European Pressure Ulcer Advisory Panel

IncontPressure Ulcers Risk Evaluation (PURE) Project

Jane Nixon, Claudia Gorecki and Julia Brown

On behalf of the PURE Project Collaborative Group, University of Leeds (contact: C.Gorecki@leeds.ac.uk)

Introduction:

A major problem with current pressure ulcer (PU) prevention practice and research is the inability to identify patients at high risk of PU development. In 2001 a EPUAP working group formulated an evidence based position statement on risk assessment in PU prevention and management (De-Floor et al. 2001). Although this statement was accepted at the meeting in Le Mans in September 2001, debate remains about the predictive value of various risk factors mentioned in the literature and included in risk assessment scales. Current risk assessment tools were developed at a time when little risk factor data was available to support theoretical hypotheses on risk. However, in recent years there has been an increase in the number of studies undertaken and reported and in order to provide a foundation for further research and development of the risk assessment process, the existing research base has been systematically appraised.

Methods:

A systematic review of primary research was undertaken to identify variables which are independently predictive of PU development in adult patient populations. A search strategy consisting of PU search terms and OVID maximum sensitivity filters for Prognosis and Aetiology or Harm and for RCTs was used in seven databases (AMED, British Nursing Index, MEDLINE, EMBASE, PsycINFO, CINAHL, EBM reviews-CCTR). In addition specialist journals and conference proceedings were hand searched, theses and dissertation abstracts were searched and experts in the field were contacted.

Prospective cohorts and RCTs of adult patient populations in any setting where the primary outcome was the development of (or time to development of) a new PU(s) were included if they met the following criteria: the study outcome was clearly defined as > Grade 1; length of followup was at least three days; multivariate statistical methods were used to identify factors affecting PU outcome and; for prospective cohort studies no more than 20% of the study sample were excluded from analysis for reasons including withdrawal, death, lost to follow-up and missing records and for RCTs no more than 5% of the study sample excluded from the analysis for reasons including withdrawal, death, lost to follow-up and protocol violations.

Results:

3591 abstracts were retrieved and 360 of these were prospective cohorts and RCTs of adult patient populations with an outcome of development, or time to development of, a new PU(s). Of these 318 studies were excluded and 42 fulfilled the criteria for inclusion in the review. The 42 studies include a total of 31,556 patients in a range of patient populations including intensive care, surgery, various mixed specialty acute care environments, long-term rehabilitation and nursing home populations, community populations and specific diagnostic groups e.g., fractured hip and spinal cord injured. The studies used a median of 11 potential risk factors in multivariate analyses and identified a median of 3 factors as independently predictive of pressure ulcer outcome. The factors identified as predictive of PU outcome included a total of 102 differently named variables. These variables were reviewed and summarised by theme and will be presented.

Conclusions:

There is considerable evidence about PU risk factors, but the interpretation and application of this evidence in practice is complicated by the heterogeneity of patient populations, methodological limitations and the absence of a minimum data set in risk factor research.

Collaborative Group:

• Jose Closs, School of Healthcare, University of Leeds
• Tom Defloor, University Gent, Belgium
• Ruud Halfens, Maastricht University, the Netherlands
• Andrea Nelson, School of Healthcare Studies, University of Leeds
• Lisette Schoonhoven, Univ. Med. Centre, Nijmegen, the Netherlands

Demographics of Pressure Ulcers: An Analysis of the International Pressure Ulcer Prevalence™ Survey

Catherine VanGilder, BS, MT, CCRA, Gordon MacFarlane, PhD, and Stephanie Meyer

Introduction:

Pressure ulcers (PUs) remain a significant problem for patients and healthcare facilities. Little is published regarding the demographics of pressure ulcer patients. This report will summarize the data from the International Pressure Ulcer PrevalenceTM Survey results for patient BMI, weight, Braden Risk Score, and age of patients in whom pressure ulcers were identified.

Methods:

Clinical teams assessed all admitted patients over a defined 24-hour period in a participating facility. Clinical assessments are recorded and analyzed at both the facility and aggregate data levels.

Results:

Height and weight was available in 64,372 (70%) of the 92,192 adults surveyed, with weight only available in another 4,592 patients yielding 68,964 patients for weight analyses. Of all patients with a recorded BMI, 5.5% were considered underweight (BMI<18.5); 31.3% normal (BMI 18.5-24.9); 27.7% overweight (BMI = 25-29.9); 25.7% obese (BMI = 30-39.9); 9.8% morbidly obese (BMI = 40-49.9); with 2.8% having BMIs > 50. Overall PU prevalence was greatest in the underweight patients (25.3%), decreased with normal (16.6%), overweight (12.2%), and obese (10.5%), and increased at BMI>50 (12.3%). Facility acquired prevalence followed the same trends. Mean weights per BMI class were 104 lbs, 139 lbs, 171 lbs, 203 lbs, 245 lbs, and 311 lbs respectively.

Weight categories were created at 50 pound intervals and mean BMI per weight class was analyzed. Mean BMI per weight category were <100 lbs (17.6-underweight), 101-150 lbs (23-normal), 151-200 lbs (28.6-overweight) and 201-250 lbs (35.1-obese), and above 251 lbs morbidly obese. PU prevalence was highest in the underweight population (25.0% in the under 100 lbs class), decreased to 10.3% in the 200-249 lbs class, and then increased to 19.2% in the over 500 lbs class. When classified by BMI, 35.5% of the patient population is considered obese, however, only 7.5% of the population is over 250 lbs, and 24.3% is over 200 lbs.

