y J Wound Ostomy Continence Nurs. 2013;40(5):469-474. Published by Lippincott Williams & Wilkins
WOUND CARE
Pressure Ulcer Prevalence, Use of Preventive Measures, and Mortality Risk in an Acute Care Population A Quality Improvement Project Siv Leijon
Ingrid Bergh
Karin Terstappen
■ ABSTRACT
■ Introduction
The primary aim of this quality improvement project was to determine pressure prevalence, risk of mortality, and use of preventive measures in a group of hospitalized patients. Two hundred fifty-eight patients recruited from Skaraborg Hospital in Sweden were assessed. A 1-day point prevalence study was carried out using a protocol advocated by the European PU Advisory Panel. Patients’ age, gender, severity of PU (grades I-IV), anatomical location of PU, and use of preventive measures were recorded. The Swedish language version of the Modified Norton Scale was used for PU risk assessment. Data were collected by nurses trained according to the Web-based training: PU classification, “ePuclas2.” After 21 months, a retrospective audit of the electronic records for patients identified with pressure ulcers was completed. The point prevalence of pressure ulcers was 23%. The total number of ulcers was 85, most were grade 1 (n = 39). The most common locations were the sacrum (n = 15) and the heel (n = 10). Three percent of patients (n = 9) had been assessed during their current hospital stay using a risk assessment tool. There was a statistically significant relationship between pressure ulcer occurrence and a low total score on the Modified Norton Scale. The patients’ ages correlated significantly to the presence of a pressure ulcer. Patients with a pressure ulcer had a 3.6-fold increased risk of dying within 21 months, as compared with those without a pressure ulcer. Based on results from this quality improvement project, we recommend routine pressure ulcer risk assessment for all patients managed in a hospital setting such as ours. We further recommend that particular attention should be given to older and frail patients who are at higher risk for pressure ulcer occurrence and mortality. KEY WORDS: Modified Norton Scale, Mortality, Pressure ulcer, Pressure ulcer risk assessment, Prevention
Pressure ulcers (PUs) are associated with pain,1-3 impairment of activities of daily living,2,3 feelings of hopelessness, and altered body image.3 They extended hospital length of stay, resulting in increased costs,1,4-6 risk of sepsis,1 and death.1,7,8 Factors that increase the risk of developing a PU include age, mobility, poor functional status, urinary or fecal incontinence, fever, decreased serum albumin, decreased diastolic blood pressure, diabetes mellitus, low body weight, decreased dietary intake, and male gender.1,9 The prevalence of PU in different populations of patients has been studied in several countries. In Canada, the prevalence has been estimated at 26%,10 it was reported as 15% in the United States, and 15%11 and 12% in Jordan.12 It is difficult, however, to compare prevalence data between studies due to differences in data collection methods and definitions.11 In an attempt to overcome this problem, a working group was established in 2000 by the European Pressure Ulcer Advisory Panel (EPUAP), named the Pressure Ulcer Prevalence Monitoring Project, which developed a method that provided better potential to Siv Leijon, MSc, RN, Wound Nurse, Department of Dermatology, Kärnsjukhuset, Skövde Hospital, Sweden. Ingrid Bergh, PhD, RN, Professor, Nursing Science, School of Life Sciences, University of Skövde, Sweden. Karin Terstappen, MD, PhD, Chief Physician, Department of Dermatology, Kärnsjukhuset, Skövde Hospital, Sweden. Author contributions: S.L. and K.T. were responsible for the project design, S.L. was responsible for the data collection, and S.L., I.B., and K.T. conducted the data analysis and manuscript preparation. This project was supported by funding from the Research and Development Council (FoU) in Skaraborg. Correspondence: Ingrid Bergh, PhD, RN, School of Life Sciences, University of Skövde, Box 408, SE-541 28 Skövde, Sweden ([email protected]). DOI: 10.1097/WON.0b013e3182a22032
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compare results from different studies.13 This method includes nurses with specialist knowledge of wounds/PUs as basic data collectors. All participants in the survey are trained in PU classification, risk assessment. The method also calls for measurement of interrater reliability.13-15 Using this method, 5947 patients were surveyed regarding PUs in 5 European countries. Reported PU prevalences were 8.3% in Italy, 12.5% in Portugal, and 21% to 22.9% in Belgium, Sweden, and the United Kingdom.14 This protocol used in the EPUAP methodology was translated into Swedish,15-17 and it has been used to complete several prevalence studies.17,18 The protocol includes a PU risk assessment scale. In Sweden, the Modified Norton Scale (MNS)19 and the Braden Scale for Pressure Sore Risk20 are the most commonly used instruments for evaluation of PU risk. Swedish national guidelines emphasize the use of assessment tools as a complement to clinical judgment.21 Both the