European Pressure Ulcer Advisory Panel

PILOT SURVERY OF THE PREVALENCE OF PRESSURE ULCERS IN EUROPEAN HOSPITALS

Over two days in November (14th and 15th) 2001, a pilot survey recording the prevalence of pressure ulcers across a number of European hospitals was undertaken by the EPUAP. Data was collected across ten countries (Belgium, England, France, Italy, Netherlands, Northern Ireland, Portugal, Scotland, Spain and Wales) with a minimum of two hospitals participating in the survey, typically each country collected data from around 1000 patients. While the data is currently being collated and analysed, with the first presentation to occur during the Sixth Open Meeting of the EPUAP (Budapest September 2002), this article highlights some of support material provided to participants by the EPUAP Prevalence Working Group. Each National Co-ordinator received a CD-ROM containing all of the forms and supporting documentation required to undertake the survey. From this material the research protocol and photographic guide provided to assist pressure ulcer classification are reproduced in this issue of the EPUAP Review. The Budapest meeting in 2002 will provide ample opportunity for debate regarding the methods, results and future steps the EPUAP should take to improve our understanding of the epidemiology of pressure ulcers. The EPUAP Prevalence Working Group would like to thank Smith & Nephew Ltd for their generous financial support that made this pilot study possible.

European Pressure Ulcer Prevalence Survey

Research Protocol

1. Introduction
Pressure ulcers are an important problem in all health care settings. Each year a lot of time and money is spent on the treatment of pressure ulcers. The prevention of pressure ulcers receives less attention, partly because there was no specific policy for pressure ulcers. In addition, the basis to develop a prevention policy for pressure ulcers was rather small (Dutch Steering Committee Pressure Ulcers, 1997). In the Netherlands a national pressure ulcer prevalence survey started in 1998, and this was the onset of more attention for the prevention of pressure ulcers.
Last year it was proposed to conduct an audit with the aim of collecting prevalence or incidence data on pressure ulcers at several European acute care hospitals and nursing homes, prior to implementing the EPUAP Guidelines (EPUAP, 1998). A similar exercise would be performed again after an agreed period, six months or one year, in order to ascertain whether the implementation of the guidelines had had any effect on prevalence or incidence figures. However, a discussion of this strategy concluded that this audit was too ambitious. It was obvious that more time would be needed to prepare the audit and it was felt that the highest priority had to be given to the development of a minimum data set, which would be valid across Europe. We started by inviting various experts in the field of pressure ulcers from different European countries to discuss a minimum key data set. Furthermore, it was agreed that operational definitions would be needed for the key terms. Finally, we wanted to know the minimum level of interest and commitment required for countries to be selected as participants.
The data collection procedure is designed on the basis of experience gained in the Netherlands, where three national measurements of pressure ulcers have been conducted (Bours, 1998; Bours, 1999; Bours, 2000).

2. Registration
Literally, to register means to record by using an instrument in order to establish the course of a process or phenomenon (Geerts and Heestermans, 1997). Registration can roughly be divided into two types, i.e., continuous registration and discontinuous registration.
Continuous registration means that phenomena, in this case the prevalence of pressure ulcers, is constantly being measured. The incidence of pressure ulcers can be established by means of continuous registration. The incidence rate indicates the number of new cases of a particular disease or condition, in this instance pressure ulcers, in the studied population over a particular period of time. (Bouter and van Dongen, 1995). All members of the study population should in principle run the risk of developing pressure ulcers and have no pressure ulcers at baseline.
Discontinuous registration, in this case, means that the prevalence of pressure ulcers is recorded incidentally, with or without a certain regularity. Discontinuous registration can, therefore, only establish the prevalence of pressure ulcers. The prevalence rate indicates the numbers of a studied population who have pressure ulcers at a particular moment in time (Bouter and van Dongen, 1995). Previous research has shown that discontinuous registration is easy to carry out in health care institutions, whereas permanent registration appears to be much more difficult to realise. Although daily inspection and registration of pressure ulcers are an essential part of the nurses' duties; it is inadequately executed in practice. Continuous registration, both by nurses and by doctors, may therefore lead to an underestimation of pressure ulcers. In addition, this type of registration is labour-intensive (Gunning-Schepers, et al., 1993). The EPUAP has therefore decided to limit their measurement to the prevalence of pressure ulcers and to use the results to establish whether their guidelines have had the intended effect.

3. Data collection form
The data collection form that will be used for the European data collection of pressure ulcers has been outlined by eighteen people from ten different European countries, and was further elaborated in greater detail by a small working group. The form was piloted in three different countries, the UK, Belgium and in the Netherlands. After piloting a few amendments were made for the final form.
The data collection form consists of five categories of questions, i.e.

The form is included as an appendix (Appendix 1). All participating institutions will be provided with sufficient data collection forms to conduct the survey. The national co-ordinators will be asked to translate the forms and all the other training and information documents for their own countries.

