1. Baharestani, M. M., J. M. Black, et al. (2009). “Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus.Int Wound J 6(2): 97-104.

    Pressure ulcer prevalence and incidence data are increasingly being used as indicators of quality of care and the efficacy of pressure ulcer prevention protocols. In some health care systems, the occurrence of pressure ulcers is also being linked to reimbursement. The wider use of these epidemiological analyses necessitates that all those involved in pressure ulcer care and prevention have a clear understanding of the definitions and implications of prevalence and incidence rates. In addition, an appreciation of the potential difficulties in conducting prevalence and incidence studies and the possible explanations for differences between studies are important. An international group of experts has worked to produce a consensus document that aims to delineate and discuss the important issues involved, and to provide guidance on approaches to conducting and interpreting pressure ulcer prevalence and incidence studies. The group’s main findings are summarised in this paper.

  2. Bale, S., C. Dealey, et al. (2007). “The experience of living with a pressure ulcer.Nurs Times 103(15): 42-3.

    This short paper presents a qualitative study, reported in detail elsewhere (Hopkins et al, 2006) that investigated the experience of older people with pressure ulcers. The researchers were surprised to find how significant pain associated with the pressure ulcer was to patients or the impact it had on their lives. All quotes from the participants are taken from Hopkins et al (2006).

  3. Beeckman, D., L. Schoonhoven, et al. (2007). “EPUAP classification system for pressure ulcers: European reliability study.J Adv Nurs 60(6): 682-91.

    AIM: This paper is a report of a study of the inter-observer reliability of the European Pressure Ulcer Advisory Panel pressure ulcer classification system and of the differential diagnosis between moisture lesions and pressure ulcers.

    BACKGROUND: Pressure ulcer classification is a valuable tool to provide a common description of ulcer severity for the purposes of clinical practice, audit and research. Despite everyday use of the European Pressure Ulcer Advisory Panel system, its reliability has been evaluated in only a limited number of studies.

    METHODS: A survey was carried out between September 2005 and February 2006 with a convenience sample of 1452 nurses from five European countries. Respondents classified 20 validated photographs as normal skin, blanchable erythema, pressure ulcers (four grades), moisture lesion or combined lesion. The nurses were familiar with the use of the European Pressure Ulcer Advisory Panel classification scale.

    RESULTS: Pressure ulcers were often classified erroneously (kappa = 0.33) and only a minority of nurses reached a substantial level of agreement. Grade 3 lesions were regularly classified as grade 2. Non-blanchable erythema was frequently assessed incorrectly as blanchable erythema. Furthermore, the differential diagnosis between moisture lesions and pressure ulcers appeared to be complicated. CONCLUSION: Inter-observer reliability of the European Pressure Ulcer Advisory Panel classification system was low. Evaluation thus needs to focus on both the clarity and complexity of the system. Definitions and unambiguous descriptions of pressure ulcer grades and the distinction between moisture lesions will probably enhance clarity. To simplify the current classification system, a reduction in the number of grades is suggested.

  4. Beeckman, D., L. Schoonhoven, et al. (2010). “Pressure ulcers and incontinence-associated dermatitis: effectiveness of the Pressure Ulcer Classification education tool on classification by nurses.Qual Saf Health Care 19(5): e3.

    CONTEXT: Previous studies report that pressure ulcer classification and differentiation from incontinence associated dermatitis are difficult. Incorrect classification and differentiation result in incorrect prevention and treatment. Education is important to spread evidence-based insights about this topic and to improve classification skills.

    AIM: To assess the effectiveness of the Pressure Ulcer Classification (PUCLAS) education tool. PUCLAS was developed by the PUCLAS Workgroup of the European Pressure Ulcer Advisory Panel.

    DESIGN: Randomised controlled trial.

    SETTING AND PARTICIPANTS: A convenience sample of 1217 Belgian, Dutch, British and Portuguese nurses.

    OUTCOME MEASURE: Correct classification of pressure ulcer photographs and differentiation from photographs of incontinence-associated dermatitis.

    RESULTS: Baseline, 44.5% of the photographs were classified correctly. In the post-test, the results in the intervention group were significantly higher (63.2%) compared with the control group (53.1%; p < 0.001). The percentage of correct assessments of incontinence associated dermatitis (IAD) was 70.7% in the intervention group and 35.6% in the control group (p < 0.001). The skill to differentiate IAD from pressure ulcers was significantly associated with the experimental intervention (OR 4.07, 95% CI 3.21 to 5.15, p < 0.001).

    CONCLUSION: The PUCLAS tool improved pressure ulcer classification and IAD differentiation significantly.