Braden and Norton scales have been shown to be more predictive of risk than nurses’ clinical judgment and more preventive measures are initiated when risk assessment scales are used.22 There is, however, no evidence that the use of a risk assessment scale reduces PU incidence.22 In Sweden, the MNS is most commonly used for risk assessment.23–25 Knowledge about the prevalence of PU and risk factors is key to developing methods for preventing facility-acquired PU. The aims of this quality improvement project were to investigate PU prevalence using a sample recruited from the Västra Götaland region of Sweden. We posed the following aims: (1) measure the point prevalence of PU; (2) analyze the association between PU prevalence and MNS scores, (3) evaluate the use of preventive measures and their association with MNS scores, and (4) analyze the association among PU development, age, and mortality
■ Methods Point prevalence is defined as the proportion of individuals in a population with a given disease or a given state at a given time; it is typically measured using a cross-sectional study design.24 This project is a part of a larger Six Sigma project. Six Sigma is a concept for improving quality in the organizational process and is based on 5 phases: Define— Measure—Analyze—Improve—Control, often referred to as a Define, Measure, Analyze, Improve, Control (DMAIC) methodology. Six Sigma was originally developed in industry but in recent years the concept has come to be used in healthcare.25 The data collection setting was the Skaraborg hospital (KSS) in Sweden; data were collected during a single day in June 2008. The hospital provides care within medicine and surgery including intensive care as well as gynecology, obstetrics, and rehabilitation with a total of 460 hospital beds. Only patients from the labor and delivery unit and children’s unit were excluded. All other units were included, totaling 382 beds; 83% of eligible beds (n = 318) were occupied on the day of data collection.
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Permission to conduct the quality improvement was granted by the hospital’s management team. Because this study was conducted as a quality assurance project (Six Sigma), no ethics approval from the Ethics Committee is required under Swedish law.26 Study procedures were completed in a moral and ethical manner, according to the guiding principles of the Declaration of Helsinki.27 Participants received both oral and written information about the purpose of the study and were notified that participation was voluntary and all gave oral assent prior to data collection. All data were treated as confidential and all data collectors were bound by professional secrecy according to the “Regulation of work in the health and medical domain.”28
Project Procedures The EPUAP protocol used for this project is based on15-17 collection of (1) general data (type of hospital, the number of beds of the hospital, and the country); (2) patient data (gender, age, expected length of stay, and the care group and medical specialty); (3) risk assessment using a PU assessment scales (the Braden Scale); (4) details provided about the skin observations and its location. Prevention is defined as the use of equipment for the bed and chair designed to redistribute pressure and preventive nursing actions including regular turning or repositioning. Data collectors are trained to assess and categorize PUs.16 A Web-based training program (ePuclas2) has been developed by the EPUAP to aid this process.29,30 All data are collected during a single day.16 Observation of the skin included grading and localization of pressure and their categories; PUs were classified according to the EPUAP grading system.14 Grade 1 PUs were defined as nonblanchable erythema of intact skin; grade 2 was as partial-thickness skin loss involving epidermis, dermis, or both; grade 3PU was defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; and grade 4 PU is defined as full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Necrotic ulcers were classified as grade 4.14 Preventive measures were measured using retrospective medical record review. Preventive measures included pressure redistribution surfaces such as mattresses, cushions, and associated devices. Documented schedules for repositioning or turning were also noted. Prior to data collection, we conducted 2 pilot projects that enrolled 11 and 17 patients, respectively, to evaluate feasibility of our protocol, and enhance training of nurses who acted as data collectors in the main project. Data collectors were trained in risk assessment and PU grading by an experienced nurse. The training was based on the Swedish version of EPUAP’s Web-based training: PU classification, “ePuclas2.”29,30 Nine nurses collected the data with support from a coordinator, who was available by phone to support data collection and to assist in case of
