EUROPEAN PRESSURE ULCER ADVISORY PANEL

c) Number, severity and distribution of encountered pressure ulcers.

Across the five countries represented within the survey 1078 patients were reported to have pressure ulcers, with the overall prevalence by country illustrated in Figure 1. Three countries (Belgium, Sweden and the United Kingdom) had similar prevalence proportions ranging from 21.1% to 22.9%. The prevalence of pressure ulcers was reported to be lower in both Italy (8.3%) and Portugal (12.5%).

The 1078 patients with pressure ulcers experienced a total of 1860 pressure ulcers, with the sacrum the commonly affected site (n = 532, 28.6%). Figure 2 illustrates the anatomical distribution of all encountered pressure ulcers. Almost 88% (1630/1860; 87.6%) of all encountered pressure ulcers were found at one of eleven anatomical locations (Table 7). Several differences were apparent between the relative distributions of pressure ulcers over body sites. For example both Italy and the United Kingdom exhibited higher percentages of sacral pressure ulcers compared with the other countries (40.9% and 37.5% respectively of all pressure ulcers reported during the Italian and British surveys were located on the sacrum). Other differences between countries were also evident; for example the high percentages of ankle and hip pressure ulcers in Sweden and Portugal respectively.

The most severe pressure ulcer was recorded for all patients with pressure ulcers. Typically the most severe pressure ulcer presented as areas of non-blanchable erythema (n = 454, 42.1% of all patients with pressure ulcers experienced such wounds as their most severe area of pressure damage). The severity and anatomical locations of the most severe pressure ulcer experienced by the surveyed patients are illustrated in Figures 3 and 4 respectively. Typically the sacrum was the body site that experienced the most severe pressure ulcers.

The most severe form of pressure ulcer (Grade 4) occurred in 143 patients; the anatomical distribution having been recorded for 140 of these. Table 8 illustrates the anatomical distribution of all recorded Grade 4 pressure ulcers. In Italy and Portugal at least 50% of all Grade 4 pressure ulcers were located at the sacrum while in Sweden and the United Kingdom most Grade 4 pressure ulcers were found over the heels.

Above: Figure 1 Prevalence of pressure ulcers by country. Vertical columns show the
percentage of patients with pressure ulcers in each country.

Above: Figure 2 Anatomical distribution of pressure ulcers encountered across all
patients surveyed. Numbers refer to the number of pressure ulcers at each anatomical
site. Pressure ulcers also occurred 118 times at sites not illustrated in the figure.

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Above: Table 7 Anatomical distribution of the pressure ulcers encountered at the most commonly affected body sites by country. Data shows absolute numbers of pressure ulcers and the percentage, shown in parenthesis, within each category. (L/R denotes that the category combines pressure ulcers reported at the left and right body sites).


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Above: Table 8 Anatomical distribution of all Grade 4 pressure ulcers (n = 140) shown by country. Data shows absolute numbers of pressure ulcers and the percentage, shown in parenthesis, within each category.

Above: Figure 3 Severity of the most severe pressure ulcer experienced by the surveyed patients.
The numbers adjacent to each slice of the chart give the absolute numbers of patients whose
worst ulcer was of this grade.

Above: Figure 4 Anatomical location of the most severe pressure ulcer experienced by the
surveyed patients. The number adjacent to each slice of the chart give the absolute numbers
of patients whose worst pressure ulcer was found at the body site. Location of the most
severe pressure ulcer was unreported in 69 cases.

d) Pressure ulcer preventive care allocated to the surveyed patients.

Preventive care (defined as either the provision of a pressure redistributing support surface or regular manual repositioning) was recorded for all surveyed patients. Given the wide range of specialist mattresses and cushions in use across Europe, no attempt has been made during the EPUAP pilot pressure ulcer prevalence survey to identify individual products, rather all support surfaces are defined as being non-specialist (e.g., standard mattress), non-powered (for example, low pressure foam mattresses) or powered (any device with a mains electrical supply). Regular repositioning was recorded as either not planned or allocated, or reported to be performed at differing time intervals. It should be noted that it was not possible to verify whether reported repositioning was in fact performed.

To explore the allocation of preventive care, the surveyed patients have been divided into two groups; those considered vulnerable to pressure ulcer development (Braden score of 16 or below or with an established pressure ulcer regardless of its severity) and those patients considered to be at minimal risk of pressure damage (Braden score 17 or above and no pressure ulcers). This division provides an impression of the appropriateness of the allocation of preventive care and not an absolute measure given the imperfect prediction of true vulnerability as provided by risk assessment tools such as the Braden scale.

Based upon these definitions or risk, 2114 (36.5%) patients were considered to be in need of preventive intervention. Table 9 highlights the allocation of pressure-redistributing equipment while in bed and when seated for each country.

Three columns have been highlighted in Table 9 to focus attention upon areas where equipment allocation may be improved. Highlighted column (a) notes where patients assessed to be vulnerable to pressure damage were not allocated a pressure-redistributing mattress, whereas column (b) identifies instances where powered devices had been provided to patients apparently at minimal risk of developing pressure ulcers. Finally, column (c) notes where patients were at risk but not provided with a cushion; however, column (c) also included 871 bedfast patients that may have been expected not to have been allocated a cushion.

Interestingly, 138 bedfast patients were reported to have been allocated a special cushion! Of these 92 were encountered in the United Kingdom (8 using powered cushions) with 24 in Portugal. Two further columns were identified in Table 9. Column (d) marked an apparent high level of allocation of non-powered mattresses to patients at minimal risk, and this may mark hospitals where low-pressure foam mattresses were used as the standard bed mattress. Finally, column (e) marks the general low provision of powered cushions regardless of patient vulnerability to pressure ulcer development.

Table 10 highlights the reported repositioning of patients by nursing staff. Most patients were not repositioned (for example in bed, 4720 (81.6%) patients were not repositioned). Where patients at risk were not repositioned this may mark the allocation of special beds and mattresses. Interestingly approximately 260 patients were repositioned while in bed but did not appear to be vulnerable to pressure ulcer development.

A final indicator was developed from the data collected during the survey to mark the allocation of 'appropriate' preventive care. Appendix 4 sets out the structure of the algorithm used to identify whether the recorded care was likely to be appropriate or potentially inappropriate. Figure 5 identifies the proportion of patients who received appropriate or inappropriate preventive care. While most patients in the participating countries received some preventive care, relatively few (n = 265, 4.6%) were allocated fully appropriate care. The percentage of the surveyed patients considered to receive adequate preventive care ranged from 0% (Italy) to 9.3% (United Kingdom).

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Above: Table 9 The allocation of special beds, mattresses and cushions to patients encountered during the prevalence survey.


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Above: Table 10 Reported repositioning of patients by nursing staff.