EUROPEAN PRESSURE ULCER ADVISORY PANEL

EPIDERMIOLOGY, PREVENTION AND TREATMENT OF PRESSURE ULCERS IN HUNGARIAN HOSTPITALS; 1992 - 1998. PART 1
Dr Laszlo Gulacsi, President, Hungarian Wound Healing Society

(Editor’s note: this paper will be published over two issues of the EPUAP Review with the second part in the next issue)

Abstract

Objectives: This project had three objectives:
(1) In patients nursed in acute care hospitals and considered to be at risk of pressure ulcer (PU) development, what was the baseline prevalence and incidence of PU.
(2) To establish the current patterns of preventive and treatment interventions and to investigate the economic burden imposed by the prevention and treatment of PU within the hospital population.
(3) To improve the quality of both PU prevention and treatment through the creation, dissemination and implementation of quality assurance programmes in hospitals.

Design: Data were collected from several sources: (1) Retrospective PU data gathered during the quality assurance activities undertaken within seventeen (COMAC/QA/HSR Programme) and twenty (BIOMED/PECO Programme) general public hospitals between 1992 and 1997 (*). (2) Retrospective national data describing the prevalence of PU between 1993 and 1998. (3) Retrospective chart review to identify PU management across 1,200 adult patient records drawn from seven hospitals in 1994. (4) Analysis of the national financial reimbursement of the in-hospital PU cases in 1994. (5) Prospective active surveillance of 705 adult patients in one county hospital. (6) Prospective active surveillance of 2,702 adult patients along with the costing of 100 PU patients (1,350 PU patient-days). (7) Changing PU prevention and treatment practices through the use of clinical protocols and guidelines.

Main results: (1) The actual prevalence of pressure ulcers is estimated to be 16–27 fold higher (3.7%–5.7%) than the officially published rate (0.18–0.21%) in Hungary. (2) On average 1.0%–2.5% of the direct costs of PU treatment, along with the estimated one to five days prolonged hospitalisation, are reimbursed under the current DRG financing mechanism. (3) As a result of this four-year PU study and quality assurance intervention, the Hungarian Wound Healing Society was created in 1997 in order to improve the quality of patient care through education, training, creating, disseminating and implementing guidelines and conducting surveillance in the field of prevention and treatment of PU.

Conclusion: (1) In order to monitor the true incidence and prevalence of PU active surveillance has to be established. (2) Both the prevention and appropriate treatment of pressure ulcers are in the economic interest of the hospitals reimbursed under the current DRG mechanism, because they are not reimbursed for any additional costs incurred by the PU patients. (3) Appropriate PU surveillance and documentation, including risk assessment, PU guidelines, PU costing and disease forecast tools have to be implemented and, in addition, disease-specific PU quality of life tools have to be created if health care professionals and managers want opinion leaders, media, and financing organisations to be on their side. (4) Incidence and prevalence of pressure ulcers can be decreased by appropriate prevention and treatment.

This study was part of the ‘Concerted Action Programme on Quality Assurance in European Hospitals (COMAC/HSR), 1992–1994, and part of its follow-up programme, the ‘Co-operation in Science and Technology with Central and Eastern European Countries and with the New Independent States of the Former Soviet Union, Les Pays d’Europe Centrale et Orientale (BIOMED/PECO)’ of the the European Union, DG XII, between 1994–1997, and This study was performed under the aegis of the Hungarian Society for Quality Assurance in Health Care and the Hungarian Wound Healing Society,

The author expresses special thanks to European Union, DG XII., the Dutch Ministry of Health, Welfare and Sport, the Hungarian Ministry of Health and Mölnlycke Health Care for funding the study.

Pressure ulcers are a serious problem most commonly found in nursing homes and hospitals. Reported PU prevalence rates within the international literature suggest that, among hospitalised patients, PU’s can affect between 3.5% and 29.5%, and in particular sub-populations, such as hospital quadriplegic patients, can be as high as 60% (for example Clark and Watts (1991), Haalboom, et al (1997) among many others). An increasing number of patients survive serious illness, severe disability and the multiple pathologies of old age and therefore are at high risk of developing PU. Today, high technology enables us to treat patients who are sicker and/or older than could be achieved only a decade ago. However, high-technology health care also entails higher levels of risk of developing pressure ulcers for many. That many patients suffer pressure sores is the unfortunate consequence of the treatment of patients suffering from diabetes, high blood pressure, fracture, or treated with steroid or having undergone an organ transplantation procedure.