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a heavy workload. Each unit provided clinical staff to assist data collectors with their skin examination and to provide continuity of care. A second review of the patients’ electronic medical records was conducted 21 months after the day for the point prevalence study. The purpose of this review was to identify mortality among patients and to determine the principal diagnosis of patients with grade 2-4 PU. These diagnoses were grouped according to the Swedish PHC version of the International Classification of Diseases and Related Health Problems.31
Instrument The Swedish language version of the MNS was used for PU risk assessment. We chose this scale because this instrument is more widely used in Sweden than the Braden Scale.19 This substitution was also discussed with one of the Swedish Trustees of the European PU Advisory Panel (Professor Christina Lindholm, personal communication 11/22/2010).32 The MNS includes 7 variables: mental condition, physical activity, mobility, food and fluid intake, intake, urinary or fecal incontinence, and general physical condition. Each variable includes 4 possible responses; a score of 1 indicates impaired function and a score of 4 indicates normal function. The maximum score is 28 and a cutoff score of less than 20 is used to predict an increased risk of developing a PU. The MNS has shown good interrater reliability (r = 0.63–0.83).33,34 Its use is also recommended in guidelines issued by the Swedish Association of Local Authorities and Regions.21
■ Data Analysis Data were analyzed in SPSS for Windows version 18.0 (Statistical Package for the Social Sciences, Chicago, Illinois). Descriptive statistics were used to describe patients involved in this quality improvement project. Logistic regression analysis was completed to identify and quantify associations among PU occurrence, age, the use of preventive measures, and risk of mortality. Logistic regression implies that the dependent variable is dichotomized and a probability is calculated from the beta coefficients from this in relation to the continuous independent variable.24 Dichotomized variables were as follows: presence of PUs, 0 = no ulcer; 1 = ulcer, preventive measures; 0 = no preventive measures, 1 = preventive measures; mortality, 0 = deceased within the previous 21 months, 1 = alive after 21 months. Two-tailed P values < .05 were considered statistically significant for all tests.
■ Results Three hundred patients were deemed eligible for participation in this quality improvement project. Thirty-eight declined to participate, 16 were not on the ward, and
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7 were excluded owing to severe illness or terminal state. Therefore, analysis is based on a cohort of 258 patients, representing 81% of the target population. The ratio of women to men was nearly equal with 126 (49%) women and 132 men (51%). Their mean age ± SD was 72 ± 16 years. The mean hospital length of stay was 11 ± 16 days; range 1-164 days. Sixty patients (23%) were found to have 1 or more PUs; the total number of PUs was 85. Almost half (n = 28) of patients were found to have grade 2-4 ulcers. Gender was not associated with presence or severity of PU (Table 1). One-third of the PUs were present on admission to hospital; and one-third were hospitalacquired. It is not known when the ulcer developed in the remaining third. The most frequent locations for PU were the sacrum (n = 15) followed by the heel (n = 10) and the ear (n = 8) (Figure 1). If grade 1 PUs were excluded, the most common locations were the heel (n = 6) followed by the sacrum (n = 5) (Figure 1). The most common principal diagnosis leading to hospital admission among patients with grade 2-4 PU (n = 28) was cardiovascular diseases (n = 8; 29%), followed by infection-related diseases (n = 6; 21%). Diabetes mellitus was a comorbid condition in 25% (n = 7).
PU Prevalence and MNS Score Modified Norton Scale scores identified 64 patients (25%) as being at risk of developing a PU. Logistic regression analysis revealed a significant association between MNS score and the presence of PU. The lower the MNS score, the higher the probability (P < .001) of PU (Figure 2). The likelihood that preventive measures were being used increased as the MNS score decreased (P < .001) (Figure 3). Nevertheless, we observed multiple patients with low MNS scores without preventive measures. We also observed a number of patients who had no ulcers and a high MNS score and yet underwent preventive measures (Figure 4). Logistic regression analysis showed a significant (P = .007) association between advancing age and PU prevalence (Figure 5). Forty percent (n = 104) of all 258 patients with and without PUs were deceased 21 months after this quality improvement project was conducted. In patients with PUs, 66% (n = 40) had died. If grade 1 PUs are TABLE 1.
Gender Breakdown of Ulcer Incidence Based on the most Severe Ulcer (n = 60) Grade
Women
Men
Total
1
16
16
32
2
9
10
19
3
5
2
7
4 Total
1
1
2
31
29
60
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FIGURE 1. Frequency and location of the patient’s most severe
pressure ulcers.
excluded, 68% (n = 19) had died. A logistic regression analysis (age-adjusted) showed that the relative risk of dying within 21 months was 3.6 times higher (P < .001) for patients with a PU compared to those without.
