
==== Front
Int Wound J
Int Wound J
10.1111/(ISSN)1742-481X
IWJ
International Wound Journal
1742-4801
1742-481X
Blackwell Publishing Ltd Oxford, UK

39254059
10.1111/iwj.70036
IWJ70036
Review Article
Review Article
The uptake of the international pressure ulcer/injury prevention and treatment guidelines: An updated systematic citation analysis
El Genedy‐Kalyoncu and Kottner
El Genedy‐Kalyoncu Monira https://orcid.org/0000-0001-5947-847X
1 monira.el-genedy@charite.de

Kottner Jan https://orcid.org/0000-0003-0750-3818
1
1 Institute of Clinical Nursing Science Charité—Universitätsmedizin Berlin Berlin Germany
* Correspondence
Monira El Genedy‐Kalyoncu, Institute of Clinical Nursing Science, Charité—Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.
Email: monira.el-genedy@charite.de

10 9 2024
9 2024
21 9 10.1111/iwj.v21.9 e7003612 8 2024
11 7 2024
12 8 2024
© 2024 The Author(s). International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Abstract

The European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance collaboratively developed three editions of the International Clinical Practice Guidelines for preventing and treating pressure ulcers/injuries in 2009, 2014, and 2019. Dissemination and uptake of these guidelines are important to improve care. The aim of this work was to provide an updated and expanded citation analysis of the three published guidelines. Referencing formats, citation counts, and global distribution of citations of the 2009, 2014, and 2019 guidelines were searched in the citation database Scopus from 2009 to 2023. Duplicates were removed manually. The search identified 330 referencing formats with 2887 citations from 2009 to 2023 for the three guideline editions. Citations displayed geographical diversity, with citation peaks observed approximately 4 years after each edition's release and ongoing citations to the present. The International Clinical Practice Guidelines for preventing and treating pressure ulcers/injuries updated since 2009 were cited more than 2800 times in the scientific literature exceeding the thresholds of highly cited papers in the field of clinical medicine. This indicates successful dissemination worldwide.

information dissemination
practice guideline
pressure injury
pressure ulcer
skin
source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:10.09.2024
El Genedy‐Kalyoncu M , Kottner J . The uptake of the international pressure ulcer/injury prevention and treatment guidelines: An updated systematic citation analysis. Int Wound J. 2024;21 (9 ):e70036. doi:10.1111/iwj.70036 39254059
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pmc1 INTRODUCTION

Clinical practice guidelines (CPGs) are systematically developed statements that include recommendations intended to assist practitioners and patients in making decisions about appropriate health care in specific clinical circumstances. 1 CPGs are based on a thorough review of evidence and a careful assessment of the benefits and harms of alternative care options to optimize patient care. 2 For many years, the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) collaborated to develop and update CPGs in the field of pressure ulcer/injury prevention and treatment. 3 , 4 , 5 These guidelines aim to provide evidence‐based recommendations for the prevention and treatment of pressure ulcers/injuries. They target healthcare professionals, patients, and all caregivers. This includes both formal caregivers and informal caregivers, such as family members who provide care at home, across various populations and settings globally. The first joint guideline was released in 2009, 6 followed by its first revision in 2014, 7 and the most recent update in 2019. 8 A fourth edition is in preparation already. 9

Despite extensive research and advancements in practice, pressure ulcers/injuries remain a significant burden on patients and healthcare systems. Particularly in high‐risk settings and populations such as long‐term or intensive care, and especially in geriatric populations, the incidence and prevalence of pressure ulcers/injuries are high. 7 , 10 , 11 Pressure ulcers/injuries also represent a substantial financial burden on healthcare resources and personnel. 12 For patients, these conditions often result in prolonged hospital stays, increased pain and discomfort, and a reduced quality of life. 13 , 14 Their occurrence is widely considered an adverse outcome and used as an indicator of care quality. 15 , 16 Consequently, enhancing prevention and treatment strategies for pressure ulcers/injuries remains crucial.

Adhering to CPGs has been shown to improve care and patient outcomes. 17 , 18 , 19 However, effective adoption requires awareness among the target audience, making the dissemination of CPG information and materials crucial. To promote effective dissemination among target groups, the Guideline Development Groups and the sponsoring organizations EPUAP, NPIAP, and PPPIA use various strategies, including conference presentations, social media campaigns, journal publications, and editorials. Additionally, the CPGs are available not only as comprehensive full versions but also as short versions (quick reference guides, QRGs), provided free of charge and translated into nearly 20 different languages. Given the extensive work involving dozens of individuals —from experts to caregivers and patients—to create, update, translate, and disseminate these guidelines, it is necessary to explore the effects of these activities.

