Pressure Ulcer Care in the Netherlands: A Short Historical Overview

JMGA Schols MD PhD¹, RJG Halfens FEANS PhD², JMM Meijers MSc², JTM Weststrate RN PhD³

1. Department Tranzo, Tilburg University & Department of General Practice, Faculty of Health, Medicine and Life Sciences, Maastricht University; and Vivre Maastricht
2. Faculty of Health, Medicine and Life Sciences, Department of Health Care and Nursing Science, Maastricht University
3. Netherlands Centre for Excellence in Nursing, Utrecht.

This article gives a short overview of the developments in pressure ulcer care (PU-care) in The Netherlands.

The Dutch health care system is characterized by relatively sharp boundaries among community health care services, hospital services and longterm care services. All three kinds of health care services have their own regulations and financing systems.¹ Table 1 shows the most important health care services in The Netherlands.

Table 1. Health care services in The Netherlands

Domiciliary services:	Institutional services:
www.minvws.nl · www.rivm.nl
General Practitioners (n = 7,500)	University hospitals (n = 8)
Physical therapists (n = 14,000)	General hospitals (n = 86)
Occupational therapists (n = 2,800)	Psychiatric hospitals (n = 43)
Speech therapists (n = 4,500)
Dieticians (n = 2,500)	Rehabilitation clinics (n = 23)
Dentists (n = 8,000)
Home care services (nursing) (n = 175)	Residential homes (old people’s homes) (n = 1,340)
Community mental help (n = 46)	Nursing homes (n = 345)

Pressure ulcers are an important problem in all health care settings, as is shown in Table 2, in which the prevalence rates for pressure ulcers in the last eight years are shown for university hospitals, general hospitals, home care, nursing homes and residential homes.² In The Netherlands some interesting developments have been taking place in PU-care during the last two decades (Table 3). They will be addressed in this article.

Table 2. Prevalence of pressure ulcers (%) 1998-2006 in different health care sectors in The Netherlands.²

	1998	1999	2000	2001	2002	2003	2004	2005	2006
University Hospital	13,2	14,4	15,8	18,4	16,5	14,7	14,8	15,6	15,2
General Hospital	23,3	20,3	20,9	22,3	22,3	22,2	18,7	17,0	14,8
Nursing Home	32,4	28,3	32,1	33,4	33,0	28,8	30,5	25,4	24,2
Residential Home	15,4	11,6	13,6	14,6	16,2	13,3	16,1	13,3	10,5
Home Care	21,3	17,7	17,7	20,5	18,5	16,7	14,2	12,2	9,7

Table 3. Developments in PU-care in the last two decades.

www.minvws.nl · www.rivm.nl · www.cbo.nl · www.verpleeghuisartsen.nl
National Guidelines:
1985/1986:	First National Guidelines on PU prevention and treatment (CBO).
1992:	First review of National Guidelines (CBO).
2002:	Second review of National Guidelines (CBO). Guidelines more and more EB.
Professional Guidelines (based on CBO-guidelines but targeted on different professionals or health care sectors):
1985/1986:	Dutch PU guidelines for General Practitioners.
1992:	Dutch PU guidelines for Home Care.
2002:	Dutch PU guidelines for Nursing Home Care (SALODE).
Other important national developments:
1995:	Installation of a national steering group on PU.
1996:	Dutch National Law on Quality of Care.
1997:	Dutch National Law on Registration of Health care disciplines. (Wet BIG).
1998:	Start of yearly national measurement of PU prevalence in different Health Care Sectors (Maastricht University).
>2000:	Trend towards chain supply of healthcare services. including PU-care.
2004/2005:	PU (prevalence) acknowledged as an important quality indicator in health care (incorporated in main national health care quality improving programmes).
2005:	Introduction of a National Centre for Pressure Ulcer prevention at the Netherlands Centre for Excellence in Nursing and start of wider implementation of PU-guidelines by breakthrough projects.

Developments in PU-care before 1995

Before 1995 the policy to take care for patients suffering from pressure ulcers originated in the various health care services themselves and the PU-care itself was carried out by individual professionals. Depending on the enthusiasm of particular professionals, more or less attention was paid to the problem of pressure ulcers in health care facilities. Furthermore, in most cases it was the expertise of individual professionals which was leading in PU-care.

In 1985/1986 the first National Guidelines on PU prevention and Treatment (from The Dutch Institute for Healthcare Improvement) (CBO-PU guidelines) became available of which a first review took place in 1992.

These guidelines offered professionals practice based and consensus based information to improve their performance in PU-care; yet they did not launch health care sector specific as well as national activities to improve PUcare all over the country.

So, before 1995, the quality and intensity of pressure ulcer care showed a varied picture all over the country.

Developments in PU-care since 1995

Since the mid-nineties interesting developments in Dutch PU-care have been taking place. (Table 3) In 1995 a national steering committee on PU was established to develop a national strategy to improve PUcare in the total Health Care System of the Netherlands. Attention and alertness on pressure ulcers in home care, long-term institutional care and hospital care was provoked and the importance of implementing PU-guidelines was promoted.

In 1996 and 1997 national legislation on quality of care and on registration of health care disciplines came into operation. These laws facilitated the process of professionalisation of most health care disciplines (e.g., doctors. nurses) and urged them to improve their performance in patient care.

In the meantime the evidence-based era had started and the development of EB-guidelines received an extra impulse.

In the time period 1998-2003 a second review and more evidence based founding of the national CBO-PUguidelines took place and sector specific PU-guidelines for general practitioners, home care and nursing home care appeared. However, no national strategy or initiative was used to disseminate and implement these guidelines.