■ Discussion We measured a point prevalence of 23.3%; this statistic describes PU of all grades, including grades I and II. This finding is consistent with previous studies in Sweden using similar methodologies, in which PU prevalence rates between 18.1% and 23.9% have been reported.14,35,36 Our findings were also comparable to other Swedish-based studies regarding PU grade and location.11,14,18,35,37-39 Our results also confirm the association between age and prevalence of PUs shown by other studies.9,11,36
FIGURE 2. Probability of pressure ulcer based on the MNS scores (cutoff score for risk = 20) (constant = 3.78; β value for MNS score = −0.223; SE = 0.038; P < .001).
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FIGURE 3. Probability of preventive measures, depending MNS scores (cutoff score for risk = 20) (constant = 3.731; β value for MNS score = −0.191; SE = 0.35; P < .001).
Findings from research are consistent with previous studies suggesting that a validated risk assessment instrument is indicated as part of an effective prevention program.21-23,36 Nevertheless, we also recognize that some patients may have an increased risk for PU development that is not detected by these instruments. Examples might include patients with arterial insufficiency of the lower extremities. Therefore, we recommend combining PU risk assessment, using a validated instrument such as the MSN scale with clinical assessment based on the patient’s underlying medical history. There was an association between advancing age and PU; this may indicate that PU is a sign of an overall fragility.
FIGURE 4. Distribution of preventive measures between
patients with and without ulceration, associated with the MNS scores (cutoff score for risk = 20).
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■ Conclusions We found a point prevalence rate of 23%. However, we also found that PU risk assessment tools such as the MNS are not consistently used. Our results further suggest that some patients at risk of PU may receive few preventive measures. Findings also show that patients with ulcers had a higher probability of dying within 21 months. The implications of these results are that procedures for PU risk assessment should include all patients and include a risk assessment instruments, for example MNS. Special attention should be given to older patients.
■ References FIGURE 5. Probability of pressure ulcers, depending on age (constant = −3.461; β value for age = 0.031; SE = 0.011; P = .007).
However, when controlling for age when association between PU and mortality was analyzed using logistic regression, this showed that patients with a PU had an increased risk (3.6 times higher) of dying within the next 21 months compared to those without a PU. This indicates that advancing age may increase the risk of PU, but also that occurance of a PU increases the risk of dying, regardless of age. Previous studies that evaluated the association between PU and mortality reported mixed results.7,40 For example, Thomas and colleagues report that developing a PU during acute hospitalization was not associated with reduced 1-year survival. In contrast, Berlowitz and Wilking7 reported that patients in longterm care with PU had a 2- to 3-fold increased risk of dying within 6 weeks of admission. However, they also observed that the PU was not identified as the direct cause of death. Instead, they noted that the PU was a sign of an underlying disease, resulting in an increased risk of complications and thus increased mortality.
■ Limitations Data collection was based on data collected from 81% of the target population. For example, we anecdotally note that ambulatory fitter patients were more likely to decline to participate than were patients with higher acuity illnesses. It is not known whether findings from patients not included in the study may have influenced outcomes. The EPUAP protocol for measuring PU prevalence recommends the use of the Braden Scale for Pressure Sore Risk, but we elected to use the MNS because this instrument is more familiar to Swedish nurses.14 In addition, the MNS is recommended by the Swedish Association of Local Authorities and Regions21 and has proved to have high interrater reliability.33,34 Nevertheless, the influence of this substitution on project outcomes is unknown.
