EUROPEAN PRESSURE ULCER ADVISORY PANEL

Lena Gunningberg
Department of Nursing Research and Development, University Hospital, Uppsala.
Christina Lindholm
Associate Professor, Karolinska hospital, Stockholm, Sweden.

Introduction
During a recent research project, the incidence of pressure ulcers has been reduced significantly from 55% in 1997 to 29% in 1999, and the comprehensiveness of nursing documentation in the patient records has improved significantly. Contributing to the change of clinical practice is most likely a combination of three preventive interventions; risk assessment and pressure ulcer grading, a pressure-reducing mattress and an educational programme. The aim of the present paper is to describe the philosophy and the content of the educational programme.

Methods
The educational programme on pressure ulcer prevention was developed according to the EPUAP guidelines and conducted in 1998.

Results
The philosophy was to encourage staff to improve care, supporting them with research-based instruments and guidelines. The programme included education provided by a multi-disciplinary team and consisted of 40 hours of theory and 40 hours of practical tasks. The main practical task was to perform two case studies in the nurse's own unit, in which the theory should be applied. The patients' history and status were described, as were risk factors, risk scores, prevention and treatment. The pressure ulcers were photographed and graded. These case studies were presented and discussed in a seminar. Twenty- five registered nurses participated from the university hospital and from the community setting. The 'Pressure Ulcer Nurses' who attended the course have subsequently met regularly for continuous updated education and exchange of experiences.

Summary
The overall awareness of prevention of pressure ulcers has increased. The Pressure Ulcer Nurses has initiated quality improvement work in their own units. For example, written guidelines has been developed and implemented and minor educational seminars has been conducted. Now, a repeated educational programme is on-going with a specific pre-post evaluation.

PROMOTING PRESSURE-RELIEF MOVEMENT IN WHEELCHAIR USERS -THE EVALUATION OF A THEORETICALLY DESIGNED STUDY

Lesley Stockton and Dianne Parker
University of Manchester, Psychology Department, Manchester, England.

Introduction
The United Kingdom Department of Health guidelines and the Agency for Health Care Policy and Research guidelines on pressure ulcer reduction recommend that wheelchair users move to relieve pressure on vulnerable points every 15 minutes. Previous approaches at improving wheelchair users health prevention behaviour have focused upon engineering aspects with little success in the long-term modification of wheelchair user behaviour. The aim of the strategy is to improve preventative health behaviour, and addresses the problem from a health psychology perspective. Health psychologists have developed theoretical models to explain and predict behavioural choices in other health domains. One of the most relevant is the Theory of Planned Behaviour.

Methods
This study used the TPB as a framework for the development and evaluation of a health intervention specifically designed for wheelchair users living in the community It involved an interview study of wheelchair users (n = 20), a theoretically developed questionnaire study (n = 136) and the design, implementation and evaluation of a theoretically based health intervention (n = 38). The study identified factors that could be influenced and an intervention strategy was developed to address them. The intervention involved four experimental conditions, information only (control condition), information plus TPB, information plus TPB, information plus TPB plus personalised delivery, and information plus TPB plus personalised delivery and the encouragement of implementation intentions about the type of movement and when and where the movement would be performed.

Results
The outcome of the intervention was measured against psychological variables pre and post intervention, along with reported frequency of movement. Statistical analyses of the intervention indicated that the wheelchair users' overall attitude towards performing pressure-relieving movement, based on negatively held beliefs, was significantly less negative after the intervention, (t[df = 37] = -2.71, p =<.01) and perceived behavioural control became significantly more positive (t[df = 37] = 2.84, p<.01). There were significant changes in several of the specific individual behavioural and control beliefs of the whole sample, which will be reported upon. Anova was used to examine the differences of the mean scores on the individual behavioural and control beliefs by experimental condition. The most significant changes in beliefs occurred in those wheelchair users who had received information plus TPB plus personalised delivery, however, the most reported behavioural change was in those who had formed implementation intentions.

Summary
This work has confirmed that wheelchair users are not following Department of Health guidelines. This theoretically designed intervention was effective in influencing the attitudes, beliefs and reported behaviour of wheelchair users.

AN ASSESSMENT OF MEDICAL AND NURSING KNOWLEDGE OF PRESSURE ULCERS IN AUSTRALIA

Prentice JL and Stacey MC
University Department of Surgery, Fremantle Hospital, Perth, Western Australia.

Introduction
Few studies that have investigated either doctors or nurses knowledge of the aetiology, predisposing factors and management of pressure ulcers have been reported in the literature. Results of studies conducted have indicated varying levels of knowledge within each group. These differences have been related to years of experience and additional tertiary qualifications.
Clinical practice guidelines should provide a framework within which clinicians can provide the best clinical care. These should lead to improved patient outcomes that have occurred as a result of clinician's increased knowledge of the particular health problem.
An aim of this Study was to determine if there was a change in the clinical practice and knowledge of medical and nursing staff following the introduction of the Australian Wound Management Association's (AWMA) guidelines for predicting and preventing pressure ulcers together with an education programme.

