European Pressure Ulcer Advisory Panel: Review 4,2

SUMMARY REPORT ON THE PREVALENCE OF PRESSURE ULCERS

Data collected in Belgium, Italy, Portugal and the United Kingdom over 14-15 November 2001,
and in Sweden on 5 February 2002. This data forms part of the European Pressure Ulcer Advisory Panel's
pilot European hospitals' pressure ulcer prevalence monitoring project.
Michael Clark, Gerrie Bours and Tom de Flour, on behalf of the EPUAP Prevalence Working Group.

Early in 2000 the EPUAP committed to developing a minimum data set for use within pressure ulcer prevalence surveys. Over many months this set emerged from a series of intense meetings with the evolution of the minimum data set described in past EPUAP Reviews. Finally in 2001 the project collected data upon the condition of the skin of approximately 5000 hospital patients located in Belgium, Italy, Portugal and the United Kingdom. Early in 2002 further data was collected in Sweden. The first presentation of this important new data set was made in Budapest in September 2002 and the EPUAP is pleased to provide a summary of the data collected across the five counties that participated in the pilot project in this issue of the EPUAP Review.

Summary report on pressure ulcer prevalence

This data was collected in Belgium, Italy, Portugal and the United Kingdom over 14-15 November 2001, and in Sweden on 5 February 2002. It forms part of the European Pressure Ulcer Advisory Panel's pilot European hospitals' pressure ulcer prevalence monitoring project.

The data contained in this report is not to be disseminated or published in whatever format without the prior permission of the European Pressure Ulcer Advisory Panel.

Summary

The European Pressure Ulcer Advisory Panel (EPUAP) has conducted a pilot survey of the prevalence of pressure ulcers across a range of hospitals located within five European countries (Belgium, Italy, Portugal, Sweden and the United Kingdom). This report describes the data gathered across all of these countries. A total of 5947 patients were surveyed over 14-15 November 2001 (and on 5 February 2002 when all Swedish data was obtained), and of these 1078 (18.1%) had pressure ulcers. The prevalence of pressure ulcers within each country ranged from 8.3% (Italy) to 22.9% (Sweden).

The anatomical locations most commonly affected by pressure ulcers were the sacrum (in Italy and the UK) and the heels (Belgium, Portugal and Sweden). Of the 1078 patients with a pressure ulcer(s) the greatest number (n = 454, 42.1%) experienced non-blanching erythema as their most severe form of pressure damage. However, 143 patients experienced the most severe form of pressure damage (Grade 4 wounds).

The proportion of surveyed patients who received no pressure ulcer preventive interventions ranged from 10.4% (UK) to 92.1% (Italy), with relatively few patients receiving interventions deemed to be fully appropriate (n = 265, 4.6%). It should be noted that the pilot study did not recruit a representative sample of hospital sites and so the data presented within this report can not be considered to represent the 'true' picture of the prevalence and characteristics of pressure ulcers across acute care in Europe.

Background

One of the most common measures of the occurrence of pressure ulcers has been their prevalence, defined as the number of people with a pressure ulcer as a proportion of the entire patient population over a defined period of time. Pressure ulcer prevalence has been reported over the years across many countries and many health care providers. This measure provides information upon the current numbers of patients with pressure ulcers and the characteristics of their wounds. Measures of prevalence are not however suitable for identifying improvements in pressure ulcer occurrence following changes in practice given that prevalence includes patients admitted to a hospital with established pressure ulcers.

Comparison between these myriad prevalence proportions has been limited by various issues related to the performance of each survey - among the many confounding issues are;

In each country a National Co-ordinator (NC) was appointed from among the ranks of the EPUAP Trustees and their colleagues. The primary roles of the NC were to identify potential hospitals in which data on the prevalence of pressure ulcers would be collected, and to facilitate staff within these hospitals to undertake the survey. The goals of the pilot survey were: a) to collect data from approximately 1000 hos-pital patients within each country and, b) to explore issues related to the implementation of a system for collecting prevalence data that could be used in different countries.

Having identified potential hospitals within each country, Research Ethics applications covering the performance of the survey were submitted (where each country's regulations required this to be done) and approval for data collection obtained. Over the period 14-15 November 2001 (and 5 February 2002 in Sweden) the skin of all in-patients staying overnight on the day of the survey was inspected by two nurses; one drawn from the clinical area's staff while the second formed part of the research team within each participating hospital.

During the survey information was collected upon the presence, anatomical location and severity of pressure ulcers. Each pressure ulcer's severity was assessed using the EPUAP pressure ulcer classification tool (see Appendix 3), while each patient's vulnerability to developing pressure ulcers was assessed using the Braden Scale. While the Braden Scale allows assessment of skin moisture it does not specifically address continence, and the EPUAP working group also included the continence section of the Norton scale within the data collection instrument. No attempt was made to combine the Braden and continence scores into a single indicator of possible vulnerability to pressure ulcers.

On two selected wards within each hospital, two members of the research team independently inspected the skin of patients to establish the level of agreement between observers. Across all participating countries the level of agreement between observers was very high (for the Braden scale 0.985, for the most severe pressure ulcer 0.963, and for the location with the most severe grade of pressure ulcer 0.934 all of these were significant at a p value of < 0.001). All completed forms were copied with the original data sheets returned to a central point for data processing and analysis.

A total of 5947 patients were surveyed across the five countries, of these 1078 (18.1%) had established pressure ulcers. Patients were surveyed across twenty-six hospital sites with 48.2% (n = 2868) of all patients nursed within teaching hospitals, the remainder within general hospitals (Table 1). Of the 5947 patients surveyed, 2544 (42.8%) were located in the United Kingdom (drawn from eleven hospitals in England, two in Wales and two in Northern Ireland).

a) Patient demographic information.

The age of the surveyed patients was collected as a series of age ranges (for example whether the patient was aged between 80 and 89 years) and as such it is not possible to calculate the mean age of the surveyed population. Table 2 highlights the age distribution of the surveyed patients with 2921 (49.1%) aged over 70 years old. The age of 42 (0.7%) subjects was unreported. The mode age range varied by country, for example in Belgium most patients surveyed were between 40 and 49 years old, with over 12% under 18 years old. Across the other four countries patients tended to be older; mode age range 70-79 years (Italy and Portugal) and 80 to 89 years in Sweden and the United Kingdom. Most patients were female (n = 3088, 52.9%) with the sex of 109 (1.8%) unreported. The percentage of each country's surveyed patients where gender was unreported ranged from 0.9% (Portugal) to 3.6% (Italy). It is important to note that the demographic information presented in this section of the report includes all surveyed patients and not just those with pressure ulcers.