Wounds International 2(3) SeptemberPractice Expert Commentary on 'Advances in pressure ulcer management in Brazil'

Expert Commentary on 'Advances in pressure ulcer management in Brazil'

01/09/11 | Pressure ulcers, Service development and delivery | Nicola R Waters

Like their Brazilian counterparts, Canadian nurses often take the lead in PU management.

An aging population and increasing incidence of chronic disease means that pressure ulcers (PUs) are also a significant concern in Canada [1]. The country's immense demographic diversity (including the Aboriginal population of Inuit, First Nations [Indians] and Métis), however, presents unique challenges in monitoring the full extent of the issue. While a 2004 survey estimated the average national prevalence of PUs at 26.2% across all healthcare settings in Canada, significant disparities exist in the way PUs are measured, managed and funded in each of the 10 provinces and three territories[2, 3].

Like their Brazilian counterparts, Canadian nurses often take the lead in PU management. Collaboration between nurses, physiotherapists, occupational therapists, physicians, dietitians and pharmacists decrease the incidence and improve healing rates of PUs[4]. Efforts to address the escalating economic burden of PUs, while maintaining high-quality patient-centred care include the development of clinical guidelines and awareness programmes [1, 4, 5]. Each of these recommends an interdisciplinary team approach, focusing on prevention and using validated assessment tools to identify risks and determine appropriate interventions.

One factor driving these initiatives is the increasing organisational requirement for staff to report and explain the presence of PUs[6]. Heated debate on this subject is fueled largely by recent policy changes in the US, where PU development is increasingly linked to staff accountability and funding decisions[7]. While associated practice improvements have undoubtedly reduced prevalence rates, concerns have been raised about negative consequences for the small percentage of patients whose underlying conditions mean an ulcer is inevitable, even with the best possible care[7]. In these situations, the requirement to provide clearly documented evidence is further emphasised. Although health litigation and quality-related reimbursement have traditionally been less prevalent 'north of the border', PUs are now considered a quality measure in a significant number of Canadian long-term care facilities[6] and clinicians here are following these deliberations closely.

Canadian best practice PU recommendations are intended for use across all care settings,[4] yet uptake across the country varies considerably. At a recent wound workshop in northern Canada, I was reminded of the difficulties faced by some clinicians trying to follow existing guidelines. The event was held at a large urban hospital that serves a vast area of sparsely populated and geographically isolated communities. More than half of the residents are Aboriginal people and the population's incidence of chronic disease is growing at an alarming rate[8]. During a discussion about what makes an ideal wound team, participants described how they may be the only clinician for many square kilometres. Connections with other disciplines are often only available electronically. While there is evidence to suggest that telewound programmes are significantly improving outcomes in remote regions,[8] best practice takes on a whole new meaning for these clinicians as they struggle to find resourceful ways to prevent and treat pressure ulcers and other chronic wounds.  

Nicola R Waters, Assistant Professor, Mount Royal University, Calgary,  Alberta, Canada


  1. Registered Nurses’ Association of Ontario [RNAO]. Nursing Best Practice Guideline: Risk Assessment and Prevention of Pressure Ulcers. March 2005. Available at: http://www.rnao.org/Storage/12/638_BPG_Pressure_Ulcers_v2.pdf. (accessed 3 August, 2011)
  2. Waters N. The challenges of providing cost-effective quality wound care in Canada. Wound Care Canada. 2005; 3(1): 22–6,52.
  3. Woodbury M, Houghton P. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy Wound Manage 2004; 50(10): 22–38.
  4. Keast DH, Parslow N, Houghton PE, Norton L, Fraser C. Best practice recommendations for the prevention and treatment of pressure ulcers: update 2006. Wound Care Canada 2006; 4(1): 31–43.
  5. Health Quality Council [HQC]. Saskatchewan skin and wound care guidelines 2006. Available at: http://bit.ly/pyQACg. (accessed 3 August, 2011).
  6. Poss J, Murphy KM, Woodbury GM, et al. Development of the interRAI Pressure Ulcer Risk Scale (PURS) for use in long-term care and homecare settings. BMC Geriatr 2010. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2955034/?tool=pubmed (accessed 3 August, 2011).
  7. Levine JM, Humphrey S, Lebovits S, Fogel J. The unavoidable pressure ulcer: A retrospective case series. J Clin Outcome Manag 2009; 16(8): 359–63.
  8. Canada Health Infoway. Telehealth Benefits and Adoption Connecting People and Providers across Canada 2011. Available at: https://www2.infoway-inforoute.ca/Documents/telehealth_report_2010_en.pdf. (accessed 3 August, 2011).