  5. Beeckman, D., L. Schoonhoven, et al. (2009). “Prevention and treatment of incontinence-associated dermatitis: literature review.J Adv Nurs 65(6): 1141-54.

    AIM: This paper is a report of a review conducted to describe the current evidence about the prevention and treatment of incontinence-associated dermatitis and to formulate recommendations for clinical practice and research.

    BACKGROUND: Incontinence-associated dermatitis is a common problem in patients with incontinence. It is a daily challenge for healthcare professionals to maintain a healthy skin in patients with incontinence.

    DATA SOURCES: PubMed, Cochrane, Embase, the Cumulative Index to Nursing and Allied Health Literature, reference lists and conference proceedings were explored up to September 2008.

    REVIEW METHODS: Publications were included if they reported research on the prevention and treatment of incontinence-associated dermatitis. As little consensus about terminology was found, a very sensitive filter was developed. Study design was not used as a selection criterion due to the explorative character of the review and the scarce literature.

    RESULTS: Thirty-six publications, dealing with 25 different studies, were included. The implementation of a structured perineal skin care programme including skin cleansing and the use of a moisturizer is suggested. A skin protectant is recommended for patients considered at risk of incontinence-associated dermatitis development. Perineal skin cleansers are preferable to using water and soap. Skin care is suggested after each incontinence episode, particularly if faeces are present. The quality of methods in the included studies was low.

    CONCLUSIONS: Incontinence-associated dermatitis can be prevented and healed with timely and appropriate skin cleansing and skin protection. Prevention and treatment should also focus on a proper use of incontinence containment materials. Further research is required to evaluate the efficacy and effectiveness of various interventions.

  6. Beeckman, D., K. Vanderwee, et al. (2009). “Pressure ulcer prevention: development and psychometric validation of a knowledge assessment instrument.Int J Nurs Stud 47(4): 399-410.

    BACKGROUND: Profound knowledge of pressure ulcers is important to enable good prevention. Validity and reliability of instruments assessing pressure ulcer knowledge are limited evaluated in previous research.

    AIMS AND OBJECTIVES: To develop a valid and reliable instrument to assess knowledge of pressure ulcer prevention. DESIGN: Prospective psychometric instrument validation study.

    METHODS: An extensive literature review was performed to develop an instrument to assess knowledge of pressure ulcer prevention. Face and content validity were evaluated in a double Delphi procedure by an expert panel of nine trustees of the European Pressure Ulcer Advisory Panel (EPUAP) who each have extensive experience in pressure ulcer care and research (PhD level). A convenience sample of 608 nurses and nursing students from Belgium and The Netherlands participated to evaluate validity of the multiple-choice test items (item difficulty, discriminating index, quality of the response alternatives), construct validity, internal consistency, and stability of the instrument. The data were collected between February and May 2008.

    RESULTS: A 26-item instrument was developed, reflecting 6 themes expressing the most relevant aspects of pressure ulcer prevention. The content validity was excellent (CVI=0.78-1.00). Group scores of nurses with a (theoretically expected) high level of expertise were found to be statistically significantly higher than those of participants with (theoretically expected) less expertise (p < 0.001). The item difficulty index of the questions ranged from 0.27 to 0.87, while values for item discrimination ranged from 0.29 to 0.65. The quality of the response alternatives was found to be good. The overall internal consistency reliability (Cronbach’s alpha) was 0.77. The 1-week test-retest intraclass correlation coefficient (stability) was 0.88.

    CONCLUSION: The instrument demonstrated acceptable psychometric properties and can be applied in both research and practice for evaluating knowledge about pressure ulcer prevention.

  7. Clark, M., J. M. Schols, et al. (2004). “Pressure ulcers and nutrition: a new European guideline.J Wound Care 13(7): 267-72.

  8. Dealey, C. (2009). “A joint collaboration: international pressure ulcer guidelines.J Wound Care 18(9): 368-72.

    After four years in development, the EPUAP and the NPUAP are ready to release their joint, international, evidence-based pressure ulcer guidelines. This article considers the practice implications of a selection of the new guideline’s statements.

  9. Defloor, T., M. Clark, et al. (2005). “EPUAP statement on prevalence and incidence monitoring of pressure ulcer occurrence.J Tissue Viability 15(3): 20-7.

  10. Defloor, T. and L. Schoonhoven (2004). “Inter-rater reliability of the EPUAP pressure ulcer classification system using photographs.J Clin Nurs 13(8): 952-9.

