EUROPEAN PRESSURE ULCER ADVISORY PANEL

RESEARCH INTO PRESSURE SORE PREVENTION

Mr Miles E Maylor* and Prof Colin Torrance†

*Clinical Nurse Specialist – Tissue Viability/Lecturer (Research), Pembrokeshire and Derwen NHS Trust, School of Health Science, University of Wales, Swansea.
†Professor of Nursing Research and Professional Development, University of Glamorgan, Wales

This research is an investigation into how staff perceptions of the locus of control of pressure sore prevention affects prevalence rates. It attempts to identify whether personal expectations about control of life in general, and pressure sore prevention in particular, affects levels of knowledge and value of the latter, and whether this correlates with pressure sores for differing departments. The assumption that lack of equipment is an explanation for pressure sore development is addressed.

Data were gathered through existing attitude scales, and by a new pressure sore specific locus of control scale modelled on them. Equipment itineraries and prevalence survey was done, and assessment made of social desirability responses and value.

The report concludes that there is a relationship between a cluster of factors and prevalence rates. These include: knowledge levels, value of pressure sore prevention, and locus of control. Factor analysis demonstrated that these factors accounted for 90% of the variance. Mann-Whitney U Tests showed significant differences between community and hospital staff, and between trained and support staff in terms of knowledge, value, locus of control, and prevalence rates. Spearman correlations also indicated significant associations between these factors, varying from weak to strong.

Knowledge and equipment levels were considered to be satisfactory for adequate preventative measures to be taken. The longer a person had been in a post or qualified, the lower their knowledge score. Key personnel, such as sisters, were significantly correlated with prevalence in that the more they believed they controlled pressure sore prevention, the higher the prevalence rate. This has been explained in terms of the priority and importance they attach to pressure sore prevention relative to other demands. Also, the more they believe that fate controls pressure sore prevention, the lower the prevalence rates, perhaps because they invest more in trying to stave off that which they expect to happen.

The recommendations include more refinement and/or replication of the methods, and that effort should be invested in raising the value of pressure sore prevention. Further, organisational lines of control need to be clear to staff. There is also a possibility that certain types of attitudinal stances amongst staff may be unhelpful in a broader range of conditions and outcomes. Selection processes for influential positions should take attitudes and beliefs into account, and attention may be needed to changing control expectations of groups personnel.

INFLUENCING EUROPEAN GOVERNMENTAL POLICY ON PRESSURE SORES

Dr Jeen R E Haalboom
Associate Professor of Internal Medicine,
Department of Internal Medicine,
University Hospital Utrecht,
Utrecht, The Netherlands.

In 1998 health care is strongly connected with policy and economy. The financing of projects in health care largely depends on the ability to influence politicians. There is hardly any connection between the prevalence of a certain disease and the attention of politicians. An interesting example is AIDS. More determining in this respect is the availability of pressure groups and networks. Pressure ulcer patients lack both. Furthermore, pressure sores have an image of defeat, deterioration, death and still usually are not treated by doctors but by nurses. All these aspects make it difficult to attract interest in the decision making groups.

As in all management problems the use of a certain model, for instance the Deming-model, clarifies the method of how to influence it. In the Netherlands we used four different processes to achieve this:

1. definition of the extent of the problem: the installation of prevalence studies at regular intervals
2. implementation projects: methods on how to diffuse new insights and experiences into periferal hospitals and other institutions
3. the installation of quality ratings: some kind of ISO, DIN, CE or TuV normation in order to use only approved devices
4. information of groups of interest: inf. to patients, nurses, doctors, the production of leaflets, videos etc.

The EPUAP could play an important role in most of the processes. Especially the coordination of processes is an important field. In one country registration could be helped, in another the making of the instruction material etc. In a questionnaire we asked some details about the dealing with pressure sore problems in the participating countries. There is until now no common handling of prevention and treatment protocols in our countries. The filling of the lacks, using the experiences of countries who did already is a main target.

