EUROPEAN PRESSURE ULCER ADVISORY PANEL

NETHERLANDS: IS THERE A BENEFIT FROM SURVEYING?

Gerrie JJW Bours and Ruud JG Halfens
Maastricht University, Dept. Nursing Science, Maastricht, the Netherlands.

Introduction

In the Netherlands a national prevalence survey is carried out yearly in different health care institutions, from which the majority are acute care hospitals and nursing homes. These measurements give insight into the prevalence and severity of pressure ulcers.

By giving the settings feedback after each survey about their results, a positive effect on the consciousness of the health care workers to this problem may be obtained. This may result in better prevention strategies and therefore in a decrease of the prevalence. Last year this assumption has been shown that acute care hospitals and nursing homes that participated in the national survey from the first year had lower prevalence rates than those who participated for the first time. However, these lower prevalence rates may be misleading, due to differences in the distribution of patients' risk factors. To adjust statistically for differences in risk factors may be a better strategy to compare the early adopters with those who follow later in participating in the national prevalence survey.

For this the next research questions are formulated:

• Is there a decrease in prevalence rates for acute care hospitals during the years they participate in the national prevalence survey?
• Do settings (acute care hospitals) who participated from the first time (1998) have lower prevalence rates than those who participated last year for the first time?
• Is there a difference in policy conditions and preventive strategies between those early adopters and those who follow later?

Methods

The data of the prevalence surveys in 1998, 1999, 2000 (and 2001) are used for answering these research questions. Potential risk factors for pressure ulcers will be assessed by logistic regression if the p-value is less than 0.05 on univariate analyses in the sample. Expected rates of pressure ulcer development will be calculated from the logistic model and compared with the observed rates. The settings will be compared by means of their average predicted probability among their patients.

Results and Summary

The analyses are not yet finished. The results and conclusions will be presented at the conference.

PRESSURE ULCERS IN AMERICA: PREVALENCE, INCIDENCE, AND IMPLICATIONS FOR THE FUTURE

Submitted by the NPUAP Board of Directors
Presented by Janet E. Cuddigan, NPUAP Monograph Editor, and Elizabeth A. Ayello, Associate Editor.

Introduction

In 1989, the National Pressure Ulcer Advisory Panel (NPUAP) set a national goal to reduce the incidence of pressure ulcers by 500/0 by the year 2000. During the ensuing decade, the NPUAP engaged in an active program to improve clinical practice on pressure ulcers through education, research, and public policy. At the close of the twentieth century, the NPUAP assessed the progress toward this goal.

Methods

A Medline database search for all articles published and indexed between 1 January 1990 and 1 June 2000 (and later updated through 31 December 2000) yielded over 300 studies on pressure ulcer incidence and prevalence over the past decade. Data were analyzed across care settings and in specific populations such as persons with spinal cord injuries, the elderly, infants and children, hip fracture patients, persons of colour, and those at the end of life.

Results

Study data presented in the NPUAP monograph, 'Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future', indicate a wide variation in the range of incidence rates (i.e., acute care, 0.4% to 38%; long term care, 2.2% to 23.9%; and home care, 0% to 17%). Inconsistencies in methodologies used and the populations studied contribute to these differences and make comparisons and analyses of trends problematic. However, many positive developments in prevention and treatment of pressure ulcers have occurred over the past decade, including development of evidence-based practice guidelines, standardization of risk assessment, and improved technologies for prevention and treatment. Small studies from individual settings have shown that 50% reductions in pressure ulcer incidence rates are possible. A 25% reduction in the rate of pressure ulcer development was reported in a nursing home chain, using the Minimum Data Set (MDS). Several studies reported fewer full-thickness (Stage III or IV) ulcers.

Summary

The NPUAP monograph is an important contribution to the literature. The scholarly critique and recommendation for standardizing methods to determine pressure ulcer prevalence and incidence will have a pivotal influence on the pressure ulcer community. The NPUAP reaffirms its mission to improve patient outcomes in pressure ulcer prevention and management through education, public policy, and research by setting new goals to address the unresolved issues and concerns surrounding this international health issue.

PREVALENCE OF PRESSURE ULCERS IN ELEVEN GERMAN HOSPITALS IN APRIL 2001

Nils Lahmann and Theo. Dassen
Department for the Education of Nurse and Paramedic Teachers; and Nursing Science. Centre for the Humanities and Health Sciences, Humboldt University, Berlin, Germany

Introduction

As the first step of evaluating the quality of care regarding the important nursing care problem 'pressure ulcers' it is necessary to determine the actual prevalence of it. The department of nursing science of the Humboldt University Berlin conducted - as an independent institution - a regional survey in the states Berlin, Brandenburg and Mecklenburg-Vorpommern in April 2001. The survey was conducted with a German version of an instrument, that was developed and already in use in the Netherlands. The German version of the instrument was tested in a pilot study in November 2000 and proved to be reliable and valid.