    BACKGROUND: Many classification systems for grading pressure ulcers are discussed in the literature. Correct identification and classification of a pressure ulcer is important for accurate reporting of the magnitude of the problem, and for timely prevention. The reliability of pressure ulcer classification systems has rarely been tested.

    AIMS AND OBJECTIVES: The purpose of this paper is to examine the inter-rater reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel classification system when using pressure ulcer photographs.

    DESIGN: Survey was among pressure ulcer experts.

    METHODS: Fifty-six photographs were presented to 44 pressure ulcer experts. The experts classified the lesions as normal skin, blanchable erythema, pressure ulcer (four grades) or incontinence lesion. Inter-rater reliability was calculated.

    RESULTS: The multirater-Kappa for the entire group of experts was 0.80 (P < 0.001). Various groups of experts obtained comparable results. Differences in classifications are mainly limited to 1 degree of difference. Incontinence lesions are most often confused with grade 2 (blisters) and grade 3 pressure ulcers (superficial pressure ulcers).

    CONCLUSIONS: The inter-rater reliability of the European Pressure Ulcer Advisory Panel classification appears to be good for the assessment of photographs by experts. The difference between an incontinence lesion and a blister or a superficial pressure ulcer does not always seem clear.

    RELEVANCE TO CLINICAL PRACTICE: The ability to determine correctly whether a lesion is a pressure ulcer lesion is important to assess the effectiveness of preventive measures. In addition, the ability to make a correct distinction between pressure ulcers and incontinence lesions is important as they require different preventive measures. A faulty classification leads to mistaken measures and negative results. Photographs can be used as a practice instrument to learn to discern pressure ulcers from incontinence lesions and to get to know the different grades of pressure ulcers. The Pressure Ulcer Classification software package has been developed to facilitate learning.

  11. Defloor, T., L. Schoonhoven, et al. (2005). “Statement of the European Pressure Ulcer Advisory Panel–pressure ulcer classification: differentiation between pressure ulcers and moisture lesions.J Wound Ostomy Continence Nurs 32(5): 302-6; discussion 306.

  12. Defloor, T., L. Schoonhoven, et al. (2006). “Reliability of the European Pressure Ulcer Advisory Panel classification system.J Adv Nurs 54(2): 189-98.

    AIM: This paper reports a study examining the interrater and intrarater reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel classification system when using photographs of pressure ulcers and incontinence lesions.

    BACKGROUND: Pressure ulcer classification is an essential tool for assessing ulcers and their severity and determining which preventive or therapeutic action is needed. Many classification systems are described in the literature. There are only a limited number of studies that evaluate the interrater reliability of pressure ulcer grading scales. The intrarater reliability is seldom studied.

    METHODS: The study consisted of two phases. In the first phase 56 photographs, together with a random selection of nine photographs from the same set, were presented to 473 nurses. In the second phase, the 56 photographs were presented twice to 86 other nurses with an interval of one month and in a different order. All the nurses were familiar with the European Pressure Ulcer Advisory Panel classification. They did not receive any additional training on classification, and were asked to classify the lesions as normal skin, blanchable erythema, pressure ulcers (four grades, European Pressure Ulcer Advisory Panel classification) or incontinence lesions.

    RESULTS: In the first phase, the multirater-Kappa for the 473 participating nurses was 0.37 (P < 0.001). Non-blanchable erythema was often confused with blanchable erythema and incontinence lesions. Also incontinence lesions were frequently not correctly classified. The intrarater agreement was low (kappa = 0.38). In the second phase, the interrater agreement was not significantly different in both sessions. The intrarater agreement was 0.52.

    CONCLUSION: Both the interrater and intrarater reliability of the European Pressure Ulcer Advisory Panel classification of lesion photographs by nurses was very low. Differentiation between pressure ulcers and incontinence lesions seems to be difficult.

  13. Gethin, G., J. Jordan-O’Brien, et al. (2005). “Estimating costs of pressure area management based on a survey of ulcer care in one Irish hospital.J Wound Care 14(4): 162-5.

    OBJECTIVE: Pressure ulceration remains a significant cause of morbidity for patients and has a real economic impact on the health sector. Studies to date have estimated the cost of management but have not always given a breakdown of how these figures were calculated. There are no published studies that have estimated the cost of management of pressure ulcers in Ireland. A two-part study was therefore undertaken. Part one determined the prevalence of pressure ulcers in a 626-bed Irish acute hospital. Part two set out to derive a best estimate of the cost of managing pressure ulcers in Ireland.

    METHOD: The European Pressure UlcerAdvisory Panel (EPUAP) minimum data set tool was used to complete the prevalence survey. Tissue viability nurses trained in the data-collection tool collected the data. A cost was obtained for all items of care for the management of one patient with three grade IV pressure ulcers over a five-month period.

