EUROPEAN PRESSURE ULCER ADVISORY PANEL

LIFETIME ACHIEVEMENT AWARD

Prevalence and Prevention
J. C. Barbenel
University of Strathclyde, Glasgow, G1 1XW, U.K.

This presentation will, inevitably, be both retrospective and prospective, and reviews what I have done in the past and suggests actions for the future. The concentration will be on two areas of major importance to pressure ulcers.

The prevalence of pressure ulcers has been the subject of innumerable studies and reports, but the first extensive investigations were made twenty-five years ago in Glasgow and in the Scottish borders. The aim of these was clearly defined – that of convincing sceptics that pressure ulcers were a significant problem. The Glasgow survey was preceded by a smaller pilot survey and followed by a 5% random survey to assess the reliability of the results. What was learned from these smaller surveys influenced both the structure and wording of the substantive surveys and the presentation of the results; these will be described and discussed. The purposes of prevalence surveys have changed and prevalence, and its change over time, have become important indicators of the quality of patient care. It is important that the need for both reliability and the estimation of reliability be recognised.

The prevention of pressure ulcers should ideally be based on a detailed and quantitative understanding of causation, but progress in this area has been disappointing. There are, however, effective, empirically based methods of prevention, but these are often costly, either financially or in the time and effort required. The identification of patients at risk is a key procedure for the cost effective prevention of pressure ulcers and there are a variety of risk assessment scales. The risk factors, method of characterisation and the conversion of these to numerical scores and their combination in an overall numerical assessment will be reviewed. The difficulty of validation and its consequences in the light of current views of safety and risk assessment will be discussed.

Hip fractures. Anatomy, operation and rehabilitation
Karl-Göran Thorngren
Department of Orthopedics, Lund University Hospital, SE–221 85 Lund, Sweden

Hip fractures have increased dramatically in all western countries during the last decades both due to increase in the number of elderly in the population and also due to increase of the risk of hip fractures, particularly in the oldest above 80 years. This constitutes a threat to the medical resources. Increased attention has been focused on the full treatment panorama of femoral neck fracture patients including the operation, rehabilitation, functional outcome and comparison of costs.

Practically all hip fractures require an operation. This is performed as soon as practicable, usually within the first 24 hours after the fracture. It is the task of the orthopaedic surgeon to stabilize the fracture in such a way that full weight bearing and walking training can commence as early as on the day after the operation. The optimal treatment of femoral neck fractures requires a differentiated selection between primary osteosynthesis and arthroplasty. For unstable pertrochanteric fractures there is a choice between different osteosynthesis methods.

In Scandinavia, particularly in Sweden and Norway, primary osteosynthesis with hook pins or screws has been chosen for the majority of femoral neck fractures. If a healing complication occurrs, a secondary total hip arthroplasty is performed without delay to maintain the functional capacity of the patient. The advantages with the smaller primary operation, both for the patient in terms of morbidity and mortality as well as the saving in operation time, has been considered advantageous in spite of the need of a secondary arthroplasty in some cases. In other parts of the world the principle for primary operation of femoral neck fractures has been an arthroplasty, usually a hemiarthroplasty and in recent years a bipolar hip arthroplasty with the expectation to diminish the wear of the acetabular cartilage and secondary arthrosis. This means that a major operation is performed to save efforts for reoperation of healing complications. But other complications are introduced by the arthroplasty.

For undisplaced femoral neck fractures there is international agreement to use a primary osteosynthesis. For displaced fractures the goal is to find the right balance between primary osteosynthesis and primary arthroplasty. Optimized osteosynthesis technique with the use of traction table, biplanar x-ray image intensifier and hook pins has shown healing complications (both pseudarthrosis and femoral head necrosis) for displaced femoral neck fractures in 23%. Some studies with screw fixation have shown similar results. The need for reoperation with a total hip arthroplasty was just below 20%. After a primary arthroplasty a major reoperation can be expected in around 10% of the cases. These re-arthroplasties are then larger operative interventions with more expected complications. For trochanteric fractures, comminution is a problem in around 10%. Screw plate is the operation most used.

With increased knowledge about epidemology and treatment outcome of hip fractures, hopefully this resource consuming group of elderly persons will get better care and, in the future, prevention.

Improvements in Pain Relief, Handling Time and Pressure Sores through Internal Audit of Hip Fracture Patients
Ami Hommel, RN, BSN, CNS in Orthopedic Care
Dept of Orthopedics, University Hospital, Lund, Sweden
Kerstin Ulander, RN, BSN, PhD.
Assistant Professor, Department of Nursing, Lund University, Sweden
Karl-Göran Thorngren, MD, PhD.
Professor, Department of Orthopedics, University Hospital, Lund, Sweden

The aim of this project was to improve the outcome of hip fracture patients by optimising preoperative pain relief, diminishing the time from admission to operation, and reducing the occurrence of pressure sores. A retrospective study of all medical records of hip fracture patients from the last four months in 1998 was compared with prospective registrations during the same period in 1999 and 2000 after the introduction of quality improvements. The number of patients who waited more than one hour to get pain relief was almost halved after improvements. In 1998 close to half of the patients had to wait more than 24 hours for an operation. After attention was given to quality improvements, 36% of the patients in 1999 had to wait more than 24 hours and 34% of the patients in 2000. In addition 18% of the patients in 1999 and 24% of the patients in 2000 versus 11% in 1998 were operated on within 12 hours. Pressure sores were considerably reduced. From in total 19% of the patients in 1998 to 8% in 1999 and to 4.5% in 2000 had pressure sores at discharge from the hospital. The outcome for hip fracture patients was improved through attention to quality improvements with all staff involved and focused on these patients.