All these projects are expensive. The aspect of ‘money’ and the possibility to share costs in a European experiment attracts interest in politicians. Especially the use of a certain quality mark seems to be the first and rather easy to obtain target. Individual actions are not effective. It is necessary to form a committee out of the EPUAP to deal especially with the contacts with politics.

PRESSURE ULCERS AND THE SPINAL CORD INJURED PATIENT

Dr Dan Bader
University Reader in Biomaterials and Bio mechanics,
Queen Mary and Westfield College,
Mile End Road,
London, E1 4NS

Soft tissue breakdown leading to the development of pressure ulcers largely affects individuals, who are debilitated with impaired mobility and sensations. These conditions are often present in young patients with Spinal cord injury (SCI) who can, as a consequence, be at a high risk of tissue breakdown. This risk can be present at any time following the injury, commonly leading to a delay in the initial rehabilitation as well as being a cause for readmittance to hospital at some later stage. Although the cause of the condition is multifactorial, it is well established that prolonged pressure ischaemia will affect the viability of soft tissues leading to their eventual breakdown.

Several techniques have been employed to assess the viability of soft tissues in SCI patients. These include Laser Doppler Fluxmetry (Schubert and Fagrell, 1991), reflective spectrophotometry (Hagisawa et al., 1994) and tissue oxygenation. The author demonstrated that the latter technique could be used as a research tool in a clinical setting (Bader, 1990). This led to a fruitful collaboration with a multidisciplinary team led by Mr Isaac Nusiebath, based at the spinal injuries unit at Stoke Mandeville Hospital. Several studies have been conducted on SCI patients at different stages following their injury. For example, we showed that during the acute phase some patients were at risk of compromising tissue viability in supported tissue area (Bogie et al.,1995). In a separate study, the effectiveness of prescribed wheelchair cushions has been assessed in terms of tissue response at the ischial tuberosities (Bogie et al., 1995). A total of 42 subjects who had sustained traumatic SCI within one year, were monitored on at least two occasions during initial rehabilitation. Changes in transcutaneous gas response (TcPO2 and TCPO2) were monitored concurrently with regional interface pressures. Results indicated some significant correlations between the transcutaneous gas variables established as markers of tissue viability. The results also imply that some sub-group of paraplegics are at a potentially very high risk of tissue breakdown and thus require effective support cushions with strict adherence to a pressure relief regime.

Although the combination of interface pressure and tissue gas tension is now used routinely in a specific clinic setting, there are still no definitive guidelines indicating the precise relationship between compromised tissue gas levels for a set time period and the onset of tissue breakdown (Bader, 1998). In addition the cost of these techniques would clearly prove prohibitive for general use. Therefore other techniques would need to be developed to satisfy the ultimate goal of a universal screening method for assessing the risk of all SCI patients.

References:

• Bader DL. The recovery characteristics of soft tissues following repeated loading. J.Rehab.Res.Dev., 27(2), 141–50, 1990
• Bader DL. The role of the researcher in tissue viability. J. Tiss Viability 8, 19–23, 1988.
• Bogie KM, Nuseibeh I and Bader DL. Trancutaneous gas tensions in the sacrum during the acute phase of spinal cord injury. Engineering in Medicine 206, 1–6, 1992
• Bogie KM, Nuseibeh I and Bader DL. New concepts in the prevention of pressure sores. In: Handbook of Clinical Neurology (H Frankel Ed.) Vol 23, Elsevier: Amsterdam, pp. 347–366, 1992
• Bogie KM, Nuseibeh I and Bader DL. Early progressive changes in tissue viability in the seated spinal cord injures subject. Paraplegia, 33, 141–47, 1995
• Hagisawa S et al. Assessment of skin blood content and oxygenation in spinal injured subjects during reactive hypothermia. J. Rehabil. Res. Dev. 31,1–14, 1994