1. Maklebust, JoAnn MSN, RN, ACNS-BC, AOCN, FAAN

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I was asked to write a Happy 25th Birthday tribute to the National Pressure Ulcer Advisory Panel (NPUAP), in conjunction with the silver anniversary of this journal. As a founding member of the NPUAP and former editor-in-chief of Advances in Skin & Wound Care, it is a great honor for me to have this opportunity. I have chosen to reflect on my association with the NPUAP and what the panel has meant to me.


In 1987, Dr Thomas Stewart, then President of Gaymar Industries, Inc (now Stryker Corporation), called together a multidisciplinary group of healthcare professionals interested in pressure ulcer (PrU) prevention. After the invitees arrived at the meeting, I looked around the room at the individuals gathered there and did not recognize many of them. When introductions were made, however, it became clear to me that I was in the company of greatness. These were people whose names I recognized well from the PrU literature. I had read published works by most of them but never before had the opportunity to meet them face-to-face. Many of us were not sure why we had been selected to come together. But Dr Stewart knew the reason. He was a scientist who had a dream and a plan that was unknown to us. Together, Dr Stewart and Gaymar were prepared to have us become something greater than we could imagine. The plan was to bring life to the old adage ''the whole is greater than the sum of its parts,'' and each of us as individuals were the parts. Little did we know that our destiny was to become an advocacy group known as the NPUAP. Initial members included researchers, physicians, nurses, wound care specialists, educators, rehabilitation specialists, geriatric specialists, therapists, a journal editor, and a hospital administrator. Together, we were to champion the cause of PrU prevention and provide leadership and guidance toward making PrU prevention a reality.


After initial discussions about ''how to begin'' this enormous responsibility, most of us enthusiastically agreed to participate. Membership and the impending workload were a voluntary effort, and this needed to fit into our already busy job responsibilities. After making decisions about housekeeping tasks, such as frequency of NPUAP meetings, selection of officers, mission committees, and policies and procedures needed, we began to devise various ways to accomplish our mission. In order to have any credibility as an organization, we needed to become a recognized entity. We decided to dream BIG. First, Tom Stewart would announce our existence and publish the NPUAP mission statement and tenets. We decided a quick way to get noticed was to support a House Bill about caregiver responsibility in long-term-care facilities that was already in process. We also planned to hold a consensus development conference on PrU prevention. Some of us went to Washington, District of Columbia, to try to meet with the National Institutes of Health (NIH), the National Academy of Sciences (NAS), and US Congressional members or their aides. We pleaded our case for a Pressure Ulcer Consensus Development Conference with the NIH, who agreed with the need, but told us their already full agenda would require us to wait several years. We were impatient and wanted the conference now, so we plunged ahead and arranged it ourselves. The NIH supported our efforts by sending us 3 conference speakers and 2 US Congress members. The NPUAP Consensus Conference was a resounding success, and fortunately, our journal editor panel member was able to publish the proceedings. Several members of the industry assisted in underwriting some of our PrU prevention efforts, such as publishing our mission statement and tenets, printing the NPUAP Consensus Conference Statements, and building us an exhibitor booth for visibility at conferences.


Our visit to the NAS got us an invitation to submit an objective to Healthy People 2000. Because I live and work near Wayne State University, Detroit, Michigan, a site where the US Public Health Service was holding regional hearings for the Healthy People 2000 Objectives for the Nation, I was assigned to testify on behalf of the NPUAP. As I listened to speakers from other organizations present their data, I noticed they included ways to measure their objectives. I had no such data because our organization was brand new, and data did not yet exist. On the spot while testifying, I declared that the NPUAP would decrease PrUs by 50% by the year 2000. Imagine my surprise when this goal became the overarching NPUAP objective for the next 10 years! In fact, 10 years later, members of the NPUAP published a very important monograph titled ''Pressure Ulcers in America: Prevalence, Incidence and Implications for the Future.'' This document is currently undergoing an update.