Dissemination of all three editions of the international pressure ulcer/injury guidelines has been robust. The 2009 edition was distributed to over 200 000 individuals on 7 continents and translated into 17 languages. The 2014 edition was disseminated to over 225 000 individuals world‐wide and translated into 14 languages. The most recent edition (2019) has been disseminated to over 275 000 individuals and translated into 20 languages. Requests for CPGs and QRGs usually peak in the first 18 months after release. Free digital copies of the 2019 CPG and QRG are still available at www.internationalguideline.com.

Dissemination of CPGs and QRGs is a necessary, but not sufficient measure of acceptance and integration of the evidence‐based guideline recommendations. One method to assess the dissemination of publications is through citation analysis, by evaluating the uptake in the academic literature based on the number of citations. This information can be retrieved by cited reference searches in citation databases. For this analysis, Scopus 20 was used as the primary citation database. Scopus includes, beside its core records, approximately 227 million non‐core or secondary documents which are retrieved from reference lists or citations of core records but are not themselves indexed in Scopus. 21 With over 2.4 billion cited references, Scopus provides the opportunity to find citations even for non‐indexed items. 21 Neither the three published CPGs, 6 , 7 , 8 nor the QRGs are regularly indexed in the Scopus Core Collection.

The aim of this research is to provide a comprehensive overview of the global uptake of these guidelines in the academic literature.

2 MATERIALS AND METHODS

2.1 Search strategy

The search for citations of the 2009, 2014, and 2019 versions of the CPGs and QRGs (including translated versions) was conducted in May 2024 in the Scopus database from January 2009/2014/2019 to December 2023. The search was based on a previously developed search strategy, 22 which was iteratively developed to ensure high sensitivity and specificity (complete search queries see Appendix). The Scopus search was conducted using the advanced search feature, which allows for more precise and complex queries compared to the standard search. It enables the use of specific field codes, Boolean operators, wildcards, and proximity operators, ensuring higher accuracy and relevance of the retrieved records.

The search utilized the “REF” field code for each key term/phrase. This combined field allows searching within the author, document title, source title, publication year, page number, or URL of a cited reference, making it particularly effective for retrieving specific citations and variations thereof. Key terms and phrases, including names and abbreviations of the guideline documents and sponsoring organizations, were searched using the Boolean operator “OR”. The secondary document search was limited to the year of publication of the respective guideline edition by the field code “REFPUBYEAR” and the date range of retrieved items citing the guidelines was limited by using the field code “PUBYEAR”. Both of these field codes were included in the search query string by using the Boolean operator “AND”. Wildcards, such as the asterisk “*”, were employed to replace one or more characters in a search term. For example, “gui*” would retrieve “guideline,” “guidelines,” and “guidelining.” These were used to account for spelling variations and misspellings, ensuring comprehensive retrieval of relevant citations. Proximity operators were used to find words within a certain distance of each other, which allowed to narrow down the search results by ensuring that relevant terms appear close together in the retrieved documents. For example, the operator “w/n” was used to find terms within “n” words of each other, improving the precision of the search.

2.2 Data retrieval

Using the search strategy described above, Scopus displays all search results based on the search query. Along with these results, a separate tab “View Secondary Documents” can be found. These secondary documents were of particular interest for this search as they include documents not currently indexed in the Scopus database but extracted from reference lists of indexed content of the Scopus Core Collection. This allows tracking of non‐indexed materials, such as guidelines, cited by articles listed in Scopus. Secondary documents were retrieved to identify potential cited references of interest. After retrieving the secondary documents in Scopus, each result was individually checked to ensure it actually referred to the guideline documents of interest and not to similar or related entries (e.g., references to newsletters, conference contributions, or associated websites). Relevant database entries were then selected and exported as a CSV file.

In this analysis, “referencing formats” refers to the various ways in which the guidelines were cited and listed as secondary documents in the database. Therefore, referencing format and secondary document counts can be considered synonymous in this context. These formats include differences in how authors, titles, publication years, and other citation elements were presented. To better understand the impact of these variations, we examined the total counts of relevant selected secondary documents, which reflect the variety of citation styles used. The total counts of relevant selected secondary documents reflect the variety of different referencing formats for the respective guideline documents in the database. For each selected secondary document (or referencing format), the number of times this document was cited can be found in the row “Cited by”. Additionally, citing documents were manually reviewed for duplicates, and any duplicates found were removed.

