European Pressure Ulcer Advisory Panel

The Dutch National Prevalence Measurement of Care Problems: results on pressure ulcers of the last ten years (of 1998-2007)

Dr J.C.L. Neyens, Dr R.J.G. Halfens and Prof. Dr J.M.G.A. Schols

Introduction

The National Prevalence Measurement of Care Problems (in Dutch: Landelijke Prevalentiemeting Zorgproblemen, LPZ) represents an annual, independent measurement of care problems in several Dutch healthcare sectors, including pressure ulcers, malnutrition, incontinence, intertrigo, falls and restraints. The LPZ provides participating institutions with relevant and benchmarking information that enables them to take any specific measures necessary in order to improve their quality of care. The number of institutions participating in the LPZ grows by the year. The LPZ measurement on pressure ulcers has been conducted already for ten years since 1998.

Methods

The measurement involves general and specific questions about the prevalence, prevention and management of pressure ulcers on institutional level, ward level, and patient level. In intramural institutions, the measurement is conducted in a single day; for homecare organizations, the measurement is conducted over four days.

On completion of the measurement, the data can be uploaded by the participants using a web-based programme. All data are processed anonymously. After a few days, each institution receives it's institution-related data in a personal section of the LPZ-website. Later, each institution also receives an overview of the national data in a book.

Results

Data on prevalence and management of pressure ulcers of 1998 are compared with data of 2007, showing that the prevalence rate of pressure ulcers on national level is declining. Comparing only the data of institutions which participate already during a longer period (academic hospitals (2000-2007), general hospitals (2000-2007), and nursing homes (2003-2007)) shows that prevalence data also decline, with exception of academic hospitals.

Conclusions

The prevalence rate of pressure ulcers has declined in the Netherlands during the last ten years. Reasons for this decline will be discussed. Furthermore an overview will be given of international developments of the LPZ.

Patient safety in Sweden - A national initiative

Lena Gunningberg, RN, PhD¹ and Christina Lindholm²

1. Surgery Division, University hospital, Uppsala, Sweden,
2. Kristianstad University. Sweden.

Introduction

Inspired by the Institute for Healthcare Improvement in the United States, the Swedish Association of Local Authorities and Regions has initiated a national effort to increase patient safety. The CEO's of each County Council have prioritised six areas for patient safety. These are: nosocomial infections (urinary tract, central venous line, surgical wound infection), pressure ulcers, falls and medication errors. Six groups of experts have developed evidence-based guidelines with intervention kits for each area. The aim of this paper is to describe an intervention kit for pressure ulcer prevention.

Methods

A format was provided from the Swedish Association of Local Authorities and Regions. The evidence was gathered and a pamphlet of 18 pages was developed. The authors also had experiences from recent major prevalence studies on prevalence, prevention and risk assessment in Sweden. About twenty nurses around Sweden, interested in pressure ulcers, commented on the text. The guideline is now available on the web and as a free pamphlet. This work was published in March 2008.

Results

Mandatory interventions to prevent pressure ulcers are:

1. risk assessment,
2. skin inspection,
3. skin care,
4. pressure reduction,
5. nutrition,
6. information to patient and relatives, and
7. discharge information.

A description of each intervention is stated, for example ‘Skin inspection should be conducted immediately when the patient is admitted to the hospital or nursing home, and should be repeated daily for all patients over 70 years, and for patients who are bed-, or chair-bound most of the day'. The evidence for the interventions is also presented, as well as suggestions for monthly evaluations of performance.

Conclusions

By developing a simple, evidence-based national guideline, a standard for local care- programmes can be set. By working on a national political/organizational level, the message is widely distributed, and a tool for more effective pressure ulcer prevention can be provided both to hospital and community care.

Long-term follow-up of pressure ulcer prevention guideline adherence in home care

Verstraete S., Paquay L. and Van Gansbeke H.