As editor-in-chief of Advances in Skin & Wound Care, I had the opportunity to publish editorial opinions. David Margolis, MD, PhD, a dermatologist at the University of Pennsylvania in Philadelphia, and I published an opinion that identified the fallacies of the MDS-2 format for documentation of PrU screening in long-term-care settings. I like to think that this helped force the issue to revise MDS-3 for correct documentation of PrUs in long-term-care facilities. Many of the PrU measurement criteria on the new MDS-3 came directly from the NPUAP Pressure Ulcer Scale for Healing tool. Recently, the Centers for Medicare & Medicaid (CMS) MDS 3.0 Team received an award from the NPUAP for revising and modeling the MDS-3.0 to coincide with evidence brought forward by the NPUAP.


For me personally, as chair of the NPUAP Public Policy Committee I will always feel proud of the NPUAP's accomplishment of changing the Medicare Policy Manual. After a long and difficult process, we finally convinced our leaders to continue coverage and payment for wound care dressings for Medicare beneficiaries with chronic wounds such as PrUs. Without that, Medicare would not cover wound care materials as a benefit for patients with anything but surgical wounds. Members of our NPUAP public policy committee spent many hours on the hill in Washington, District of Columbia, and in telephone conferences with the Health Care Financing Administration (now CMS) advocating successfully for this Medicare benefit for the American public. It is not every day that you can change government policy, but the NPUAP did!


As the NPUAP became noticed more and more, many healthcare professionals and companies asked to join our efforts. We also had many requests to include PrU treatment as part of our mission. After the Agency for Health Care Policy and Research (AHCPR [now the Agency for Healthcare Research and Quality (AHRQ)]) announced that pressure ulcer prevention and treatment of pressure ulcers were on the list to become Clinical Practice Guidelines, it became clear that this was a good fit for NPUAP involvement. In fact, many NPUAP members were chosen for membership on the AHCPR clinical practice guideline panels. Often people confused the 2 panels because there were so many members seated on both. In fact, the NPUAP held a very helpful and successful conference to critique the draft of the AHCPR Guideline on Treatment of Pressure Ulcers.


In the United States, much of PrU care is modeled after the NPUAP consensus conference findings. The National Database for Nursing Quality Indicators and NPUAP Biennial Conferences and publications continue to fill the educational needs of healthcare personnel. New questions are asked, and the NPUAP strives to answer them with rigorous review of the literature or by holding consensus conferences. In 2010, the NPUAP hosted a multidisciplinary conference to establish consensus on whether there are individuals in whom PrU development may be unavoidable. The NPUAP also conferred on whether there are changes in human skin at the end of life that relate to pressure ulceration.


Perhaps the NPUAP's greatest accomplishment has been acting as a role model for the United States and other countries. The European Pressure Ulcer Advisory Panel (EPUAP) and the Japanese Society of Pressure Ulcers were formed because the NPUAP has been so successful. Many other countries, including China, South Korea, Australia, and the United Arab Emirates, have attended NPUAP conferences. Indeed, PrUs are a worldwide problem. This became very evident when the NPUAP and EPUAP joined to update the AHCPR Guidelines on Pressure Ulcers. The EPUAP reviewed the literature on PrU prevention, and the NPUAP reviewed the literature on PrU treatment. The newly revised document is titled the ''NPUAP/EPUAP International Pressure Ulcer Guidelines for Prevention and Treatment.'' A joint presentation of the updated PrU guidelines was cohosted in both nations. This international document is now the standard of care for most first-world countries.


The NPUAP started as a dream in Dr Stewart's mind and developed into something that is changing the standard of care worldwide. Indeed, the NPUAP has grown into greatness by fulfilling its mission of serving as the authoritative voice for improved patient outcomes in PrU prevention and treatment through public policy, education, and research. I was an NPUAP board member for 9 years, and I count it as a peak experience in my life because I know that together we made a difference for patients. Many NPUAP members dislike rotating off the panel because it is such a fulfilling experience to serve on something so worthwhile. Some members run for a second term, even though it is volunteer work. I have no doubt that, because of panel member commitment, the NPUAP will continue to become even greater. So, Happy Birthday NPUAP, may you live forever!