    RESULTS: Of the patients, 2.5% had pressure ulcers. It cost Euros 119,000 to successfully treat one patient.

    CONCLUSION: We estimate that it costs Euros 250,000,000 per annum to manage pressure ulcers across all care settings in Ireland.

  14. Gorecki, C., J. M. Brown, et al. (2009). “Impact of pressure ulcers on quality of life in older patients: a systematic review.J Am Geriatr Soc 57(7): 1175-83.

    OBJECTIVES: To identify the impact of pressure ulcers (PUs) and PU interventions on health-related quality of life (HRQL).

    DESIGN: Systematic review and metasynthesis of primary research reporting the impact of PU and PU interventions on HRQL according to direct patient reports. Quality assessment criteria were developed and applied. Data extraction identified findings in the form of direct quotes from patients or questionnaire items and domain results. Combined synthesis of qualitative and quantitative research was performed using content analysis to generate categories and themes from findings. Thirteen electronic databases were searched, and hand searching, cross-referencing, contact with experts, and an online search was undertaken. No language restrictions were applied.

    SETTING: Adults with PUs in acute, community, and long-term care settings across Europe, the United States, Asia, and Australia.

    PARTICIPANTS: Thirty-one studies including 2,463 participants with PUs were included in the review. Ages ranged from 17 to 96.

    RESULTS: The review included 10 qualitative and 21 quantitative studies; 293 findings, 46 categories, and 11 themes emerged. The 11 HRQL themes were physical impact, social impact, psychological effect, PU symptoms, general health, and other impacts of PUs: healthcare professional-client relationships, need for versus effect of interventions, impact on others, financial impact, perceived etiology, and need for knowledge.

    CONCLUSION: There is evidence that PUs and PU interventions have a significant impact on HRQL and cause substantial burden to patients.

  15. Gunningberg, L. (2004). “Risk, prevalence and prevention of pressure ulcers in three Swedish healthcare settings.J Wound Care 13(7): 286-90.

    OBJECTIVE: This cross-sectional survey set out to delineate risk, prevalence and prevention of pressure ulcers in a university hospital, a general hospital and a nursing home in Sweden. It also looked at the differences in risk factors and preventive strategies between patients with and without pressure ulcers.

    METHOD: The one-day survey followed the methodology developed by the European Pressure Ulcer Advisory Panel (EPUAP). It was conducted on Tuesday 5 February 2002. Each patient was visited by two registered nurses, their skin was inspected and any pressure ulcer classified according to the EPUAP grading system. A total of 695 patients were included: 612 from the university hospital, 38 from the general hospital and 45 from the nursing home.

    RESULTS: The prevalence of pressure ulcers was 23.9% (university hospital), 13.2% (general hospital) and 20.0% (nursing home). Most (60-66%) of the pressure ulcers in the hospitals were assessed as grade I. Only half of the patients at risk or with pressure ulcers were placed on a pressure-reducing mattress and a third of these patients had a plan for repositioning. Significant variables associated with pressure ulcers were old age, geriatric care, low Braden score and incontinence.

    CONCLUSION: Prevalence of pressure ulcers was higher than expected. Results relating to both prevalence of pressure ulcers (grade I excluded) and the preventive care given to patients at risk or with pressure ulcers accord with those of a larger Dutch study. Attention must focus on the appropriate risk-assessment skills, highlighting grade I as pressure damage, and the use of appropriate preventive strategies, based on the level of risk.

  16. Gunningberg, L. (2006). “EPUAP pressure ulcer prevalence survey in Sweden: a two-year follow-up of quality indicators.J Wound Ostomy Continence Nurs 33(3): 258-66.

    OBJECTIVE: The aim of this study was to determine the effects of quality improvement programs for pressure ulcer prevention by conducting a follow-up survey in a hospital in Sweden.

    DESIGN: A cross-sectional survey design with comparison between data collected in 2002 and 2004.

    SETTING AND SUBJECTS: All inpatient areas were surveyed in the surgical, medical, and geriatric departments in a university hospital. A total of 369 patients were included.

    INSTRUMENTS: The European Pressure Ulcer Advisory Panel data collection form including some additional questions.

    METHODS: The 1-day survey was conducted on March 23, 2004. Each patient was visited by 2 registered nurses, who inspected the patient’s skin for any pressure ulcer classified according to the EPUAP grading system.