2.3 Analysis

Extracted data were used to determine the number of citations per year and referencing formats of the guidelines listed in the Scopus database. For all identified referencing formats of the guidelines, the individual citation count was documented separately and displayed in tables. The total number of citations for the 2009, 2014, and 2019 guidelines were displayed in grouped bar graphs per year (from 2009 to 2023). Additionally, the global distribution of citations was analysed based on authors' affiliations, irrespective of the journals' publishers' location, using heat maps.

3 RESULTS

3.1 Referencing formats and citation counts

The advanced search for the 2009 CPGs/QRGs resulted in a total of 93 secondary documents, that were cited by 767 documents until the end of the year 2023. Further, a total of 124 secondary documents with 1439 citing references were identified for the 2014 CPG/QRGs and 113 secondary documents with 681 citing references were found for the 2019 CPG/QRGs (detailed overview see Appendix Tables A.1–A.3).

3.2 Citations per year

Citations per year are shown in Figure 1. Since the release of the first edition in 2009, there has been a gradual upward trend in citation counts, reaching its peak in 2014. Following the release of the second edition of the guideline in 2014, citations for the 2009 edition began to decline within the following years, though it continues to be cited. In parallel, the numbers of citations for the 2014 guideline continuously increased after its release. This trend mirrors the previous pattern, with the 2014 guideline reaching its citation peak in 2019, coinciding with the release of the third edition. Similar to the earlier observation, the number of citations for the 2014 guideline decreased following the release of the 2019 guideline, while citations for the 2019 guideline gradually increased.

FIGURE 1 Number of citations of the Clinical Practice Guidelines and Quick Reference Guides per year in Scopus (22 May 2024).

3.3 Global distribution of citations

The global distribution of citations for the 2009, 2014, and 2019 CPGs/QRGs shows a range of countries and regions. The three most relevant regions in terms of citation counts were North America, Europe, and Asia‐Pacific (Figure 2). North America was the leading region, with the United States contributing the highest number of citations for all three editions (235/382/169). Canada also showed a significant number of citations (30/49/15). In Europe, the United Kingdom stood out with (159/281/114) citations, followed by Germany (43/75/28). The Asia‐Pacific region demonstrates considerable engagement, with Australia contributing (81/181/125), Japan (29/47/19), and China (28/83/79) citations.

FIGURE 2 Heat map of global distribution of citations based on author affiliations for the (A) 2009, (B) 2014, and (C) 2019 Clinical Practice Guidelines and Quick Reference Guides.

4 DISCUSSION

Since their respective releases, the 2009 guideline 6 has been cited more than 750 times, the 2014 guideline 7 over 1400 times, and the 2019 guideline 8 more than 650 times. According to the Essential Science Indicators (ESI) from Clarivate, 23 the threshold for highly cited papers is defined as the minimum number of citations received by the top 1% of papers in a research field published in a given year. It was found that citation numbers of the 2014 CPG/QRGs in the years 2017 to 2023 exceeded these thresholds for “Highly Cited” papers in the field of “Clinical Medicine”. 24 The same applies for the 2019 guideline 8 for the years 2021 to 2023 and the 2009 guideline for the year 2023. These findings indicate that all three guideline documents, including their derivative versions, have achieved substantial uptake in the scientific literature. These data also support the conclusion that the comprehensive dissemination strategies have been and remain effective, resulting in widespread recognition and utilization within the academic community. The consistent citation numbers across multiple editions reflect the guidelines' ongoing relevance and impact in the field of pressure ulcer/injury prevention and treatment.

