EUROPEAN PRESSURE ULCER ADVISORY PANEL

DEVELOPING A MINIMUM COMMON DATA SET TO RECORD
THE PREVALENCE OF PRESSURE ULCERS IN EUROPEAN HOSPITALS

Since the early 1970s many investigators have reported the prevalence of pressure ulcers in different care settings and across different countries and a forthcoming EPUAP Review will publish a comprehensive list of such publications and reports. Such data lends itself to immediate comparison between health care providers and their respective countries. For example, a prevalence of 9% in one location and 5% in a second often gives rise to the impression that the second centre somehow is ‘better’ in terms of its pressure ulcer prevention and management. Such impressions of the quality and effectiveness of care may have major consequences in health care systems where the allocation of funding is partly dependent upon a care provider’s position within ‘league tables’ of comparisons between competing providers. However, to date comparisons based upon pressure ulcer prevalence rates are essentially meaningless due to issues of methodology. These methodological differences between studies have included:

• The definitions of pressure ulcers – with some studies reporting non-blanchable erythema with others restricted to reporting breaks in the epidermis
• How data is collected – is the data generated through discussion with ward staff or has the skin of all patients been inspected for the presence of pressure ulcers?
• Who gets included in the comparison – some studies (in hospitals) have reported upon all in-patients including paediatrics, maternity and new-born babies others have only surveyed specific in-patient populations
• How has the denominator been calculated – how has each study decided the total number of patients present during the survey?
• Was the survey conducted on a single day or over a period of time?
• How have data collectors been trained, and to what effect?

These are some, but by no means all, of the methodological issues that have restricted comparison between pressure ulcer prevalence surveys. One further pitfall remains before appropriate comparisons can be made – the patient populations covered by different care providers differ – some populations may be intrinsically healthier than others (often influenced by socio-economic factors), and so a 5% prevalence in a ‘healthy’ population may reflect a greater problem than a 10% prevalence in another care provider.  Any attempt to compare pressure ulcer prevalence rates must consider how to adjust the raw epidemiological data to remove the influence of differences between patient populations.

All of these influences upon comparisons of pressure ulcer prevalence rates were discussed during the 3rd Open Meeting of the European Pressure Ulcer Advisory Panel, last year in Amsterdam. One action arising from these discussions was the formation of a working group charged with the development of a common minimum data set that will allow capture of risk-adjusted prevalence rates. This working group (Plate 1, opposite) included representatives from eleven European countries, with 18 members in attendance when the group met at Heathrow Airport, London on 29 January 2000. Chaired by Jacqui Fletcher (England) and Michael Clark (Wales) (Plate 2, opposite) substantial progress was made on the day, with three key decisions reached:

• Initially the focus of the use of the minimum data set would be to record the prevalence of pressure ulcers across European acute care providers. Extension of the minimum data set to other care settings is a goal for future activity of the EPUAP.
• The items considered to be required in a minimum data set consisted of general data listing the country, type and size of hospital and patient specific data reporting age, gender, Braden score, continence (as indicated by the continence item of the Norton scale), severity and location of pressure ulcers and any interventions used to assist prevention (support surfaces and repositioning). Other data items such as wound dressing use, nutritional status could be collected by individual centres that participated in the survey but these items would not form part of the minimum data set. The minimum data set items would be collected for all in-patients regardless of the presence of a pressure ulcer.
• Data upon the presence of pressure ulcers would be collected only through thorough skin inspection and would not rely upon reports that an individual patient had a pressure ulcer(s).

The meeting decided that a pilot project would be established during 2000 and that the results and recommendations from this pilot work would be presented during the 4th Open Meeting of the EPUAP in Pisa during September 2000. A small group was formed to undertake the detailed work involved in preparing a data collection form and the organisation of the pilot survey. This group included Gerry Bennett (England), Gerrie Bours (Netherlands), Michael Clark (Wales), Tom Defloor (Belgium), Jacqui Fletcher (England) and Luc Téot (France). During the spring and early summer of 2000, the group met on two occasions to develop the data collection instrument, with a third meeting scheduled for August 2000. The latest version of this instrument is illustrated in Figure 1 (opposite) and we would welcome your comments upon both its content and presentation.  The reverse of the form presents a series of notes aimed at assisting data collectors to complete the form in a manner that will allow the automated processing of the data forms received by the EPUAP.

Over the summer the minimum dataset data collection form has been translated into several languages – English, French, Dutch, Flemish, Spanish, Finnish, Portuguese, Italian and German forms now exist and pilot data collection is underway across several countries. The purpose of the data collection (covering 30–40 patients per country) is not to provide definitive comment upon the prevalence of pressure ulcers across Europe but to:

1. explore issues that arise in the completion of the form,
2. identify any country specific challenges that are encountered, and
3. to provide data to allow different case-mix adjustment models to be explored. 

The fruits of this pilot stage will be presented during the forthcoming Pisa meeting of the EPUAP, following comments from conference participants any modifications to the form will be made and widespread data collection across European hospitals is planned to occur during 2001. If you would like to become involved in this project through comments on the data collection instrument or to volunteer to collect data next year, please do not hesitate to contact the EPUAP Business Office.

One of the key training needs for potential data collectors lies in the identification of the severity of encountered pressure ulcers. Plate 3 illustrates (in monochrome) a draft classification guide that will be developed over the coming months. The aim of the guide is to provide illustrations of the different presentations of the four stages of pressure ulcers as described in the EPUAP guidelines on pressure ulcer treatment. For EPUAP members two immediate challenges present; for clinicians we would welcome copies of slides showing ‘difficult to grade’ pressure ulcers along with good illustrations of each grade, these should be forwarded to the EPUAP Business Office and for commercial sponsors we seek support both to produce and disseminate this classification guide. Once again contact the Business Office if your company would be interested in helping the EPUAP produce the classification guide.