EUROPEAN PRESSURE ULCER ADVISORY PANEL

AN ALTERNATIVE DESIGN TO STUDY THE VALIDITY OF PRESSURE ULCER RISK ASSESSMENT SCALES

T. Defloor, PhD, RN and M.H.F. Grypdonck

Aim

To compare the predictive value of two pressure ulcer risk assessment scales (Braden and Norton) and to evaluate the effect of effective preventive measures on the predictive validity.

Methods

314 out of the 1,772 participating geriatric patients were randomly selected and assigned to the 'turning' group; 1,458 patients were assigned to the 'non-turning' group.

Intervention

Each patient in the 'turning' group with a Braden score <17 or a Norton score <12 was randomly assigned to a two-hour turning schedule or to a four-hour turning schedule in combination with a pressure-reducing mattress. The 'non-turning' group received preventive care based on the clinical judgement of the nurses.

Data Collection

Pressure ulcer risk was scored twice weekly during a four-week period. The nurses were blinded for the Braden and Norton scores for their individual patients. Clinical risk assessment, pressure ulcer development, friction, spontaneous movements, sitting posture, skin condition, skin circulation, extra nutrients Ifluid intake, pain were monitored daily.

Results

With exception of turning, no statistically significant relation was found between pressure ulcer development and the preventive measures used. Thrning patients decreased the number of pressure ulcer lesions significantly (5.1% instead of 10.6%) (X2 = 12.042; df = 1; p<0.001). It did not lead to a reduction in non-blanchable erythema (19.4% and 20.7%).

The diagnostic accuracy given by the area under the ROC curve was similar for both scales (between 0.74 and 0.77) and did not help to discriminate between the Braden and Norton scales. If nurses act according to risk assessment scales, 80% of the patients would receive preventive measures, although not needed. Only 20% of the patients who should receive preventive measures, according to the risk assessment scales, would develop pressure ulcers if they did not. A lot of needless work is done and expensive material is wrongly allocated.

The use of effective preventive measures decreased the predictive value of the risk assessment scales. The area under the ROC curve decreased with 4 to 5%, the sensitivity decreased with 16 to 24%, and the specificity remained constant.

Nurses predicted pressure ulcer development even worse than the Braden and Norton scale. In only 46.6% of the patients that nurses considered as at risk, preventive measures were taken.

Only activity (OR 0.76, 95%Cl = 0.47-0.96) and sensory perception (OR 0.73, 95%Cl = 0.55-0.95) of the Braden scale, skin condition (OR = 1.63, 95%Cl = 1.25-2.12) and existence of old pressure ulcers (OR = 1.85, 95%Cl = 0.1.13-3.04) were significant predictors of pressure ulcer lesions (stage 2 and higher).

Conclusion

Sensitivity and specificity are not the most appropriated methods to evaluate the predictive value of risk assessment scales. The effectiveness of the Braden and the Norton scale seems to be very low, and the development of a new adapted scale is of the utmost importance.

THE DARK AREAS OF PRESSURE SORE COUNTRY

M.J. Lubbers, AMC, Amsterdam, Holland

• The risk of decubitus development is everywhere.
• Hard data is only available from a few areas (Hospital Ward / ICU / Nursing Homes).
• What about the other areas?
• Good literature or hard data about these areas does not exist. These are dark spots.
• A survey of these forgotten and neglected places will be presented.
• The P.S. equipment of Ambulances, Emergency Rooms, Diagnostic Centres and Operation Rooms will be discussed.
• Much work has to be done by the EPUAP

PRESSURE ULCER PROJECTS: IMPLEMENTATION AND PITFALLS

F.M.J. Hortag, Research Nurse, B.F.G. Apotheker, Pressure Ulcer Consultant, Th. Bots, Pressure Ulcer Consultant, Academic Medical Centre, University of Amsterdam, The Netherlands

Introduction

'Why does implementation of new ideas or projects need commitment from management, ward executives and bedside nurses?' The Dutch Government has recently made the creation of a national pressure ulcer policy a priority and the Academic Medical Centre has therefore decided that they would like to actively participate in its development.

Methods

The AMC has already started several implementation projects aimed at lowering the overall prevalence of pressure ulcers, including: a Quasi-experiment within six wards; prevention of heel pressure ulcers during an operation and the use of risk scales by bedside nurses. The project leaders have one goal in mind: how to involve and commit managers, ward executives and bedside nurses to prevent pressure ulcers in patients.

Results and Discussion

At this point, a number of difficulties or pitfalls during the implementation are worth mentioning.

1. Development of a pressure ulcer policy must be implemented on a multidisciplinary basis with the organisation. However, managers, ward executives and bedside nurses have different priorities. Some managers will use results of the national pressure ulcer measurement in the development of their policy while others will simply ignore them; bedside nurses think of patient centred quality of care; ward executives think of hospital costs. So employees in different settings have different interests. Friction becomes inevitable along with passivity. Nobody feels directly responsible in implementing new ideas or policies.
2. Diversity in interests will greatly hamper the implementation. Therefore it is important that all interests have a place within the overall concept.
3. Participants want to see results from their efforts. No supervision or feedback means no results. No results means no commitment and the loss of the patient centred approach.

The pitfalls mentioned above can be tackled. One of the methods to tackle low involvement and commitment is to impose a policy from above. To impose implies sanctions: rewarding or punishing participants. A point of discussion is whether the board of an organisation has to use this kind of method.

EVALUATING THE CLINICAL AND ECONOMIC OUTCOMES OF IMPLEMENTING A STANDARDIZED ALGORITHM TO HEAL STAGE II PRESSURE ULCERS

Courtney H. Lyder, Ophelia Empleo-Frazier¹ and Doreen McGee²
1) Yale University, New Haven, Connecticut, USA.
2) West Haven Veterans Administration Hospital, New Haven, Connecticut, USA.

Introduction

Pressure ulcers remain a major health condition in nursing homes in the United States. The pressure ulcer incidence rate in nursing homes have consistently ranged from 2.2% to 23.9% with a conservative annual cost of $1.5 billion. Due to changes in government reimbursement rates, it has become imperative for nursing homes in the United States to heal these ulcers in a timely and cost-effective manner. Thus, the purpose of this study was to evaluate the clinical and economic outcomes of implementing a standardized algorithm to heal Stage II pressure ulcers in nursing homes.

Method

The SOLUTIONS program is based on the principle of moist wound healing and evidenced based assessment tools with corresponding plans of care. Two nursing homes were used in this two phase study. In Phase I, a retrospective chart review of all residents with pressure ulcers was conducted to ascertain standard of care and baseline healing rates. In Phase II, a prospective double cohort repeated measures design was used to implement the SOLUTIONS program over a five-month period. An activity-based costing model was used to ascertain the cost to heal the pressure ulcers in Phase II.

Results

The baseline pressure ulcer data (N = 81) found that wet to dry gauze dressings and various hydrocolloids were the standard practice at both nursing homes with a mean healing rate of 10.19 weeks. After standardizing wound care (control cohort) and the implementation of SOLUTIONS (intervention cohort), the mean healing rate for Stage II pressure ulcers was significantly different in the control cohort 7.14 (n = 32) compared to 3.64 weeks (n = 40) for the intervention cohort (p. =0.0009). The activity-based cost model revealed that the total cost to heal the ulcers in the control cohort was $22,140 compared to the intervention cohort $4,918 (p. =0.0009).

Summary

This study concluded that the SOLUTIONS program was significantly more effective in healing Stage II pressures ulcers as compared to the standard intervention.

This research was funded by ConvaTec and Meade Johnson