An initial iterative search process conducted in 2020 identified already over 100 referencing formats for the 2014 CPG, 7 resulting in about 800 citations by February 2020. 22 This finding highlighted the significant heterogeneity in the referencing formats, which complicates the identification of the times cited. The pronounced heterogeneity in referencing formats is unexpected, especially considering that each CPG and QRG document provided a recommended citation format and an ISSN. Additionally, information about the citations for the other two editions (2009 and 2019) was limited, and the dynamics of citation uptake post‐release over time were unclear. This is critical, as guidelines typically require revision within a five‐year cycle and outdated CPGs should not be used, especially when up‐to‐date, evidence‐based recommendations are available. 4 To address these gaps and provide a more comprehensive analysis, a thorough search in the databases Scopus and Web of Science was conducted for the 2009, 2014, and 2019 versions of the guideline, covering the years 2009 to 2021. 22 Within this updated project, the previously developed search strategy 22 was used again in the Scopus and Web of Science databases, to include data up to the present. However, results from the Web of Science search were not reproducible and provided implausible citation counts, which persisted even after several revisions of the search strategy. One possible explanation could be more variable indexing practices and inconsistent coverage over time at Web of Science. This inconsistency may be attributed to differing indexing algorithms, periodic database updates, or changes in the indexing policies at Web of Science. Scopus performed better in this context, likely due to its broader and more consistent coverage of citation data, as well as its advanced search capabilities, which can more accurately identify and count relevant citations. Additionally, Scopus is a subscription‐based product with a single paid access model, while Web of Science offers a basic version for free (Web of Science Platform) and an additional subscription‐based access (Web of Science Core Collection). In this analysis, only the Web of Science Platform was available, which may have further contributed to the inconsistency and limitations in the citation data retrieved. Therefore, it was decided to focus on the Scopus database only.

Our review has limitations. Although comprehensive and sensitive search strategies were developed and used, it is possible that relevant referencing formats and citations were not identified. In this update, the previously developed search strategy 22 was used without modification to allow consistency and comparability. However, adjustments and alternative search strategies were tested beforehand to exclude the possibility that a different approach might yield better results. These adjustments did not produce any additional or improved results, confirming the robustness of the original strategy. The biggest challenge in our review is that the three CPGs/QRGs editions are not standardized records, and the recommended citation formats within the guidelines were not strictly followed by the majority of publication citations. Therefore, there is substantial variability in referencing formats, which makes it very difficult to locate all relevant citations. Additionally, starting around 2016, select single chapters of the 2014 guideline edition were sold separately. This introduces an additional source of citation variation. These citation variations are included in the overall analysis of the 2014 guideline but were not analysed individually. It is possible that searches in databases like Google Scholar or Microsoft Academic could lead to higher citation counts, as these have higher coverage than Web of Science or Scopus. 25 However, we refrained from using these databases in this analysis because of the non‐transparent algorithms used to process queries and obtain summary results, making it difficult to generate complex searches and make reliable statements about their trustworthiness and reproducibility. 25

For the evaluation of the dissemination and uptake of CPGs and similar documents, citation analyses are one possible approach. Other methods that can be used in this context include surveys, questionnaires, or descriptive studies. 26 , 27 , 28 Citation analysis can provide insights into the academic impact and recognition of the guidelines within the scientific community. It allows us to quantify how often the guidelines are referenced, indicating their influence and integration into academic research. However, citation analysis has its limitations. It does not measure if or how well these guidelines are implemented in clinical practice or their direct impact on patient outcomes. Citations primarily reflect academic usage rather than practical application. Additionally, citation counts can be influenced by factors unrelated to the quality or utility of the guidelines, such as the preferences of the authors or dissemination through professional conferences and other scientific platforms.

To comprehensively evaluate the dissemination and implementation of the guidelines, additional methods are necessary. Surveys and questionnaires can provide direct feedback from healthcare professionals about their awareness, understanding, and use of the guidelines. Descriptive studies can offer qualitative insights into how the guidelines are integrated into clinical workflows and the barriers to their implementation. Interviews and focus groups with key stakeholders, including clinicians, policymakers, and patients, can also shed light on the practical challenges and successes associated with guideline adoption.

In conclusion, it can be stated that the CPGs/QRGs published by the EPUAP, the NPIAP, and the PPPIA have raised substantial awareness and uptake in the scientific literature. Although the effects of this wide international dissemination on implementation and improvement of pressure ulcer/injury care are unclear, this citation analysis serves as a strong foundation for further activities aimed at promoting the adoption of these guidelines in clinical practice. The high global recognition, indicated by widespread citations, reflects a significant first step towards integration into clinical practice, ultimately enhancing patient care and outcomes.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors have no conflict of interest to declare.

Supporting information

Appendix Table A.1. Cited Reference Search in Scopus Guideline Edition 2009.

Appendix Table A.2. Cited Reference Search in Scopus Guideline Edition 2014.

Appendix Table A.3. Cited Reference Search in Scopus Guideline Edition 2019.

ACKNOWLEDGEMENT

Open Access funding enabled and organized by Projekt DEAL.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.
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