    RESULTS: There were no significant differences in gender, age, or Braden score between the patients in surgical, medical, or geriatric care in 2002 and 2004. The overall prevalence of pressure ulcers was 33.3% (grade 1 excluded: 10.9%) in 2002 and 28.2% (grade 1 excluded: 14.1%) in 2004. In surgical care, the prevalence was reduced from 26.8% to 17.3% (P = .051). In medical care, the prevalence was 23.6% in 2002 and 26.7% in 2004. Corresponding prevalence figures for geriatric care were 59.3% and 50.0%. A quarter of the patients in surgical care, a third in medical care, and more than half in geriatric care had a pressure ulcer upon arrival at the ward. The use of pressure-reducing mattresses had increased significantly from 16.0% to 42.7% in medical care (P = .000).

    CONCLUSIONS: The EPUAP methodology has facilitated the introduction of pressure ulcer as a quality indicator at hospital level. Pressure ulcer prevalence surveys with a standardized methodology should be repeated on a regular basis in order to stimulate quality improvement.

  17. Hopkins, A., C. Dealey, et al. (2006). “Patient stories of living with a pressure ulcer.J Adv Nurs 56(4): 345-53.

    AIM: This paper reports the findings of a pilot study exploring the experience of older people living with pressure ulcers.

    BACKGROUND: Pressure ulcers are known to be a significant health burden, but little is known of the impact on the quality of life of the sufferer. They mainly affect older people, and this is a neglected group in previous studies of this topic.
    METHODS: A Heideggerian phenomenological approach was used and patients were recruited if they were over 65 years of age and had a grade 3 or 4 pressure ulcer that had been present for more than a month. Patients were recruited from multiple centres but the data were analysed centrally. The study took place in 2003-2004.

    FINDINGS: Analysis of the transcripts revealed three main themes, all with associated subthemes: pressure ulcers produce endless pain; pressure ulcers produce a restricted life; coping with a pressure ulcer. The endless pain theme had four subthemes: constant presence, keeping still, equipment pain and treatment pain. Some patients found that keeping still reduced their pain. Several patients also reported that pain was exacerbated by their pressure relieving equipment and at dressing change. There were three subthemes for the restricted life theme: impact on self, impact on others and consequences. Patients found that the pressure ulcer restricted their activities and had an impact on their families. In addition, for some, the restrictions delayed their rehabilitation. To cope with their pressure ulcers, patients developed ways of accepting their situation or comparing themselves with others.

    CONCLUSIONS: Although a pilot, this study has produced a wealth of data that demonstrates the impact of pressure ulcers on people. While a larger study is required to obtain a European perspective, it is still reasonable to conclude that the issues of pain and restrictions should be considered in the development of pressure ulcer treatment and prevention guidelines.

  18. James, J., J. A. Evans, et al. (2010). “Pressure ulcer prevalence across Welsh orthopaedic units and community hospitals: surveys based on the European Pressure Ulcer Advisory Panel minimum data set.Int Wound J 7(3): 147-52.

    The survey used the European Pressure Ulcer Advisory Panel (EPUAP) methodology for the collection of pressure ulcer prevalence data. The orthopaedic survey was conducted across all National Health Service Trusts in Wales between 2 and 6 July 2007 while the community hospital survey covering 25% of all community hospital beds was conducted between 21 April 2008 and 2 May 2008. Data were gathered upon 1196 patients (581, 48.6% within orthopaedic units with 615 located in community hospitals). Of these patients, 81 (13.9%) and 162 (26.7%) had pressure ulcers in orthopaedic and community hospitals, respectively. Where patients presented with multiple pressure ulcers, the most severe pressure ulcer was recorded. Across both surveys, most pressure ulcers were reported to be either category I or II with 91 category I wounds (33 in orthopaedic units and 58 in community hospitals). Severe (categories III and IV) pressure ulcers affected 78 patients (19 in orthopaedic units and 59 in community hospitals). Adoption of the EPUAP pressure ulcer prevalence methods can help achieve consistent data upon pressure ulcer prevalence in different health care organisations and specialities. The adoption of a consistent data collection capture methodology is a clear prerequisite for the compilation of meaningful pressure ulcer prevalence data sets at a national level.

  19. Kottner, J., T. Dassen, et al. (2009). “[Diagnosis and classification of pressure ulcers and other skin lesions: interrater reliability and agreement].Pflege Z 62(4): 225-30.