PILOT SURVERY OF THE PREVALENCE OF PRESSURE ULCERS IN EUROPEAN HOSPITALS Over two days in November (14th and 15th) 2001, a pilot survey recording the prevalence of pressure ulcers across a number of European hospitals was undertaken by the EPUAP. Data was collected across ten countries (Belgium, England, France, Italy, Netherlands, Northern Ireland, Portugal, Scotland, Spain and Wales) with a minimum of two hospitals participating in the survey, typically each country collected data from around 1000 patients. While the data is currently being collated and analysed, with the first presentation to occur during the Sixth Open Meeting of the EPUAP (Budapest September 2002), this article highlights some of support material provided to participants by the EPUAP Prevalence Working Group. Each National Co-ordinator received a CD-ROM containing all of the forms and supporting documentation required to undertake the survey. From this material the research protocol and photographic guide provided to assist pressure ulcer classification are reproduced in this issue of the EPUAP Review. The Budapest meeting in 2002 will provide ample opportunity for debate regarding the methods, results and future steps the EPUAP should take to improve our understanding of the epidemiology of pressure ulcers. The EPUAP Prevalence Working Group would like to thank Smith & Nephew Ltd for their generous financial support that made this pilot study possible. European Pressure Ulcer Prevalence Survey *Research Protocol* *1. Introduction* Pressure ulcers are an important problem in all health care settings. Each year a lot of time and money is spent on the treatment of pressure ulcers. The prevention of pressure ulcers receives less attention, partly because there was no specific policy for pressure ulcers. In addition, the basis to develop a prevention policy for pressure ulcers was rather small (Dutch Steering Committee Pressure Ulcers, 1997). In the Netherlands a national pressure ulcer prevalence survey started in 1998, and this was the onset of more attention for the prevention of pressure ulcers. Last year it was proposed to conduct an audit with the aim of collecting prevalence or incidence data on pressure ulcers at several European acute care hospitals and nursing homes, prior to implementing the EPUAP Guidelines (EPUAP, 1998). A similar exercise would be performed again after an agreed period, six months or one year, in order to ascertain whether the implementation of the guidelines had had any effect on prevalence or incidence figures. However, a discussion of this strategy concluded that this audit was too ambitious. It was obvious that more time would be needed to prepare the audit and it was felt that the highest priority had to be given to the development of a minimum data set, which would be valid across Europe. We started by inviting various experts in the field of pressure ulcers from different European countries to discuss a minimum key data set. Furthermore, it was agreed that operational definitions would be needed for the key terms. Finally, we wanted to know the minimum level of interest and commitment required for countries to be selected as participants. The data collection procedure is designed on the basis of experience gained in the Netherlands, where three national measurements of pressure ulcers have been conducted (Bours, 1998; Bours, 1999; Bours, 2000). *2. Registration* Literally, to register means to record by using an instrument in order to establish the course of a process or phenomenon (Geerts and Heestermans, 1997). Registration can roughly be divided into two types, i.e., continuous registration and discontinuous registration. Continuous registration means that phenomena, in this case the prevalence of pressure ulcers, is constantly being measured. The incidence of pressure ulcers can be established by means of continuous registration. The incidence rate indicates the number of new cases of a particular disease or condition, in this instance pressure ulcers, in the studied population over a particular period of time. (Bouter and van Dongen, 1995). All members of the study population should in principle run the risk of developing pressure ulcers and have no pressure ulcers at baseline. Discontinuous registration, in this case, means that the prevalence of pressure ulcers is recorded incidentally, with or without a certain regularity. Discontinuous registration can, therefore, only establish the prevalence of pressure ulcers. The prevalence rate indicates the numbers of a studied population who have pressure ulcers at a particular moment in time (Bouter and van Dongen, 1995). Previous research has shown that discontinuous registration is easy to carry out in health care institutions, whereas permanent registration appears to be much more difficult to realise. Although daily inspection and registration of pressure ulcers are an essential part of the nurses' duties; it is inadequately executed in practice. Continuous registration, both by nurses and by doctors, may therefore lead to an underestimation of pressure ulcers. In addition, this type of registration is labour-intensive (Gunning-Schepers, et al., 1993). The EPUAP has therefore decided to limit their measurement to the prevalence of pressure ulcers and to use the results to establish whether their guidelines have had the intended effect. *3. Data collection form* The data collection form that will be used for the European data collection of pressure ulcers has been outlined by eighteen people from ten different European countries, and was further elaborated in greater detail by a small working group. The form was piloted in three different countries, the UK, Belgium and in the Netherlands. After piloting a few amendments were made for the final form. The data collection form consists of five categories of questions, i.e. The first category shows whether the data were collected in a university hospital or a general hospital, as well as the number of beds in the setting. Each country has its own code. The second category, that of patient data, indicates the patients' age, gender, expected length of stay and care type. After piloting the form, the latter was simplified to intensive care, acute care or high dependence, chronic care and neurology/rehabilitation. The third category is that of risk assessment. The countries represented in the working group agreed to use the Braden scale plus the incontinence item from the Norton scale. The fourth category provides details about skin observations. The severest ulcer is to be recorded, using the EPUAP classification. It was agreed that necrotic ulcers are to be recorded as deep ulcers (grade 4). In addition, the location of the severest ulcer will also be recorded. Where multiple ulcers of the same grade are present, the pressure ulcer to be recorded is the one which, in the judgement of the nurse, has the greatest impact on the patient and his quality of life. Furthermore, a drawing is to be made to record all existing pressure ulcers. The last category involves the equipment used and whether the patient is being repositioned. Beds or chairs are to be categorised as powered or non-powered, while manual repositioning intervals (if any) are to be recorded as well. The form is included as an appendix (Appendix 1). All participating institutions will be provided with sufficient data collection forms to conduct the survey. The national co-ordinators will be asked to translate the forms and all the other training and information documents for their own countries. *4. Risk population* The prevalence measurement in acute care hospitals will take place on one particular day. The risk population will include all patients staying overnight on the day of the survey is to be physically examined for the presence of pressure ulcers. All inpatient areas have to be surveyed with the exception of psychiatry, day care and maternity units.

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