Wit-Gele Kruis van Vlaanderen

Introduction

In 2006 we found that pressure ulcer guideline adherence was higher and that pressure ulcer prevalence had decreased 18 months after the implementation of a patient and family education program in an organization for home care nursing. The main objective of the present study was to monitor long term evolution of pressure ulcer prevention practices and the effects on prevalence. Secondly, the diagnostic value of a scheme for the identification of pressure ulcer risk in an early phase was studied. The risk scheme was based on the presence of a pressure ulcer, assessment of the patient's locomotion capacity and the nurses' clinical judgement on the patient's risk for developing pressure ulcers.

Methods

In a prospective study design, data collection will take place once a year in a random sample of home nursing patients. The present study is reporting the results of the data collection of 28 November 2007. For each patient included in the study, the visiting nurse collected anonymous data by filling out a case report form, which was derived from the European Pressure Ulcer Advisory Panel (EPUAP) registration form. It included standardized questions about demographic data (sex and age category), risk factors (ADL dependency, locomotion capacity and pressure ulcer risk), characteristics of pressure ulcers and preventive measures, both materials used and interventions by home care nurses and informal caregivers.

Assessment of pressure ulcer risk was performed using the Braden scale (cut-off: sumscore < 18) and the nurses' clinical judgment. Characteristics of the pressure ulcers were evaluated using the EPUAP-criteria for grading pressure ulcers. The Belgian Guideline for Prevention of Decubitus Ulcers was used as reference standard to evaluate guideline adherence of the applied preventive measures. The Braden scale was used as reference for determining the diagnostic value of the scheme for the identification of pressure ulcer risk in an early phase.

Preliminary results

Data were collected on 6120 patients, of whom more than half were women (67.5%) and older than 70 years (81.8%). According to the risk scheme, there were 3737 (61.5%) persons at risk for developing pressure ulcers. Pressure ulcer prevalence in the total study population was 13.3%, and 2.1% (< 0.001) higher than the year before. In persons at risk, 18.0% received effective preventive measures, 55.9% received ineffective measures, and in 26.0% prevention was absent.

Discussion

Compared to the sample of 2006, pressure ulcer prevalence and guideline adherence have changed significantly. Probably continuous follow-up and giving feedback to nurses will be necessary in order to preserve and improve the percentages of 2006. The new risk scheme for identification of patients at risk resulted in higher numbers of patients at risk. Currently, a diagnostic study is carried out in order to optimize the scheme.

Full results and conclusions will be available for the Annual European Pressure Ulcer Advisory Panel Meeting in September 2008.

Findings from a government funded quality improvement program on pressure ulcer prevention in the Netherlands

J.T.M. Weststrate, RN, PhD¹; J. Mast, RN, MSc.²

1. Netherlands Centre for Excellence in Nursing, Utrecht;
2. Vilans, National knowledge centre for long-term care, Utrecht, The Netherlands.

Introduction

The pressure ulcer (PU) prevalence in Dutch nursing homes and homecare was perceived as undesirable high by the Ministry of Health. Therefore a large non profit care consultancy organisation was approached to develop and roll out a PU prevention quality improvement program in collaboration with other relevant stakeholders in the Netherlands (core team). The overall aim of the program was to disseminate an improvement model which units could use to reduce the PU incidence by changing their clinical practice.

Methodology

The program was based on the Breakthrough method from the IHI. Commitment of institutional management was ensured by signing an agreement at the start with the consultancy organisation. The project teams from each participant organisation met in a working conference four times each year for instruction, inspiration, learning, and presenting to each other about results and processes. Each project team was monthly mentored by a member of the core team. The PU incidence was measured during three 4-week periods. After each period of measurement the data were analysed and recommendations for improvement were given to the units.

Results

The program was carried out on 49 units in 25 healthcare institutions. The course of the PU incidence over the year the units took part in the project was recorded. The PU incidence including grade I was significantly lower during the third measurement compared with the 1st. There was no significant difference in the incidence of PU grade 2-4 between the three measurements. Looking more in-depth, 14 units improved their PU incidence grade 2-4 and 12 units stayed at an incidence of 0%. In 10 units the PU incidence grade 2-4 increased.