    Accurate and precise diagnosis and classification of pressure ulcers is important in clinical practice and research. In the planning phase of a cohort study 14 data collectors were trained according to the classification of the European Pressure Ulcer Advisory Panel (EPUAP). Interrater reliability and agreement was measured using 20 images of the pressure ulcer classification CD (PUCLAS). Across all categories values varied between 0.36 (95 percent CI 0.32 to 0.40) and 0.54 (95 percent CI 0.49 to 0.58). Highest values of interrater reliability and agreement were measured for the categories “Pressure ulcer grade 4”, “Pressure ulcer grade 2”, and “Blanchable erythema”. Low values were measured for the categories “Other lesion” and “Incontinence lesion”. Interpretation and transferability of these results into practice is limited due to low prevalence of some categories, artificial assessment conditions and due to small sample sizes. More efforts must be made to further improve interrater reliability and agreement.

  20. Kottner, J., R. Halfens, et al. (2009). “An interrater reliability study of the assessment of pressure ulcer risk using the Braden scale and the classification of pressure ulcers in a home care setting.Int J Nurs Stud 46(10): 1307-12.

    BACKGROUND: Measurement error can seriously affect the validity of pressure ulcer risk assessment and of pressure ulcer classification.

    OBJECTIVES: Determination of interrater reliability and agreement of pressure ulcer risk and pressure ulcers using the Braden scale and the EPUAP system.

    DESIGN AND SETTING: Duplicate assessments by trained nurses during two nationwide pressure ulcer prevalence surveys in the years 2007 and 2008 in The Netherlands in the home care setting.

    PARTICIPANTS: Home care clients which participated in 2007 (n=352) and 2008 (n=339) in the pressure ulcer prevalence surveys.

    METHODS: The Braden scale was used to assess pressure ulcer risk. Skin examination was conducted to detect pressure related tissue damages and to classify them according to the EPUAP.

    RESULTS: In 2007 and 2008, Intraclass Correlation Coefficients for Braden scale sum scores were 0.90 (95% CI: 0.88-0.92) and 0.88 (95% CI: 0.85-0.91) respectively, and corresponding Standard Errors of Measurement were 1.00 and 0.98. 95% limits of agreement were -2.8 to 2.8 and -2.7 to 2.7 respectively. The items “moisture”, “sensory perception” and “nutrition” contained largest amounts of measurement error. Proportions of agreement for the classification of pressure ulcers were 96% and interrater reliability was 0.81 and 0.79. Most disagreements were observed for the classification of grade 1 pressure ulcers.

    CONCLUSIONS: The standardized study procedure applied in the annual nationwide pressure ulcer prevalence surveys leads to reliable and reproducible results regarding pressure ulcer risk and pressure ulcer prevalence in the home care setting. Researchers and practitioners should be careful when drawing inferences from single pressure ulcer risk factors included in the Braden scale. Descriptions of the items “moisture”, “sensory perception” and “nutrition” should be made more clearly and unambiguous.

  21. Meijers, J. M., J. M. Schols, et al. (2007). “Evaluation of the dissemination and implementation of a nutritional guideline for pressure ulcer care.J Wound Care 16(5): 201-5.

    OBJECTIVE: In 2004 the European Pressure Ulcer Advisory Panel nutritional working group developed a nutritional guideline for pressure ulcer prevention and treatment. This study investigated the degree to which the guideline was disseminated and implemented in clinical practice.

    METHOD: A cross-sectional study was undertaken in health-care organisations in The Netherlands, Germany and the UK. A printed, standardised questionnaire which followed Rogers’ model of the innovation-decision process was developed, translated and distributed to 1087 health-care organisations.

    RESULTS: The response rate was 33% (n = 363). Sixty-one per cent of respondents knew of the guideline. Twenty-five per cent had applied it to their clinical practice and used it for nutritional screening. The main barrier to the provision of nutritional support appeared to be lack of knowledge and skills.

    CONCLUSION: One year after its dissemination, more than half of respondents knew of the guideline, with one in four applying it to their practice. The guideline was better disseminated and implemented in The Netherlands and UK than in Germany, where only 4% of participants had used it.

  22. Meijers, J. M., J. M. Schols, et al. (2008). “Differences in nutritional care in pressure ulcer patients whether or not using nutritional guidelines.Nutrition 24(2): 127-32.

    OBJECTIVE: Malnutrition, characterized by a loss of lean body mass, enhances the risk of pressure ulcers (PUs). Because the intrinsic risk factor nutritional status in PU development can be influenced by practitioners’ interventions, the use of clinical guidelines might be a satisfactory management approach. This study investigated the influence of using nutritional guidelines in daily practice on the actual nutritional care that PU (prone) patients receive, and barriers with regard to providing nutritional support were also explored.