Implementation of the sector specific guidelines is mostly initiated by multidisciplinary PU-committees appointed within the different health care organizations themselves. Within the different organizations — home care, hospital and nursing home — the tasks and responsibilities of the different health care professionals have gradually become more clear during the last ten years. Although the physician has overall responsibility for the care and treatment a patient receives, the nursing staff looks at the risk factors for PU and assesses the status of the PUwounds, if present. In collaboration with the medical staff often the actual treatment of the wound is discussed. The nursing staff, therefore, has an important task in identifying and monitoring the risk a patient has in developing PU (e.g., by using a PU-risk assessment tool), taking adequate preventive measures and performing the actual wound treatment (i.e., cleaning of the wound and applying the adequate dressings). Today, many organizations have tissue viability nurses who have followed a specific educational programme and who have more authority in determining the integral patient specific PU-care, including the actual wound treatment. Furthermore, physiotherapists and occupational therapists are involved in PU-prevention (helping and teaching the patient and/or nurses in performing adequate transfers and achieving the right relief of pressure and shear forces) and dieticians are involved in managing nutritional problems in PU-patients.

Since 1998, the prevalence, prevention and treatment of pressure ulcers is measured yearly within many healthcare organizations in The Netherlands (already more than 500 in 2007!). For this measurement a standardized validated instrument has been developed, which is used consistently in each patient of the participating organizations. Data are gathered regarding quality indicators regarding pressure ulcers on ward and organizational level. Based on these measurements each organization receives an overview of their own results as well as the national results, which they can use for comparison.

It has been shown that measuring prevalence yearly, has a positive and facilitating effect on the quality of PUcare in all participating organizations.²

Advanced developments in PU-care since 2000

Gradually, in the course of years, it has become clear (as pointed out at the beginning of this article) that the boundaries between different health care sectors in The Netherlands hamper the achievement of adequate continuity of care, which in fact is an important marker for quality of care. Therefore, since 2000, the focus is more and more on realizing an adequate chain supply of care.¹

This also counts for achieving an adequate approach to pressure ulcer care throughout all health care services, following the principles of integral disease management and realizing a care chain supply of tailor-made care for the patients.

At this moment, no one discusses the fact that an adequate approach to pressure ulcers requires optimal and complementary collaboration as well as bridging the gaps between all care providers and health care professionals involved. Therefore, this is a real challenge for:

• collaboration in the nursing axis,
• collaboration between the medical and the nursing axis;

and it involves also a challenge to:

• organize integral pressure ulcer care with mutual, complementary strengthening of community care services and institutional care services.

Fitting in this trend, all over the country, experiments are taking place to achieve adequate transmural PU-care by implementing transmural PU-guidelines, which have been developed by integrating sector specific guidelines. For the implementation of these guidelines transmural PU-committees, with members from different organizations (home care, hospital care and nursing home care) are appointed.

Another important actual development, with respect to the implementation of guidelines, are the breakthrough projects within the cure and care sector initiated by the Government. Pressure ulcers are one of the topics in these breakthrough projects. A lot of facilities enhance their care regarding PU in participating in the breakthrough project. In a comparable project already more then 40 nursing homes implemented the pressure ulcer guidelines for nursing homes.³

It the meantime, it also has become clear that nurses play an important role in achieving adequate continuity of care for the patient throughout the total health care chain, in which especially patients with chronic diseases often move between home and hospital care. between hospital and nursing home or home and nursing home and vice versa.

In the case of PU-care this has led to the phenomenon of link nurses within the context of pressure ulcer prevention and treatment.

Most patients really appreciate the continuous attention, that is achieved by this way of organizing PU-care throughout the health care system.

Dutch PU-care and challenges for the future

Despite all these developments the most important problem remains the adequate implementation and firmly rooting of guidelines in daily PU-care. Solving this problem will be the most important challenge for Dutch PU-care.

Regular assessment of quality of care may act as a facilitator in enhancing the actual quality of care. Therefore, the most important actors in Dutch health care (government, health care organizations, insurance companies and organizations of patients themselves) have agreed upon a new system of continuous (yearly) and integral measurement of quality of care. This system involves the yearly measurement of a set of indicators for quality of care, corresponding with the structure, the process and the outcome of care. The quality of PU-care is part of this system in which the yearly measurement of PU-prevalence will be a main outcome indicator for PU-care!

Moreover, benchmarking will take place, in which different organizations can be compared more transparently to each other.

Organisations are beginning to notice the value of measuring the incidence or prevalence in order to find the cause of the PU problem, they are faced with. In order to measure the incidence various computer programmes have been developed. One of them, The National Care Monitor is based on the PU indicators developed by the EPUAP.

Finally, we all know that insufficient implementation of health care guidelines is an important problem of health care. This also counts for many other countries all over the world. However, the goal of this article is not to explore possible reasons and solutions for this problem.

EPUAP may also play an important role in facilitating the implementation of PU-guidelines in different countries, by exploring and presenting the PU-care in her member countries and by enabling the different countries to learn from each other.

In fact, it is known that the road to optimal PU-care has no finish line! Therefore, for the sake of the patients and despite all possible hampering conditions, we have to maintain working on:

• implementing and rooting of evidence based PU-guidelines;
• lowering PU-prevalence and incidence in our institutes and throughout the care chain as a whole;
• being transparent with regard to our performance in PU-care; and
• achieving a constant high standard of PU-care.

Clearly, if we try hard, we will eventually succeed in this, so that our patients can feel themselves really safe in our hands.

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