1. Allman RM. Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med. 1997;13(3):421-436. 2. Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patient stories of living with a pressure ulcer. J Adv Nurs. 2006;56(4): 345-353. 3. Langemo DK, Melland H, Hanson D, Olson B, Hunter S. The lived experience of having a pressure ulcer: a qualitative analysis. Adv Skin Wound Care. 2000;13(5):225-235. 4. Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age Ageing. 2004;33(3):230-235. 5. Bertov K, Nordin A. Synliggöra Ekonomiska Konsekvenser av Förbättringsarbeten [Making visible the economic impact of the improvement works] (in Swedish). Jönköping; Utvecklingskraft: 2006. 6. Haalboom JR. The Dutch experience of pressure ulcers—a personal view. J Wound Care. 2000;9(3):121-122. 7. Berlowitz DR, Wilking SV. The short-term outcome of pressure sores. J Am Geriatr Soc. 1990;38(7):748-752. 8. Thomas DR. Issues and dilemmas in the prevention and treatment of pressure ulcers: a review. J Gerontol A Biol Sci Med Sci. 2001;56(6):M328-M340. 9. Lindgren M. Pressure Sores, Risk Assessment and Prevention [Medical Dissertation No. 784]. Lindköping: Faculty of Health Sciences, Linköping University; 2003. 10. Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy Wound Manage. 2004;50(10):22-24, 26, 28, 30, 32, 34, 36-38. 11. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs. 2000;27(4):209-215. 12. Tubaishat A, Anthony D, Saleh M. Pressure ulcers in Jordan: a point prevalence study. J Tissue Viability. 2011;20(1):14-19. 13. European Pressure Ulcer Advisory Panel. Summary report on the prevalence of pressure ulcers 2002;4(2). 14. Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T. Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract. 2007;13(2):227-235. 15. Gunningberg L, Carlsson S, Willman A. EPUAP-protokollet en europeisk metod för mätning av trycksårsförekomst [EPUAP-protocol—a European method to survey pressure ulcers] (in Swedish). Vård i Norden. 2006;26(2):48-51. 16. Gunningberg L. Risk, prevalence and prevention of pressure ulcers in three Swedish healthcare settings. J Wound Care. 2004;13(7):286-290. 17. Gunningberg L. EPUAP pressure ulcer prevalence survey in Sweden: a two-year follow-up of quality indicators. J Wound Ostomy Continence Nurs. 2006;33(3):258-266. 18. Lindholm CPPrag. Students learn about pressure ulcers, research methodology and to perform major quality audits—
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27. 28.
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results from 4 hospitals and 4 communities. Paper presented at: Conference of the European Wound Management Association 2006; Prag. Ek AC, Unosson M, Bjurulf P. The Modified Norton Scale and the nutritional state. Scand J Caring Sci. 1989;3(4):183-187. Braden B, Bergstrom N. A conceptual schema for the study of the etiology of pressure sores. Rehabil Nurs. 1987;12(1):8-12. Swedish Association of Local Authorities and Regions. Förebygg trycksår i samband med vård: nationell satsning för ökad patientsäkerhet [Prevent pressure ulcers associated with care: national initiative to i mprove patient safety] In Swedish. http:// www.skl.se/MediaBinaryLoader.axd?MediaArchive_FileID= ccd82192-6c89-48bf-8ce0-45bf9d3a1450&MediaArchive_ ForceDownload=true2008. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs. 2006;54(1): 94-110. Gunningberg L, Lindholm C, Carlsson M, Sjoden PO. Implementation of risk assessment and classification of pressure ulcers as quality indicators for patients with hip fractures. J Clin Nurs. 1999;8(4):396-406. Polit DF, Tantano Beck C. Nursing Research. Principles and Methods. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. Lanham B, Maxson-Cooper P. Is Six Sigma the answer for nursing to reduce medical errors and enhance patient safety? Nurs Econ. 2003;21(1):39-41, 38. SFS. Lag om Etikprövning av Forskning Som Avser Människor [The act concerning the ethical review of research involving humans]. Stockholm: Sveriges Riksdag: Utbildningsdepartementet; 2003:460. SOU. Good praxis in research [God sed i forskningen]. Utbildningsdepartementet. 1999:4. SFS. Lag om Yrkesverksamhet På hälso- och Sjukvårdens Område [Regulation of work in the health and medical domain) (in Swedish). Stockholm: Sveriges Riksdag: Rikstrycket; 1998: 531.