    METHODS: A cross-sectional study was carried out in 1087 hospitals, nursing homes, and home care organizations in the Netherlands, Germany, and the United Kingdom. Because this study focused on comparing nutritional care in daily practice in PU (prone) patients using and not using nutritional guidelines, for the analyses two groups (health care organizations with and without guidelines) were identified. Differences between groups were tested using chi-square test and by analysis of variance.

    RESULTS: Respondents from 363 organizations participated in the study, of which 66.1% used nutritional guidelines for PU care in practice. Significant differences between organizations with nutritional guidelines versus organizations without guidelines were mostly on nutritional screening (P = 0.001) and the extent of nutritional assessments that included significantly more weight history recalls, weight measurements, and body mass index measurements (all P < 0.05). The most important barrier to providing nutritional support for PU (prone) patients in both groups was knowledge and skills.

    CONCLUSION: Using a nutritional guideline in PU care contributes to the amount of nutritional screening conducted in daily practice and to the content and extent of the assessment.

  23. Russell, L. J. and T. M. Reynolds (2001). “How accurate are pressure ulcer grades? An image-based survey of nurse performance.J Tissue Viability 11(2): 67, 70-5.

    We report a descriptive study using a questionnaire and twelve digital photographs classified by a consensus panel of experts using the European Pressure Ulcer Advisory Panel and Stirling plus digits classifications. The expert panel comprised 5 tissue viability specialists/clinical lecturers in tissue viability with many years of collective experience and examined 30 images over 2 1/2 hours. In general consensus on wound grading was good; in only 2 images was there insoluble disagreement. Two hundred subjects were recruited from a Tissue Viability Society (N = 50), the European Pressure Ulcer Advisory Panel (N = 50), five Community Trusts (N = 50) and five Acute Trust (N = 50) in England and Wales. The subjects were asked for demographic details (qualifications achieved, number of years qualified, employment grade and how their knowledge of classification of pressure ulcers has been obtained). The second part of the questionnaire asked them to classify twelve digital photographs of pressure ulcers using the European Pressure Ulcer Advisory Panel (EPUAP) and the Stirling plus digits systems. The study demonstrated that there is considerable lack of consensus when pressure ulcers are graded using the Stirling plus digit grading system and less disagreement when the EPUAP scale is used. The study also demonstrates that the statistical returns from different hospital and community units cannot be considered to be directly comparable. Furthermore, the study showed that the nurses most educated in pressure ulcer care (Clinical Nurse Specialists in Tissue Viability) were the most keen to receive extra education, whilst ward nurses were happy with their current knowledge and did not believe further education on pressure ulcer grading was necessary.

  24. Tubaishat, A., D. Anthony, et al. (2010). “Pressure ulcers in Jordan: a point prevalence study.J Tissue Viability 20(1): 14-9.

    BACKGROUND: Pressure ulcers are a common problem among hospitalised patients. Several prevalence studies have been conducted internationally but there is a paucity of research on pressure ulcer in the Arab world in general and in Jordan specifically.

    PURPOSE: The aim of this study was to quantify the prevalence rate of pressure ulcers in Jordan, and to compare these figures with other studies conducted using the same methods.

    DESIGN: A cross-sectional survey design.

    PARTICIPANTS: All inpatients older than eighteen in both university and general hospitals in Jordan. Patients in the emergency, day care and maternity wards were excluded.

    INSTRUMENTS: European Pressure Ulcer Advisory Panel (EPUAP) data collection form.

    METHODS: The survey was conducted by examining patients’ skin. Pressure ulcers were classified according to the EPUAP grading system. Risk of pressure ulcer development was assessed using the Braden scale. Data were collected on preventive measures recorded in the clinical setting.

    RESULTS: The overall prevalence rate was 12% (All percentages are rounded to the nearest digit) (7% when Grade I excluded). The sacrum and heel were the most common affected sites. Grade one was the most common grade (44%). Only 17% of the patients at risk received adequate prevention.

    CONCLUSION: The pressure ulcer prevalence rate in Jordan is lower than that published in most studies utilising the same methodology. Despite this relatively low prevalence very few patients at risk received adequate prevention, and there is therefore a need to raise the awareness for pressure ulcer prevention in Jordan. Furthermore, differences in age and frailty in the Jordanian sample could explain the low prevalence.

  25. Vanderwee, K., M. Clark, et al. (2007). “Pressure ulcer prevalence in Europe: a pilot study.J Eval Clin Pract 13(2): 227-35.

    RATIONALE AND AIMS: Numerous prevalence studies have been conducted. The problem with these studies is that prevalence proportions cannot be compared with each other, because of differences in performance of each survey. There is no agreed standardized method for determining prevalence proportions. This study aimed to develop and pilot a uniform data collection instrument and methodology to measure the pressure ulcer prevalence and to get some insight into pressure ulcer prevalence across different patient groups in Europe.