Eighty-seven percent of all facilities used Braden risk assessment. Braden scores correlated well with the prevalence of pressure ulcers with very high risk (Braden 6-9) at 49%, high risk (Braden 10-12) at 44%, moderate risk (Braden 13-14) at 34%, mild risk (Braden 15-18) at 17%, and no risk (Braden 19-23) at 5%. Facility acquired pressure ulcer prevalence did not follow as tight a trend, with very high risk (Braden 6-9) at 18%, high risk (Braden 10-12) at 19%, moderate risk (Braden 13-14) at 15%, mild risk (Braden 15-18) at 8%, and no risk (Braden 19-23) at 3%. All healthcare segments had many patients who developed ulcers who were assessed at ‘low risk’ or ‘no risk’ categories.

Overall PU prevalence increased with age, with the most ulcers identified in patients age 61 and above. This follows the distribution of admitted patients except for the > 80 age group, where the percentage of the total population leveled off, but the percentage of patients with a pressure ulcer continued to increase.

Conclusions:

Pressure ulcers were more common in either end of weight distribution, with higher severity ulcers found in underweight patients. Braden Risk Scores are predictive of pressure ulcers; however, patients considered at ‘low’ or ‘no risk’ still acquire pressure ulcers. The number of patients who developed pressure ulcers followed the normal distribution of admitted patients until after 80 years old, where there was a relative percentage increase.

Frequency of pressure ulcers in one emergency hospital and one rehabilitation centre in Harare, Zimbabwe

Sibanda M. and Jonsson K.

Department of Surgery, Faculty of Medicine, College of Health Sciences, University of Zimbabwe, P. O. Box CY 198, Causeway, Harare, Zimbabwe. (contact: sibandam@comone.co.zw)

Introduction:

The frequency of pressure ulcers in hospitals in the developing world setting is not well known. No figures have been presented from Zimbabwe. The aim of this study is to record the frequency and pattern of pressure ulcers in one emergency hospital and one rehabilitation centre.

Methods:

Twenty nine patients with pressure ulcers were registered by the nursing staff during 2006. Twenty of these records were available at retrieval for evaluation. Ulcer site, whether the ulcer was hospital or home acquired, management and outcome were registered. Assessment of the immune status was noted. The frequency of pressure ulcers during one month in a rehabilitation centre was recorded.

Results:

Of the 20 patients evaluated, 10 had hospital acquired ulcers and 10 had pressure ulcers present at admission. There were 24 ulcers in these patients; 12 sacral, 5 trochanteric, 4 heel, 2 calf ulcers and 1 abdominal ulcer. The median hospital stay was 18 (1-68) days. No ulcer healed during the hospital stay. At discharge eight patients remained with ulcers. Twelve patients died with the ulcer, seven of these had hospital acquired ulcers. Skin flaps or split skin grafting was not attempted. Five patients (25%) were immuno compromised and tested positive for HIV. Four had end stage malignant disease and four had had cerebral vascular accidents. Two were trauma patients and five had miscellaneous diseases. In the rehabilitation centre four out of 26 (16%) admitted patients had a pressure ulcer.

Conclusion:

Pressure ulcers were hospital and home acquired with equal frequency. The major underlying causes were immunosuppression malignancies. Sacral ulcers were the most common.

SAFE or SORRY? Does every patient at risk for pressure ulcers get adequate prevention?

van Gaal H.G.I., Schoonhoven L., Mintjes-de Groot A.J., Koopmans R.T.C.M. and van Achterberg T.

Radboud University Nijmegen Medical Centre, The Netherlands

Background

Patients in hospitals and nursing homes are at risk for the development of pressure ulcers. Although guidelines for the prevention of pressure ulcers are available, compliance with the guidelines appears to be lacking. With our SAFE or SORRY? research project we want to implement the guideline on the prevention of pressure ulcers. We measured the incidence of pressure ulcers and the use of preventive interventions before implementing the guideline.

The aim of this presentation is to present the percentage of patient who received effective preventive interventions during the pre-test of the SAFE or SORRY? study.

Methods

The design was a prospective study at twenty wards in The Netherlands: ten hospital wards and ten nursing home wards. For three months, research nurses visited patients in hospital wards within 48 hours of admission and once a week thereafter until they were discharged. Patients were included if they stayed on the participating wards for three days or more. In nursing home wards, research nurses visited patients at the start of the study and once a week thereafter until they were discharged or at the end of our study.

At each visit, patients were examined for the presence of pressure ulcers and further information was collected by observation and reading the files of the patients. The risk of pressure ulcers was measured with the PrePURSE and Braden scales in hospitals and nursing homes respectively.

Results

During these three months we visited 928 patients: 687 patients in hospitals and 241 patients in nursing homes. 59% of the patients in hospitals and 56% of the patients in nursing homes were at risk for the development of pressure ulcers. 47% of the patients in hospitals and 43% of the patients in nursing homes who were at risk received adequate prevention.

Data collection was recently finished. Calculations of pressure ulcers incidence rates are currently performed; these will be presented at the conference.

Summary

During a three months prospective study at ten hospital wards and ten nursing home wards in The Netherlands we measured the use of preventive interventions by patients who were at risk for pressure ulcers. Less than 50% of these patients at risk received adequate preventive care.