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29. Beeckman D, Schoonhoven L, Boucque H, Van Maele G, Defloor T. Pressure ulcers: e-learning to improve classification by nurses and nursing students. J Clin Nurs. 2008;17(13): 1697-1707. 30. Pressure Ulcer Classification: ePuclas2 [computer program]. Version 8.VI.2006: EUCAP; 2006. 31. Socialstyrelsen. Klassifikation av Sjukdomar och Hälsoproblem. [Classification of diseases and related health problems] (in Swedish). Stockholm: Socialstyrelsen; 1997. 32. Lindholm C. Professor. In: PANEL EPUA, ed 11/22/2010. 33. Bååth C, Hall-Lord ML, Idvall E, Wiberg-Hedman K, Wilde Larsson B. Interrater reliability using Modified Norton Scale, Pressure Ulcer Card, Short Form-Mini Nutritional Assessment by registered and enrolled nurses in clinical practice. J Clin Nurs. 2008;17(5):618-626. 34. Lindgren M, Unosson M, Krantz AM, Ek AC. A risk assessment scale for the prediction of pressure sore development: reliability and validity. J Adv Nurs. 2002;38(2):190-199. 35. Lindholm C. Prevalence, prevention and grading of pressure ulcers in a variety of populations—utilizing the EPUAP minidata-sheet. 36. Gunningberg L, Stotts NA. Tracking quality over time: what do pressure ulcer data show? Int J Qual Health Care. 2008;20(4): 246-253. 37. Gunningberg L, Dahm MF, Ehrenberg A. Accuracy in the recording of pressure ulcers and prevention after implementing an electronic health record in hospital care. Qual Saf Health Care. 2008;17(4):281-285. 38. Källman U, Suserud BO. Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment—a survey in a Swedish healthcare setting. Scand J Caring Sci. 2009;23(2):334-341. 39. Clark M, Benbow M, Butcher M, Gebhardt K, Teasley G, Zoller J. Collecting pressure ulcer prevention and management outcomes: 1. Br J Nurs. 2002;11(4):230, 232, 234 passim. 40. Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospitalacquired pressure ulcers and risk of death. J Am Geriatr Soc. Dec 1996;44(12):1435-1440.
Call for Authors: Wound Care • Continuous Quality Improvement projects, research reports, or institutional case studies focusing on innovative approaches to reduction of facility acquired pressure ulcers. • Original research or literature review on causes and management of refractory wounds. • Case studies, case series, review articles, or research reports on management of wound-related pain. • Case studies, case series, review articles, or research reports on matrix dressings, human skin substitutes, growth factors, or other advanced wound therapies. • Research reports or literature review on pathology, prevention, and management of biofilms. • Literature review and current guidelines on skin and wound care in neonates and infants.
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Pressure Ulcer Prevalence, Use of Preventive Measures, and Mortality Risk in an Acute Care Population A Quality Improvement Project Siv Leijon
Ingrid Bergh
Karin Terstappen
■ ABSTRACT
■ Introduction
The primary aim of this quality improvement project was to determine pressure prevalence, risk of mortality, and use of preventive measures in a group of hospitalized patients. Two hundred fifty-eight patients recruited from Skaraborg Hospital in Sweden were assessed. A 1-day point prevalence study was carried out using a protocol advocated by the European PU Advisory Panel. Patients’ age, gender, severity of PU (grades I-IV), anatomical location of PU, and use of preventive measures were recorded. The Swedish language version of the Modified Norton Scale was used for PU risk assessment. Data were collected by nurses trained according to the Web-based training: PU classification, “ePuclas2.” After 21 months, a retrospective audit of the electronic records for patients identified with pressure ulcers was completed. The point prevalence of pressure ulcers was 23%. The total number of ulcers was 85, most were grade 1 (n = 39). The most common locations were the sacrum (n = 15) and the heel (n = 10). Three percent of patients (n = 9) had been assessed during their current hospital stay using a risk assessment tool. There was a statistically significant relationship between pressure ulcer occurrence and a low total score on the Modified Norton Scale. The patients’ ages correlated significantly to the presence of a pressure ulcer. Patients with a pressure ulcer had a 3.6-fold increased risk of dying within 21 months, as compared with those without a pressure ulcer. Based on results from this quality improvement project, we recommend routine pressure ulcer risk assessment for all patients managed in a hospital setting such as ours. We further recommend that particular attention should be given to older and frail patients who are at higher risk for pressure ulcer occurrence and mortality. KEY WORDS: Modified Norton Scale, Mortality, Pressure ulcer, Pressure ulcer risk assessment, Prevention