    METHODS: Pressure ulcer experts from different European countries developed a data collection instrument, which included five categories of data: general data, patient data, risk assessment, skin observation and prevention. A convenience sample of university and general hospitals of Belgium, Italy, Portugal, UK and Sweden participated in the study. In each participating hospital, teams of two trained nurses who collected the data on the wards were established. All patients admitted before midnight on the day of the survey and older than 18 years were included.

    RESULTS: The data collection instrument and study procedure of the survey were found to be effective by all participants. 5947 patients were surveyed in 25 hospitals in five European countries. The pressure ulcer prevalence (grade 1-4) was 18.1% and if grade 1 ulcers were excluded, it was 10.5%. The sacrum and heels were the most affected locations. Only 9.7% of the patients in need of prevention received fully adequate preventive care.

    CONCLUSION: The methodology is sufficiently robust to measure and compare pressure ulcer prevalence in different countries. The pressure ulcer prevalence was higher than expected and relatively few patients received adequate prevention. This indicates that more attention to prevention is needed in Europe.

  26. Vanderwee, K., T. Defloor, et al. (2011). “Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey.Qual Saf Health Care.

    Introduction: The development of a pressure ulcer is an adverse event and is often avoidable if adequate preventive measures are applied. No large-scale data, based on direct patient observations, are available regarding the pressure ulcer preventive interventions used in hospitals. Purpose The aim of this study was to obtain insight into the adequacy of interventions used to prevent pressure ulcers in Belgian hospitals.

    Methods: A cross-sectional, multi-centre pressure ulcer prevalence study was performed in Belgian hospitals. The methodology used to measure pressure ulcer prevalence was developed by the European Pressure Ulcer Advisory Panel. The data collection instrument includes five categories of data: general data, patient data, risk assessment, skin observation and prevention.

    Results: The total sample consisted of 19 968 patients. The overall prevalence of pressure ulcers Category I-IV was 12.1%. Only 10.8% of the patients at risk received fully adequate prevention in bed and while sitting. More than 70% of the patients not at risk received some pressure ulcer prevention while lying or sitting.

    Concusion: Generally, there is a limited use of adequate preventive interventions for pressure ulcers in hospitals, which reflects a rather low quality of preventive care. The implementation of pressure ulcer guidelines requires more attention. The pressure ulcer prevention used in practice should be re-evaluated on a regular basis.

  27. Wilborn, D., R. Halfens, et al. (2006). “Pressure ulcer: Prevention protocols and prevalence.J Eval Clin Pract 12(6): 630-8.

    AIMS AND OBJECTIVES: The aim of this paper is to analyse the protocols used in German hospitals and nursing homes for the prevention of pressure ulcers with regard to their contents and accordance with the national standard of the Deutsches Netzwerk fur Qualitatsentwicklung in der Pflege (DNQP) and the European Pressure Ulcer Advisory Panel (EPUAP) and Royal College of Nursing (RCN) guidelines. Additionally, it is to show the relation between the existence and contents of the protocols of pressure ulcer prevention and pressure ulcer prevalence in the institutions.

    METHODS: On a fixed date trained nursing staff gathers data regarding the frequency of pressure ulcers during a prevalence survey. The existence of a pressure ulcer is established by physical examination after the risk assessment with the Braden-Scale. The patient’s or resident’s informed consent is a precondition for his or her participation in the survey. The protocols are available as hard copies on paper or electronic files.

    RESULTS: Only two out of the 21 protocols developed in-house are completely concurrent with the expert standard. The EPUAP and RCN guidelines include the aspect of training and further education that is missing in the in-house protocols and the DNQP expert standard. Evaluation of the data reveals that there is no relation between the availability of protocols and pressure ulcer prevalence. Neither is there any relation between the contents and pressure ulcer prevalence. The institutions currently developing protocols have the lowest prevalence rates.

    CONCLUSION: It is obvious that, while developing in-house protocols, the discussion about pressure ulcer prevention has led to a higher problem awareness in nurses and thus to an increased attentiveness in daily nursing practice which then results in improved outcomes. Two years after its publication, the expert standard is still not very well known, therefore this concentrated form of the most up-to-date knowledge is not available to all nursing staff as a basis for evidence-based practice. In addition, the sometimes outdated knowledge of nursing staff impedes the implementation of evidence-based practice guidelines. A systematic implementation strategy that assists guidelines being applied in practice is therefore required.

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