all steps to PU care (the PUCI), the authors hope to increase clarity and clinical relevance of all PU steps of care. Finally, by summarizing the best available evidence supporting each step, construct validity that supports the efficacy of each step of PU management will be forged and will clarify which components of care or recommendations need further research.

     The resulting PUCI guideline will be neither a consensus-based document nor a comprehensive systematic review of all literature supporting each aspect of care. As a compendium of objectively rated, best currently available evidence supporting all recognized aspects of PU care, the guideline will reduce confusion. This “guideline of all guidelines” is designed to help wound care professionals provide consistent, high-quality PU care and improve patient and PU outcomes, professional satisfaction, and reimbursement while decreasing liability and costs of care. Absence of compelling evidence (B or C level) supporting a specific step suggests the step may not be better than preferred current practice and highlights opportunities for controlled research before that recommendation qualifies as recommended PU care. Periodic PUCI updates based on new evidence will perpetuate a continuously improving framework within which efficacy and clinical relevance of PU care can be further validated.


     The authors gratefully acknowledge their AAWCGS colleagues: Mona M. Baharestani, PhD, ANP, CWOCN, CWS, Associate Professor, East Tennessee State University Center for Nursing Research and James H. Quillen, Veteran’s Administration Medical Center; Roslyn S. Jordon, RN, BSN, CWOCN; and Sophia Kahn, MD, MBBS, MGenSurg Medical Director, New Mexico Rehabilitation Center; Patrick McNees, PhD, FAAN, Professor and Associate Dean for Research, School of Health Professions, University of Alabama at Birmingham; and Laurie Rappl, PT, Span America Medical Systems. The authors also thank the NPUAP for providing an advance copy of its draft PU guideline.


1. Margolis DJ, Bilker W, Knauss J, Baumgarten M, Strom BL. The incidence and prevalence of pressure ulcers among elderly patients in general medical practice. Ann Epidemiol. 2002;12(5):321–325.

2. Reger SI, Ranganathan VK, Sahgal V. Support surface interface pressure, microenvironment, and the prevalence of pressure ulcers: an analysis of the literature. Ostomy Wound Manage. 2007;53(10):50–58.

3. Lyder CH, Shannon R, Empleo-Frazier O, McGeHee D, White C. A comprehensive program to prevent pressure ulcers in long-term care: exploring costs and outcomes. Ostomy Wound Manage. 2002;48(4):52–62.

4. McInerney JA. Reducing hospital-acquired pressure ulcer prevalence through a focused prevention program. Adv Skin Wound Care. 2008;(2):75–78.


lboltonsays: July 29.2009 at 16:14 pm

Dear Barbara and co-editors, beautiful work on OWM!!
Please send me a .pdf file of this article:
Bolton LL, Girolami S, Slayton S, Berger TM, Foster L, Whittington KT, Merkle D and the Association for the Advancement of Wound Care Guideline Department. Assessing the need for developing a comprehensive content-validated pressure ulcer guideline. Ostomy Wound Management 2008; 54(11):22-30 and also of:
Bolton LL, Corbett L, Bernato DL, Dotson P, Laraus S, Merkle D, Patterson G, Phillips T, McNees P, Porter Riedesel P, Sheehan P and the AAWC Government and Regulatory Task Force. Development of a content-validated venous ulcer guideline. Ostomy/Wound Management 2006; 52(11):32-48.

Many thanks! Laura Bolton

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