EUROPEAN PRESSURE ULCER ADVISORY PANEL

A randomised controlled trial to examine the effect of the 30° tilt position compared to the use of the 90° lateral and supine positions in reducing the incidence of non-blanching erythema in a hospital in-patient population
Trudie Young
Tissue Viability Nurse, University of Wales, Bangor, School of Nursing, Midwifery and Health Studies

Introduction
Manual repositioning of patients by nursing staff is a recognized technique used to prevent pressure ulcer formation. The 30° tilt is a method of positioning patients that in the laboratory setting reduced the contact pressure between the patient and the support surface.

Ethical approval was received from the local ethics committee

Methodology
A randomized controlled trial to examine the effect of the 30° tilt position in reducing the incidence of non-blanching erythema in a hospital in-patient population (n = 23) when compared to the use of the 90° lateral and supine positions (n = 23). The demographic characteristics of the experimental and control groups were comparable.

Results
In this study no subject developed pressure damage that presented with visible breaks in the epidermis, all damage was restricted to areas of non-blanching erythema with five of the 39 subjects who completed the study exhibiting such injury.

Conclusions
The main finding of this study was that patient positioning using the 30° tilt did not reduce the incidence of pressure damage (as marked by areas of non-blanching erythema) compared with either the 90° lateral or supine positions. This study also investigated the feasibility of using the 30° tilt with medical in-patients and found 78% of subjects experiencing difficulty in adopting and maintaining the position. This finding seriously questions the practicality of the 30° tilt when used with a predominantly ill population.

A device for early identification of pressure ulcers
Duncan Bain, Greg Wain and Martin Ferguson-Pell
Centre for Disability Research and Innovation, University College London

Background
It has often been asserted that most pressure ulcers are preventable given sufficient preventive resources.1 More recently, it has been reported that pressure ulcers identified early can be reversed in more than 90% of cases by good nursing practice.2 Given the validity and reliability problems entailed by risk assessment, a promising adjunct strategy for reduction in ulcer prevalence is offered by diagnostic tools for early identification. In current clinical practice, grade 1 pressure ulcers are unreliably diagnosed.2 Problems include the difficulty in seeing and comparing erythema in different skin types, especially in dark skin, and the variability in subjective assessments. The authors have developed an objective measurement device based on reflectance spectroscopic principles, that examines the volume, oxygenation, and dynamics of blood in the skin. In this study, the ability of the device to identify pathological changes in the skin leading to pressure sores is examined.

Methods
Laboratory trial
Rubefactant cream was applied to one forearm of each of 100 healthy volunteers of a wide variety of skin colours in a controlled temperature laboratory. After a stabilisation period of five minutes, ten measurements were made of the area with cream applied, and of the contralateral control area, using the instrument. A neural network approach was used to train the instrument to distinguish between erythema and control areas. The network was subsequently tested on a reserved test-set of data.

Clinical trial
Sixty informed, consenting subjects at the Whittington Hospital, presenting with red areas clinically judged by an expert tissue viability nurse to be pathological, were included in the study. Suitable contol sites were chosen, and measurements were made of pathological and control sites using the instrument.

Results
The instrument distinguished reliably between pathological and non-pathological areas, regardless of skin type. In addition, the instrument distinguished between different pathologies including blanching/non blanching erythema associated with pressure ulcer onset, excoriation, and simple reactive hyperaemia which quickly resolved. The blanching dynamics examined using the device proved to be essential to effective differential diagnosis.

Summary
An objective device for assessment of skin condition has the potential to enhance reliability of clinical judgement. This is useful for consistent early identification, and steady tracking of progress, both of which are key to effective management of grade 1 ulcers.

References
1. Scales JT Lancet ii, 25 Nov (1961), 1181
2. Halfens RJ, Bours GJ, Van Ast W. Relevance of the diagnosis ‘stage 1 pressure ulcer’: an empirical study of the clinical course of stage 1 ulcers in acute care and long-term care hospital populations.
J Clin Nurs. 2001 Nov;10(6):748–57.

Hip fractures and pressure sores: is there a correlation?
M.Colombo, G.R.Carella, A.Carusone, R.Coppini, L.Tronconi, E.Volpato, A.Guaita, R.Cassino*
‘C.Golgi’ Geriatric Institute, Abbiategrasso – Milan (Italy)
* VULNERA – Italian Vulnological Center, Turin (Italy)

Introduction
In the years 2000 and 2001, 154 inpatients, whose problem was a hip fracture, have been rehabilitated in the ‘Camillo Golgi’ Geriatric Institute in Abbiategrasso, near Milan. Sixty-nine of them developed one or more pressure sores after the fracture, before the hospitalization.