The Hungarian national programme on PU prevention and treatment started as part of an European initiative focussed upon quality assurance in hospitals (COMAC/HSR and BIOMED/PECO projects). The Hungarian programme was conducted between 1992–1998 in seven interrelated study rounds. The programme design is shown in Table 1.

2.1 Phase 1: Assessment of the quality of prevention and treatment of pressure ulcers, 1992–1997 (COMAC/HSR and BIOMED/PECO programmes)

The overall objective of these two projects was to study different quality assurance strategies and their effect on the improvement of care with respect to four clinical topics: patient record keeping; use of prophylactic antibiotics in surgery; preoperative assessment in surgery; and prevention and therapy of PU. (Klazinga, 1994) The prevention and treatment of PU was the most popular quality assurance activity among the key topics, both in Hungary as well as in other countries that participated in the programme. (Gulácsi and Jakab 1993; Jakab and Gulácsi 1993a; Jakab and Gulácsi 1993b)

From the collected data, PU quality assurance activities were relatively under-developed in Hungary when compared to hospitals in the developed countries that participated in the COMAC/HSR and BIOMED/PECO programmes (Table 2). In 1993, only three of the seventeen participating Hungarian hospitals had established guidelines on PU prevention and treatment and these guidelines had only been endorsed in some departments. None of the hospitals had data on either the incidence or prevalence of PU with no use of risk assessment tools and no multi-professional PU teams. Several ambiguities were noticed in relation to both the definition and the recording of PU. For example, hospital, department and even doctor specific PU definitions were used in the participating hospitals. In one hospital, a PU that presented without concurrent fever was not recognised as a PU while in other centres Grade 1 and/or Grade 2 PU were not recorded. In some hospitals, if the PU had occurred before admission, the wound was not entered into the medical record as it was considered to be a non-hospital event!

The survey did include questions regarding the current prevalence of PU. In 1992 an average PU prevalence of 0.03% was identified across the seventeen hospitals. Compared to the literature this prevalence rate appeared to be very low. PU both as a cause of severe morbidity and as a cause of death was likely to be omitted from the patient’s medical record or death certificate, with the cause of morbidity or mortality classified as another disease. Consequently, there are no reliable estimates of either PU incidence or the mortality due to PU in Hungary. During the second round of surveys in 1995, twenty hospitals completed the questionnaires. Table 2 highlights significant advances in PU quality assurance activities, primarily related to the development of guidelines and the establishment of active pressure sore teams. Risk assessment tools were increasingly used with access available to a growing body of data upon the processes of prevention and treatment. In the case of nine hospitals the questionnaires were completed in both 1993 and in 1995, the successful implementation of quality assurance programmes within these settings can also be seen in Table 3. Different countries and type of hospitals participated in the COMAC/HSR and BIOMED/PECO programmes (3rd and 5th columns of Table 2), which makes direct comparison very difficult.

2.2 Phase 2: Retrospective national PU prevalence data collection, 1993–1998

Following patient discharge from hospital, information about the stay in hospital (main diagnosis, complications, co-morbidity, length of stay, etc.) was reported to the Centre for Healthcare Information, Ministry of Health by each hospital, this reporting also covered patients with PU. Hospital reimbursement (DRG payment) was then calculated based on the supplied data. The so-called ‘active cases’ were then reimbursed through DRG payments while hospitals also received a per diem rate to finance ‘chronic cases’. Table 3 presents the ‘officially reported PU prevalence’ within Hungarian hospitals based upon the reimbursement data.

Table 3 shows the total number of patients where PU was coded as being either the main diagnosis, or a significant complication or co-morbidity. Compared with the international literature on PU prevalence the number of reported cases in Hungary appears very low. The table demonstrates a key weakness of the data-driven approach to establish priorities for quality assurance programmes in Hungary. Based upon the available data, policy and decision-makers might fail to prioritise PU initiatives due to the apparently low prevalence of the condition. It would appear that some form of quality assurance activity has to be in place in order to identify the extent of the burden of any particular problem area. When PU quality assurance programmes began in Hungary it was widely accepted that PU were almost non-existent and that this disease and its economic burden were not important. Hospital quality assurance committees, established in 1992, were committed to defining the baseline prevalence and the real economic burden and found a completely different picture from the accepted wisdom that PU were rare. By 1997, when the Hungarian Wound Healing Society was established with its main aim being the improvement of the quality of PU prevention and treatment, health professionals in most Hungarian hospitals seemed to have a higher awareness of the importance of the topic.