EUROPEAN PRESSURE ULCER ADVISORY PANEL

Over the years it has been generally agreed that most pressure ulcers are preventable. This belief has been the foundation of most, if not all, systematic efforts to provide high quality preventive care. But what do we accept by ‘most’ pressure ulcers? Some would consider that all pressure ulcers can be avoided, perhaps the majority would accept that some are going to occur in spite of the best preventive care. So where do we draw the line? Is an incidence of 1% or 2% within specified patient populations the best we can achieve? Such questions have profound effects; there may come a point when directing more resources into preventive care may yield little or no improvement in clinical outcome (the incidence of pressure ulcers). If we do not begin to discuss the limits of prevention then our care may become economically inefficient – wasting scarce time and money that may be better used in other care practices.

Hagisawa and Barbenel (1999) recently attempted to define the effective limits of pressure ulcer prevention within one medical ward of a Japanese hospital. Over a twelve-month period, nineteen registered nurses collected pressure ulcer vulnerability data (Braden Scale) and the severity of any pressure ulcers that developed (where a pressure ulcer was marked by a definite break in the skin, Grade II and above) across ‘all non-short stay patients’ (minimum length of stay being unreported). Most of the patients recruited to the study experienced severe neurological and/or pulmonary disease. Weekly monitoring of the accuracy of both risk assessment and sore classification was undertaken. After one month, all participating nurses provided identical risk assessment scores and sore severities!

For all patients, data was collected upon their age, sex, body weight and height, blood pressure, total serum protein and medical diagnosis. A Braden Score was calculated at admission and after one week in hospital. If a patient presented with a Braden Score of at least twenty-three at both assessments, then they were only reassessed monthly unless there was deterioration in their medical condition. Weekly Braden Scores were collected on all patients with initial scores under twenty-three.

A standard preventive regimen was introduced according to the patient’s Braden Score. If a patient had a Braden Score of seventeen or higher, they were nursed upon a 5-inch spring interior mattress. Active preventive care was introduced for all patients with a Braden Score under seventeen. This preventive care included manual repositioning at two hourly intervals, daily skin inspection, use of a dynamic mattress along with appropriate continence and nutritional management. Where a patient’s skin remained red for at least thirty minutes, a hydrocolloid dressing was applied to the affected area. All preventive interventions were recorded by the nursing team and verified by a single observer.

Over twelve months, 275 patients were recruited, of these 35 were present at the start of the study with 240 new admissions over the year. Four patients were admitted to the study with established pressure ulcers, and two of these subsequently developed further ulcers. Ten patients, initially ulcer free developed pressure ulcers during the study period. Overall the prevalence of pressure ulcers was 5.1% (95% Confidence Interval (CI) 2.4–7.8) while the incidence was 4.4% (95% CI 1.9–6.9).

None of the patients (n = 239) assessed to be free from risk (Braden score of at least seventeen) developed pressure ulcers. Only thirty-six patients had a Braden Score sufficiently low as to place them in the ‘at-risk’ group, and of these only twelve developed new pressure ulcers (conversion rate from being at risk to having a pressure ulcer was 33.3% (95% CI 17.6%–49.0%). It should be remembered that two of the twelve patients developing pressure ulcers had presented with established ulcers when they were first admitted to the study. Hagisawa and Barbenel suggested that their preventive care (risk assessment and interventions) marked ‘examples of the best current practice’ and as such the incidence observed in their study of a population of medical patients may mark ‘the lowest achievable in such patients’.

This study is important in that it explicitly raised the concept that there may be definite limits to pressure ulcer prevention. If such a study was to be accepted uncritically then policy makers may support the deployment of resources into pressure ulcer prevention until the achieved incidence fell to the apparent limit of 4.4%. Two key weaknesses do present within the study report; perhaps the Braden Scale either over-predicted risk or was inappropriate for the recruited patient population? More fundamentally the paper provides no data upon the length of exposure of patients to developing pressure ulcers; we do not know how long patients stayed in the ward; perhaps those who developed ulcers stayed for longer periods (greater exposure to the development of pressure ulcers). It would be interesting to recalculate the incidence rate presented by Hagisawa and Barbenel to reflect the number of patient-days exposure to developing pressure ulcers (marked by the total length of stay of all recruited patients) rather than the absolute number of patients recruited.

The work reported by Hagisawa and Barbenel presents a major challenge for the European Pressure Ulcer Advisory Panel. What are the limits of pressure ulcer prevention and has any care setting or country reached these limits? I would encourage all members of the EPUAP to join this debate and contribute their views on what are the limits of pressure ulcer prevention. To begin this process, two Trustees of the EPUAP (Brigitte Barrois, France and Carol Dealey, UK) have offered their comments upon the work reported by Hagisawa and Barbenel.