Pressure ulcers (PUs) are associated with pain,1-3 impairment of activities of daily living,2,3 feelings of hopelessness, and altered body image.3 They extended hospital length of stay, resulting in increased costs,1,4-6 risk of sepsis,1 and death.1,7,8 Factors that increase the risk of developing a PU include age, mobility, poor functional status, urinary or fecal incontinence, fever, decreased serum albumin, decreased diastolic blood pressure, diabetes mellitus, low body weight, decreased dietary intake, and male gender.1,9 The prevalence of PU in different populations of patients has been studied in several countries. In Canada, the prevalence has been estimated at 26%,10 it was reported as 15% in the United States, and 15%11 and 12% in Jordan.12 It is difficult, however, to compare prevalence data between studies due to differences in data collection methods and definitions.11 In an attempt to overcome this problem, a working group was established in 2000 by the European Pressure Ulcer Advisory Panel (EPUAP), named the Pressure Ulcer Prevalence Monitoring Project, which developed a method that provided better potential to Siv Leijon, MSc, RN, Wound Nurse, Department of Dermatology, Kärnsjukhuset, Skövde Hospital, Sweden. Ingrid Bergh, PhD, RN, Professor, Nursing Science, School of Life Sciences, University of Skövde, Sweden. Karin Terstappen, MD, PhD, Chief Physician, Department of Dermatology, Kärnsjukhuset, Skövde Hospital, Sweden. Author contributions: S.L. and K.T. were responsible for the project design, S.L. was responsible for the data collection, and S.L., I.B., and K.T. conducted the data analysis and manuscript preparation. This project was supported by funding from the Research and Development Council (FoU) in Skaraborg. Correspondence: Ingrid Bergh, PhD, RN, School of Life Sciences, University of Skövde, Box 408, SE-541 28 Skövde, Sweden ([email protected]). DOI: 10.1097/WON.0b013e3182a22032
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compare results from different studies.13 This method includes nurses with specialist knowledge of wounds/PUs as basic data collectors. All participants in the survey are trained in PU classification, risk assessment. The method also calls for measurement of interrater reliability.13-15 Using this method, 5947 patients were surveyed regarding PUs in 5 European countries. Reported PU prevalences were 8.3% in Italy, 12.5% in Portugal, and 21% to 22.9% in Belgium, Sweden, and the United Kingdom.14 This protocol used in the EPUAP methodology was translated into Swedish,15-17 and it has been used to complete several prevalence studies.17,18 The protocol includes a PU risk assessment scale. In Sweden, the Modified Norton Scale (MNS)19 and the Braden Scale for Pressure Sore Risk20 are the most commonly used instruments for evaluation of PU risk. Swedish national guidelines emphasize the use of assessment tools as a complement to clinical judgment.21 Both the Braden and Norton scales have been shown to be more predictive of risk than nurses’ clinical judgment and more preventive measures are initiated when risk assessment scales are used.22 There is, however, no evidence that the use of a risk assessment scale reduces PU incidence.22 In Sweden, the MNS is most commonly used for risk assessment.23–25 Knowledge about the prevalence of PU and risk factors is key to developing methods for preventing facility-acquired PU. The aims of this quality improvement project were to investigate PU prevalence using a sample recruited from the Västra Götaland region of Sweden. We posed the following aims: (1) measure the point prevalence of PU; (2) analyze the association between PU prevalence and MNS scores, (3) evaluate the use of preventive measures and their association with MNS scores, and (4) analyze the association among PU development, age, and mortality
■ Methods Point prevalence is defined as the proportion of individuals in a population with a given disease or a given state at a given time; it is typically measured using a cross-sectional study design.24 This project is a part of a larger Six Sigma project. Six Sigma is a concept for improving quality in the organizational process and is based on 5 phases: Define— Measure—Analyze—Improve—Control, often referred to as a Define, Measure, Analyze, Improve, Control (DMAIC) methodology. Six Sigma was originally developed in industry but in recent years the concept has come to be used in healthcare.25 The data collection setting was the Skaraborg hospital (KSS) in Sweden; data were collected during a single day in June 2008. The hospital provides care within medicine and surgery including intensive care as well as gynecology, obstetrics, and rehabilitation with a total of 460 hospital beds. Only patients from the labor and delivery unit and children’s unit were excluded. All other units were included, totaling 382 beds; 83% of eligible beds (n = 318) were occupied on the day of data collection.