The aim of our work was to demonstrate that, with statistic analysis of the data about these patients, we could find possible correlations between development of pressure ulcers and hip fractures.

Methods
We evaluated 154 inpatients (114 osteosynthesis and 35 endoprosthesis; the other 5 patients had no surgical treatment). About any patient, besides the treatment results, we evaluated, at admission and discharge, autonomy (Barthel Index), mental attitude (Mini Mental State Examination) and hematologic values as hemogram, albumen, electrolytes and iron blood level; at last we evaluated social reintegration according with tha presence or not of skin lesions. All collected data have been statistically analyzed by SPSS.

Results
The surgical treatment had no influence in the development or not of the skin lesions.
There are statistically significantly differences about albumen, calcium and iron blood level; on the contrary, we noted no differences about hemogram and the other electrolytes. The social reintegration was hardly influenced by the presence of pressure ulcers, especially about long term care units istituzionalization and death.

Summary
After the analysis of 154 inpatients with hip fracture, we can state that there’s an important correlation between hip fractures and development of pressure sores; there are also significative differences about albumen, calcium and iron blood level – which are lower then the ones in the patients without skin lesions – and social reintegration – more patients with ulcers died or needed a long term care units istitutionalization. Anyway, the aim of our work has been fully achieved.

What was it like for you? The experience of the data collectors
A. Hopkins
East London Wound Healing Centre, Tower Hamlets Primary Care Trust, London, UK

Despite the preparation for the auditors, the audit experience proved to somewhat different than expected. The time needed to complete the audit was the biggest issue for the auditors. For some, despite extensive preparation of the organisation, this proved very difficult and exhausting. If this type of audit is to be completed again then it has to have some worth for the organisation and the auditors.

This paper will discuss the experience of the auditors across Europe. It will focus on the preparation, the influence of the organisation in the audit’s success and the use of the data set. Importantly, the worth of the experience and usefulness of the results will be discussed.

Would the auditors take part in another European pressure ulcer prevalence audit? This question will be answered!

EPUAP Prevalence project; the project results
Defloor, T., Bours.G., Clark.M. , Bennett, G., Dealey, C., Fletcher and J. Halfens, R.

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). It should be noted that the pilot study did not recruit a representative sample of hospital sites and so the data can not be considered to represent the ‘true’ picture of the prevalence and characteristics of pressure ulcers across acute care in Europe.

A total of 5947 patients were surveyed over 14–15 November 2001. 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. Most of the patients were considered to be acute care/high dependency patients (n = 3703, 63.0%). The other care groups were neurology (n = 829, 14.1%), intensive care (n = 269; 4.6%) and chronic care (n = 1078, 18.3%). Most patients were female (n = 3088, 52.9%) and 2921 (49.1%) patients were over 70 years old. Based on their Braden Scores (<17), 1733 (29.1%) of all surveyed patients were at risk of developing pressure damage.

Across the five countries represented within the survey 1078 patients (18.1%) were reported to have pressure ulcers. Three countries (Belgium, Sweden and the United Kingdom) had similar prevalence proportions ranging from 21.1% to 22.9%. The prevalence of pressure ulcers was reported to be lower in both Italy (8.3%) and Portugal (12.5%).
The 1078 patients with pressure ulcers experienced a total of 1860 pressure ulcers, with the sacrum the commonly affected site (n = 532, 28.6%); 143 patients had a grade 4 pressure ulcer as the most severe, 199 patients had a grade 3, 282 patients had grade 2 and 1454 had grade 1.

2114 (36.5%) patients were considered to be in need of preventive intervention (Braden score <17): a non-powered device was used in 870 (41.2%) patients and 643 (30.4%) had an powered device, 618 (29.2%) received a special cushion, 1067 (38.2%) patients were repositioned in bed.

While most patients in the participating countries received some preventive care, relatively few (n = 265, 4.6%) were allocated fully appropriate care. The percentage of the surveyed patients considered to receive adequate preventive care ranged from 0% (Italy) to 9.3% (United Kingdom). These low percentages would suggest that there is much scope for the improvement of pressure ulcer preventive care across Europe.