Methods
Junior Medical and Nursing Staff in ten major teaching hospitals in Australia in 2000 were surveyed to assess their knowledge of pressure ulcers. This was a pre- and post-assessment after the introduction of pressure ulcer guidelines into these hospitals. An education program to assist with the introduction, dissemination and implementation of these guidelines took place over a six-month period in only five of these hospitals. The other five hospitals received no other additional support. An education manual including independent learning modules that were accompanied by tutorial notes and audio-visual aids were used to provide in-service education on pressure ulcers.
The Staff questionnaires were a paper and pencil tool that contained 22 variables in the first survey and 24 in the second. Staff have recorded their demographics, use of risk assessment tools, knowledge of hospital pressure ulcer policies and wound management services. Staff have also been asked to identify ten risk factors that predispose a patient to being at high risk of pressure ulcer development. Respondents also identified treatment strategies for a Stage 1 and 2 pressure ulcers.

Results
In the first survey a total of 7,642 staff surveys were distributed: 1018 Medical and 6624 Nursing.
1221 were returned: a response rate of 16%. From 929 nursing responses to identification of risk factors 76% listed immobility, 65% poor nutrition, 46% incontinence, 11% spinal injury, 9% shear pressure, 6% peripheral neuropathy and 4% pressure. Only 224 (20%) of nursing respondents were able to identify that a pressure ulcer policy existed in their hospital. 548 or 50% of nurses stated a risk assessment tool used in their hospital. The main constraints to preventing pressure ulcers were lack of support surfaces (30%), time (22%), education (16%) and staff (11 %).
Respondents to the second survey from hospitals that received the education program have identified immobility, poor nutrition, and pressure and shear pressure with greater frequency.
Less than 1% of Medical staff identified pressure, shear and friction as independent causative factors in the first survey. Comparative data on the second medical survey will also be presented. Non-responder surveys were completed after each survey due to the low response rate. There are no differences between the two sets of responses.

Summary
Using an education program to facilitate the introduction of clinical practice guidelines for pressure ulcers does appear to have produced only modest improvements in staff knowledge even though a reduction in pressure ulcer prevalence occurred at the same time across these hospitals.

THE COSTS OF PRESSURE ULCERS: PREVENTION OR REACTION

C. Lourens*, J M G A Schols**, C N Kiejier
*Student University of Groningen, Faculty of Business Administration, **Verpleeghuis De Riethorst, Geertruiden-berg; Faculty of nursing home medicine, UMC St Radboud Nijmegen, The Netherlands, **Department of Scientific Services, Nutricia Nederland BV, The Netherlands

Introduction
Pressure ulcers (PU) are an important and fairly common problem in all sectors of health care. Because of their characteristics, nursing homes patients represent a particularly vulnerable group for developing PU. PU not only cause considerable patient suffering, they are also one of the most expensive disorders in the Netherlands'. The approach to this problem must focus primarily on adequate prevention, and with existing ulcers, on effective treatment.
Preventative measures have associated cost, but these costs appear to be minor in comparison to the costs of a prolonged hospital stay and more intensive nursing due to the development of PU. Empirical experience has shown that the best prevention and treatment of PU consists of three essential aspects: reducing pressure and sheer forces, adequate skin and wound care and nutritional therapy. Practice shows that nutritional therapy, is the least well integrated into patient care. This is surprising because research has shown that people in nursing homes are convinced of the fact that poor nutritional status is one of the main causes of the development and worsening of PU2.

Objective
This study was designed to emphasise the importance of nutritional intervention in the prevention and treatment of PU and to examine the actual costs of treating PU. The intention of this study is to change the (negative) thoughts concerning the too high costs of nutritional therapy. The following questions are addressed:
What are the extra costs incurred by PU in a nursing homes?
What is the influence of nutritional therapy (using sip feeds) on these costs?

Method
The study consisted of monitoring the costs of patient care in five nursing homes in the Netherlands. Forty-eight long-stay patients were divided into groups based on the four-stage grading system for severity of PU (1, 11, 111 and IV). The numbers of subjects per group were respectively 14, 13, 12, and 9. Patients were excluded when they received any specific nutritional intervention. Extra Costs (E) (i.e., material costs, medications costs and personnel costs) were recorded over a three day period and added onto the known costs of Basic Nursing Costs (B).

Results
A mathematical model was developed to make a realistic estimate of the Total Costs (TC) per patient per stage of PU. Calculations were based on the Basic Nursing Costs (B) of the 125 Euro per patient per day, Extra Costs (B) and the increased Duration of intensive nursing (D1) leading to the model: TC = (B+E) D. The TC per patient per stage of PU were 1575 Euro, 2834 Euro, 2871 Euro and 5858 Euro for the stages I, II, III and IV respectively. This model was modified to predict the effect of a PU specific sip feed for patients who developed PU.

Conclusion
A mathematical model revealed the Total Costs (TC) of PU in Dutch nursing homes. This study furthermore showed that through usage of sip feeds, a cost saving per patient, per stage of PU, can be realised if the total number of days of extra intensive nursing care (D) is reduced by one or more days.

References:
Haalboom JRE (1991). De Fosten van decubitis. Ned tijdschr Geneeskd 135: 606-610
Schols JMGA, Kleijer CN (2000). Nutrition policy for patients with pressure ulcers in Dutch nursing homes. EPUAP Review 2 (2): 51-54.