EUROPEAN PRESSURE ULCER ADVISORY PANEL

EPIDEMIOLOGY OF PRESSURE ULCERS TREATED BY COMMUNITY NURSES IN A DISTRICT OF BARCELONA

Roser Centelles Hernández
Cerdanyola del Vallès, Spain

Introduction
Community Health Care network in Spain is organized by Community Health Care Teams (CHCT). Community nurses are responsible for the prevention and treatment of pressure ulcers in homebound patients as well as the education of their family caregivers. The lack of epidemiological surveys about pressure ulcers in the community in Spain was the reason why we carried out the present survey.

Aim, Design and Population Studied
To establish the epidemiology of pressure ulcers treated by community nurses in the district of Sant Martí in the city of Barcelona – Prevalence survey that took place between 15th and 26th March 1999 – The District of Sant Martí holds an urban population with a low-medium income and a 8.3% of its population above the age of 65. The target population of the survey was 147,205 who were covered from eleven Community Health Care Teams.

Methods
The survey took place with the use of a data collecting sheet which included the definition of the parameters included in the study, and was given out to all community nurses of the eleven centres. Patients with chronic ulcers of other aetiologies were excluded. Patient records included: age, sex, risk factors, number of ulcers, stage (according to the Spanish Pressure Ulcer and Chronic Wounds Advisory Panel-GNEAUPP-classification), age of the wound, number of weekly treatments, time spent (in treatment and travel), who carried out the treatment and where ulcers were originated. Frequency, averages and medians were calculated using a SPSS statistical package.

Results
Fifty-two patients were found to have pressure ulcers, thirty-six women and sixteen men with an average age of 81.8 years and a total number of 98 pressure ulcers. Four pressure ulcers in patients less than 65, eight in the group (65–74), sixteen (75–84) and twenty-four (85 and more).

The main risk factors were: long stay in bed, cognitive impairment and incontinence. 71 pressure ulcers (73%) were originated in the patient home, 18 (18.3%) in acute hospitals, one in an elderly home (1%) and eight of unknown origin. Seven pressure ulcers were stage I, 44 stage II, 28 stage III and 19 stage IV. 24 wounds were located in heels, 21 in sacrums and 13 in trochanters. In 45 cases family caregivers contributed in the treatment of the patients. Wounds were treated 5,07 times a week. 74.4 minutes were spent a week in their treatment.

Discussion
A low prevalence was found in our community in comparison with other studies, as well as an increment in the involvement of family caregivers as a result of the health education and assessment efforts of the community nurses.

We emphasize the motivation of nurses about education and resources management.

COST EFFICIENCY ANALYSIS OF THE PREVENTION AND THE TREATMENT OF PRESSURE ULCERS

Miss Romina Miot
Commercial Engineer Student,
Hopital Erasme,
Brussels, Belgium

Introduction
It is difficulty to estimate the cost of pressure ulcers, there are some studies but the calculations are rough. The tendency to an ageing population and the weight of the pressure ulcers as co-morbidity factory justify the evaluation of the financial impact of pressure ulcers. According to an audit conducted in 204 hospitals in Belgium, in 1998, 27% of the (10,432) patients at risk were struck down by pressure ulcers and 90% of these were older than 60.

The object of this study is to determine which of the alternatives; prevention or treatment, is the most cost effective in order to lead to a better resources allocation.

Methodology
The study is based on Belgian data. Some of them are coming from the data bank of national audits realised in 1995, 1996 and 1997 and supported by the Ministry of Social Affairs, Public Health and Environment. Other data came from a questionnaire submitted to nurses in November 1998. Finally, the data of drugs consumption related to the treatment of pressure sores is provided by the suppliers. The study is realised in collaboration with the Belgian Group of Quality Assurance on Pressure Ulcers Prevention led by A Jacquerye, L Holtzer and M Vrebos.

In fact, there are two major parts in any cost efficiency analysis: the costs compilation on the one hand and the efficiency measure on the other.

The society point of view has been chosen to reveal the annual cost of the existing prevention and treatment. The total cost of prevention included the cost of the most important preventive measures and has been determined using a decision model, the decision trees while the cost of treatment used the technique of the simple counting of costs.

Then, as the existing prevention was not optimum, we have calculated the annual costs of an optimal prevention related to the lowest annual treatment cost covering only the unavoidable, extra muros pressure ulcer. The optimum prevention was based on a mobilisation time of 37 minutes per patient per 24 hours while the existing one was related to a mobilisation time of 32 minutes per patient per 24 hours.

As far as the efficiency is concerned, two measures seemed appropriate to interpret the right value of the prevention and the treatment: on the one hand, we have considered the length of the pressure ulcer, on the other, the nursing time gained without any intra muros pressure ulcer.