Key words: audit, hip fracture, nursing, pain relief, pressure sores, handling time.

Pan-European Pressure Ulcer Study (PEPUS)
Christina Lindholm RN, PhD
Karolinska Hospital/Karolinska Institute, Sweden.

Two years ago, it was decided that the European Pressure Ulcer Advisory panel should investigate the possibilities to undertake research, involving several European countries. A study with the purpose to look closer at the path-way of the hip fracture patient was discussed.

The study was designed to identify potential riskfactors for pressure ulcer development including both internal and external factors. Altogether 250 parameters were included.
After discussions with a statistician, it was decided that the study should include five centres per country, and twenty patients per hospital.

Several countries volunteered to participate, and Greece was the first country out. Since then Portugal, Sweden, Finland and Italy have completed. Spain has completed several forms but has chosen a modified model for data collection. Great Britain has completed two centres hitherto, and three more are expected to come. The first centre in the Netherlands has recently started, and plans are being set for a cooperation with the Baltic countries as well. A potential centre in Norway has been identified, and there are discussions ongoing with a Danish Centre as well. Data from some of the centres completed have been compiled and will be presented. It is likely that a risk assessment instrument specifically aimed at hip fracture patients will be the result of the present study.

The results of the total study in its complete form will be presented in Finland at next year’s EPUAP meeting. A study of this format with such a minor budget takes more time than expected to perform, and there are many formalities in different countries delaying the process. However, this is an exciting study, from which we can learn a lot. The preliminary results hitherto will be presented.

Pressure Ulcers – the quality of care indicator!
Ir. Ronald T. Boumans
Inspector Medical Technology, Public Health Supervisory Service of the Netherlands, Health Care Inspectorate

Introduction – The Health Care Inspectorate
The Health Care Inspectorate of the Netherlands is part of the Ministry of Health, but it operates independently. It can advise the minister with, or without a formal request. Reports are sent to the minister and they are simultaneously sent to the parliament. The Inspectorate concentrates its efforts on reducing dangerous situations, rather then bench marking of high quality performers.

The Inspectorate supervises the quality and accessibility of the health care in Holland. This is done by regular routine checks on practitioners, institutes and companies working in this field as well as with investigations after incidents or thematic inspections that look into structural problems. The Inspectorate employs approximately 400 people, of which 150 inspectors.

Pressure Ulcers and the Inspectorate
The typical position of the Inspectorate is at the end of the policy circle; public opinion is translated into law, which is enforced by the Inspectorate. With the problem of pressure ulcers only now finding some recognition in the field, initiatives by the Inspectorate might come unexpected. However, the provision of adequate care is required by law and therefore it is not acceptable for the Inspectorate that about one in four of every patient in Holland suffers from pressure ulcers. Only last year the internal discussion has started about how the Inspectorate should tackle the problem of pressure ulcers. The policy will be to stimulate the use of accepted field standards and to look into the products that are used in the prevention and treatment.

Dutch guidelines
This year new guidelines are presented and the Inspectorate will stimulate the institutions to use them. This will be done in steps. For 2003 the Inspectorate will concentrate on only one question: does the institution have a protocol based on the guidelines? In the following years emphasis will shift to more detailed aspects. In the Dutch guidelines it is advised that incidence of pressure ulcers is measured. The Inspectorate would like to see this recommendation specified into a protocol that is clear to follow for institutions. With a standardised way of registering incidence it should become easier to compare the results of different approaches.

Manufacturers of products will be stimulated to bring the quality of their product up to a certain level. This means, amongst other possible actions, that they should clearly specify the intended use of their products, that they should have clear manuals and that their risk analysis should be according to standards. Right now there are indications that these are not always as required by law.

Concentrating efforts
There are about 800,000 professionals working in the Dutch Health Care segment. They work in or outside about 3,000 institutions. Inspection objects can be found on about 60,000 addresses. The budget of the Inspectorate is less that 0.1% of the total budget for health care in Holland. With only 150 inspectors there is a need to concentrate efforts. The plan is to send out questionnaires to all institutions with a limited list of questions. These questions are only aimed at finding out which inspection object is in need of an inspection. Therefore, the added value of inspections would be higher compared to standard annual inspections to all institutions. The questionnaires will have a limited list of questions. An important part of the questionnaires will exist of questions about pressure ulcers: is there a protocol actually in use based on the field standard? Are the effects of this protocol monitored? How many people develop pressure ulcers (incidence or prevalence)? In other words: pressure ulcers will be used as an indicator of quality of care!