Methods

The study design is a descriptive correlation questionnaire survey. Especially advised ward nurses observed every patient as far as 'informed consent' was obtained. The instrument contains questions regarding prevention, therapy and characteristics of pressure ulcers. For risk assessment, the Braden scale was used. Additional items about falling and the care dependency scale and some German specific information (care insurance, administrative labelling) complete the questionnaire.

Results

3012 Patients of an absolute 3516 patients (85, 7%) of eleven hospitals took part in the research. First results of data-analysis show:

• Defining patients 'at risk' for pressure ulcer with value of Braden 20 or less (increases sensitivity of the instrument) 38,4% of Patients are 'at risk'.
• Prevalence in the 'at risk' group in all eleven hospitals ranges from 12% to 53.5%. Significant differences in groups with/without pressure ulcers regarding body mass.
• Index and care dependency scale.
• High association between Braden scale and care dependency scale (r = 0.85). Data analysis still in progress. Scheduled results for illness, age, sex, operation, falling, etc.

Summary

Conducted survey in eleven German hospitals showed 28.3% average prevalence and high range of pressure ulcers in the group of patients at risk.

PROGNOSTIC ABILITY OF RISK ASSESSMENT SCALES (The prePURSE study)

L. Schoonhoven¹, J.R.E. Haalboom², E. Buskens¹, M. T. Bouserna³ and D.E. Grobbee¹.
1) University Medical Centre, Julius Centre for General Practice and Patient Oriented Research, Utrecht, the Netherlands. 2) University Medical Centre, Division of Internal Medicine and Dermatology, Utrecht, the Netherlands. 3) Eernland Ziekenhuis, Department of Dermatology, Amersfoort, the Netherlands.

Introduction

Patients admitted to a hospital have an increased risk of developing pressure ulcers. In 1999 the prevalence of pressure ulcers stage 2 and higher was 8.3% - 10.2% in hospitalized patients in the Netherlands1. Most pressure ulcers may be prevented if preventive measures are taken in time. These preventive measures are expensive and sometimes also labour intensive, and should therefore only be given to patients who are at risk for pressure ulcer development. Risk assessment scales are used to identify patients at high risk for pressure ulcer development.

At least seventeen risk assessment scales have been described in literature. The Norton scale and the Braden scale are the most tested and best-documented scales. Most scales are opinion based, rather than evidence based, and most are not or minimally evaluated. Yet, expensive preventive measures are based upon their outcome. In this study we evaluated the predictive value of the Norton scale, the Braden scale, the Waterlow scale and the CBO scale in hospitalized patients.

Methods

A prospective cohort study was conducted, including patients from two large hospitals in the Netherlands. Patients admitted to the Neurology, Internal, Surgical and Geriatric wards for more than five days were included in the study. Patients were visited within 48 hours of admission and subsequently once a week until discharge or admission for twelve weeks. Patients were observed for the occurrence of pressure ulcers and information on risk assessment scales and other risk indicators from literature was collected. A total of 1,229 patients were included in the study. The scores on the Norton scale, Braden scale, Waterlow scale and CBO scale were calculated at admission and for the first follow up visit. The ability of the scales to discriminate between patients at risk and not at risk for pressure ulcer development at admission and at the first follow-up visit was determined by calculating the area under the Receiver Operating Characteristic curve (AUC). The AUC can range from 0.5 (no discrimination) to 1.0 (perfect discrimination).

Results

The incidence of pressure ulcers stage 2 and higher after the first week of admission was 6.3%. The AUC's (95%Cl) at admission were:

1. Norton scale: 0,502 (0,437-0,568);
2. Braden scale: 0,514 (0,447-0,581);
3. Waterlow scale: 0,593 (0,525-0,661); and
4. CBO scale: 0,537 (0,475-0,599).

The AUC's (95%Cl) for the first follow up visit were:

1. Norton scale: 0,690 (0,631-0,748);
2. Braden scale: 0,674 (0,614-0,734);
3. Waterlow scale: 0,797 (0,750-0,843); and
4. CBO scale: 0,669 (0,611-0,727).

Summary

The results show that the risk assessment scales (within 48 hours after admission) are not able to discriminate between patients at risk and not at risk for pressure ulcers at first follow up visit (AUC: 0,502-0,593). The scores, calculated within 48 hours after admission, do not predict which patients will and which patients will not develop pressure ulcers stage 2 or higher in the first week of admission. However, the risk assessment scales (at first follow up visit) are able to discriminate moderately between patients with and without pressure ulcers at first follow up visit (AUC: 0,674-0,797). The scores, calculated at the first follow up visit, do predict which patients have and which patients do not have a pressure ulcer stage 2 or higher at that moment. The scales are therefore better diagnostic than prognostic instruments. Taking preventive measures based solely on the results of a risk assessment scale at admission should be avoided. A risk assessment scale with better predictive value should be developed.

1. Bours, G.J.J. W., Halfens, R.J.G., Joosten C.M.C. (1999) Landelijk Prevalentie Onderzoek Decubitus [National prevalence survey pressure ulcers]. University of Maastricht, Nursing Science, Stuurgroep Decubitus, Maastricht, the Netherlands