Discussion

A significant number of units experienced a decrease in PU development. The project could not achieve an overall decrease in PU development grade 2-4 for all participatingunits. For some units changing practice towards effectively preventing pressure ulcers (grade 2-4) was hard to be achieved within the time frame of one year. Further research has to investigate the underlying reasons for this.

Analysis of pressure ulcer data obtained as part of a district-wide wound care audit: Patient characteristics, ulcer distribution and care setting

Kathryn Vowden MSc, BSc(Hons), RN¹; Peter Vowden MD, FRCS²

1. Nurse Consultant, Bradford Teaching Hospitals and University of Bradford, Bradford, UK;
2. Consultant Vascular Surgeon, Bradford Teaching Hospitals & Visiting Professor of Wound Healing Research, University of Bradford, Bradford, UK.

Introduction

A wide-ranging audit of wound care has been undertaken. The aim of this abstract is to describe pressure ulcer prevalence and characteristics using data from the overall wound care audit which was conducted in 2007 on a population of 500,000.

Method

A structured audit form was circulated to all health care organisations within a newly established Primary Care Trust, which includes two acute care organisations. Where pressure ulcers were recorded it was regarded as the most serious wound.

Results

Of the 1735 forms returned 363 (21%) (M:136, F:224, NK:3) listed a pressure ulcer as the most serious wound (Grade I:48, Grade II:195, Grade III:80, Grade IV:40 [EPUAP grading]) A further ten forms indicated a pressure ulcer was present but did not specify grade. The overall mean age of the patients with pressure ulceration was 79.1 years (M:75.8, F:81.3). For Grade II ulcers the M:F ratio was 1:2 with an overall mean age of 80.3 years. For Grade III ulcers the ratio was 3:5 (M:F) with a mean age of 77.1 years and for Grade IV the ratio was 1:1(M:F) with a mean age of 76.1 years. Ethnicity data showed that the great majority of pressure ulcers occurred in Europeans (326 - 89.8%), which, even allowing for the age characteristics of the different populations, was higher than expected as the local ethnicity data shows the proportion of Asians in the population to be approaching 19%.

Prior medical history data showed that 119 (33.8%) patients had a prior neurological deficit, 96 (26.4%) had a history of vascular disease and that 63 (17.4%) were diabetic. This represents a lower proportion (19.3%) than that for the overall population of 1735 patients. Of the 363 ulcers 156 (43%) were on the lower leg or foot and 164 (45.2%) on the sacrum or buttock. The most common site for the remaining 43 ulcers was the hip (18). The proportion of foot pressure ulceration was higher in those patients recorded as having acquired their ulcer in an acute care situation than those acquiring their ulcer in a care home, overall 48.4% as against 26.1%, this trend occurring for all ulcer grades. Ulcer duration varied widely but 71 ulcers had been present for 6 months or longer. The majority of patients had a single ulcer (232 - 64%) but 17 had four or more wounds and the mean number of wounds per patient was 1.54. The majority of pressure ulcers originated in an independent care home (142) or the patient's own home (99) and were then treated in that care location (130 care home and 178 patient's home or a residential home).

Nurses often reported that ulcers had developed in an acute sector hospital (65 cases) however validation of this data by cross referencing audit date of birth and postcode data with information stored on one of the acute hospital PAS system established that this was often not the case. Data is currently available on 57 patients, only 14 of these patient's ulcers were found to have originated in the reference acute hospital.

Conclusion

The management of patients with pressure ulcers crosses many care boundaries. This audit, covering acute and community patients, allows the health care providers to understand patient characteristics and treatment needs. Ulcer duration indicates that pressure ulcers will have a major social and quality of life impact on patients, there cares and the health care system.