Results
At this point, the results revealed that an optimum would be more cost effective than treatment. Some figures would better illustrate this conclusion. First of all, the daily individual cost for prevention is 2.5 times less than the corresponding treatment cost. This result supports the conclusion of a study realised by Oot-Giromini in 1989. Second, an optimum prevention could have saved 1.6 billion BEF in 1995, 1.4 in 1996, 1.1 in 1997. Finally, this optimum prevention was associated with 52 days of 8 hours gained per unit at risk in 1997 if there has been no intra muros pressure ulcers.

Comments
The results of this study have undergone a sensitivity analysis which has demonstrated their hardness. Nevertheless, any study has some limits. Here, we include as well the limited exploitable and available data sources as the unavoidable hypothesis of the study. To conclude, we can admit that an optimal prevention would be incredibly interesting as well as at the economical level as at the health level. In order to avoid the existing wasting, it would be better to transfer the treatment credits to prevention ones.

PRESSURE ULCERS ARE STILL BEING CAUSED BY NEGLECT

Deborah Hofman
Wound Healing Institute,
Churchill Hospital,
Oxford, England

‘Pressure damage is common in many healthcare settings, affecting all age groups, and is costly both in terms of human suffering and use of resources. With an ageing population, and changes in patterns of sickness, this problem will increase unless action is taken. In all care settings the risk of pressure damage should be highlighted.’1

Most pressure damage can be prevented, and it can be argued that not to prevent the preventable constitutes neglect.

Pressure ulcers are caused by a combination of extrinsic and intrinsic factors.2 Extrinsic causes of pressure damage are pressure, shear and friction. Pressure is the most important factor in the development of pressure ulcers resulting in localised ischaemia of the soft tissue between the bed or chair surface. Friction and shear occur when the patient slides down the bed or is dragged rather than lifted. This type of pressure damage occurs most frequently in hospitals or nursing homes. Intrinsic factors include patient’s age, weight, mobility, nutritional status, continence and general medical condition. These should all be taken into consideration when assessing risk factors.

The following case studies of avoidable pressure damage illustrate the need for vigilance from nursing and medical staff in order to prevent this debilitating , unpleasant and frequently painful condition.

Education of nurse doctors care assistants, patients and their relatives is vital in prevention of pressure damage. In order to achieve this it is desirable to have a designated specialist nurse whose aims are to define, develop, implement and evaluate a pressure ulcer prevention policy.3

1. EPUAP Pressure Ulcer Prevention Guidelines
2. Dealey, C. The Care of Wounds. Blackwell Science, Oxford 1994, pp.84–88.
3. Livesley, B. and Simpson, G.(1989) The hard cost of soft sores. Health Service Journal 99: 5138,231.

THE ACCURACY OF PRESSURE SORE DATA

Maureen Benbow
Tissue Viability Nurse,
Mid Cheshire Hospital Trust,
Cheshire, England

The occurrence of pressure sores is being viewed as a negative quality indicator of care in health care organisations by the Department of Health (Department of Health 1993). Therefore, reliable information is needed to inform national and local policy and practice decisions, supporting the provision and utilisation of appropriate resources to deal with the growing and costly problem of pressure sores.

In 1991, in response to national and local pressure from purchasers, I implemented a pressure sore strategy which included a system for measuring pressure sore incidence in the acute, 700 bedded Trust, where I am employed as a Tissue Viability Nurse. The data collected are used by my Trust to calculate resource needs for specialist mattresses, audit the pressure sore guidelines, and identify staff training needs. Over time, as the data were collected and analysed, I began to suspect that an accurate picture of the number and severity of pressure sores in the Trust was not being presented.

A search of the professional and research literature revealed that very little, if anything, had been written about how to assess the accuracy of data collection systems in general, and in particular, about pressure sore incidence monitoring systems. The majority of authors in the research literature focussed on risk assessment and management whilst the professional articles focussed concern on establishing systems for measurement of pressure sores. The practice implications for the present study were that there were few guidelines to be utilised for further research. From this the research question emerged as:

What evidence is there that the current system for monitoring pressure sore incidence produces accurate data?

Given the nature of the research question and the complex nature of collecting pressure sore data, it was decided to evaluate the pressure sore incidence system using a pluralistic approach.

The first part of the study used a questionnaire administered to Tissue Viability Nurses to explore whether they monitored pressure sores and, if so, also checked the data for accuracy. The second stage used participant observation and research diary methods to check the accuracy and reporting of data collected in my Trust. Finally, a semi-structured interview technique was used to discuss the findings from the second stage of the study with Wound Care Link Nurses.

The findings indicated that, where systems are in place, Tissue Viability Nurses do not systematically check the accuracy of data. It was also confirmed that the system of data collection in my Trust produced inaccurate data. The implications of this finding are, that given the costs of collecting pressure sore data the question must be asked how cost-effective is the method and should we perpetuate a system that produces inaccurate data?

Findings from the interviews with Link Nurses confirmed that increasing work pressures in the clinical area meant that patient care must take priority over what could be regarded as ‘more paperwork’. Qualitative data illuminated issues about ward organisation, leadership and the role of the link nurse so enabling conclusions to be drawn which have organisation-wide implications for improving quality.