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Permission to conduct the quality improvement was granted by the hospital’s management team. Because this study was conducted as a quality assurance project (Six Sigma), no ethics approval from the Ethics Committee is required under Swedish law.26 Study procedures were completed in a moral and ethical manner, according to the guiding principles of the Declaration of Helsinki.27 Participants received both oral and written information about the purpose of the study and were notified that participation was voluntary and all gave oral assent prior to data collection. All data were treated as confidential and all data collectors were bound by professional secrecy according to the “Regulation of work in the health and medical domain.”28
Project Procedures The EPUAP protocol used for this project is based on15-17 collection of (1) general data (type of hospital, the number of beds of the hospital, and the country); (2) patient data (gender, age, expected length of stay, and the care group and medical specialty); (3) risk assessment using a PU assessment scales (the Braden Scale); (4) details provided about the skin observations and its location. Prevention is defined as the use of equipment for the bed and chair designed to redistribute pressure and preventive nursing actions including regular turning or repositioning. Data collectors are trained to assess and categorize PUs.16 A Web-based training program (ePuclas2) has been developed by the EPUAP to aid this process.29,30 All data are collected during a single day.16 Observation of the skin included grading and localization of pressure and their categories; PUs were classified according to the EPUAP grading system.14 Grade 1 PUs were defined as nonblanchable erythema of intact skin; grade 2 was as partial-thickness skin loss involving epidermis, dermis, or both; grade 3PU was defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; and grade 4 PU is defined as full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Necrotic ulcers were classified as grade 4.14 Preventive measures were measured using retrospective medical record review. Preventive measures included pressure redistribution surfaces such as mattresses, cushions, and associated devices. Documented schedules for repositioning or turning were also noted. Prior to data collection, we conducted 2 pilot projects that enrolled 11 and 17 patients, respectively, to evaluate feasibility of our protocol, and enhance training of nurses who acted as data collectors in the main project. Data collectors were trained in risk assessment and PU grading by an experienced nurse. The training was based on the Swedish version of EPUAP’s Web-based training: PU classification, “ePuclas2.”29,30 Nine nurses collected the data with support from a coordinator, who was available by phone to support data collection and to assist in case of
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a heavy workload. Each unit provided clinical staff to assist data collectors with their skin examination and to provide continuity of care. A second review of the patients’ electronic medical records was conducted 21 months after the day for the point prevalence study. The purpose of this review was to identify mortality among patients and to determine the principal diagnosis of patients with grade 2-4 PU. These diagnoses were grouped according to the Swedish PHC version of the International Classification of Diseases and Related Health Problems.31
Instrument The Swedish language version of the MNS was used for PU risk assessment. We chose this scale because this instrument is more widely used in Sweden than the Braden Scale.19 This substitution was also discussed with one of the Swedish Trustees of the European PU Advisory Panel (Professor Christina Lindholm, personal communication 11/22/2010).32 The MNS includes 7 variables: mental condition, physical activity, mobility, food and fluid intake, intake, urinary or fecal incontinence, and general physical condition. Each variable includes 4 possible responses; a score of 1 indicates impaired function and a score of 4 indicates normal function. The maximum score is 28 and a cutoff score of less than 20 is used to predict an increased risk of developing a PU. The MNS has shown good interrater reliability (r = 0.63–0.83).33,34 Its use is also recommended in guidelines issued by the Swedish Association of Local Authorities and Regions.21
■ Data Analysis Data were analyzed in SPSS for Windows version 18.0 (Statistical Package for the Social Sciences, Chicago, Illinois). Descriptive statistics were used to describe patients involved in this quality improvement project. Logistic regression analysis was completed to identify and quantify associations among PU occurrence, age, the use of preventive measures, and risk of mortality. Logistic regression implies that the dependent variable is dichotomized and a probability is calculated from the beta coefficients from this in relation to the continuous independent variable.24 Dichotomized variables were as follows: presence of PUs, 0 = no ulcer; 1 = ulcer, preventive measures; 0 = no preventive measures, 1 = preventive measures; mortality, 0 = deceased within the previous 21 months, 1 = alive after 21 months. Two-tailed P values < .05 were considered statistically significant for all tests.
■ Results Three hundred patients were deemed eligible for participation in this quality improvement project. Thirty-eight declined to participate, 16 were not on the ward, and
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7 were excluded owing to severe illness or terminal state. Therefore, analysis is based on a cohort of 258 patients, representing 81% of the target population. The ratio of women to men was nearly equal with 126 (49%) women and 132 men (51%). Their mean age ± SD was 72 ± 16 years. The mean hospital length of stay was 11 ± 16 days; range 1-164 days. Sixty patients (23%) were found to have 1 or more PUs; the total number of PUs was 85. Almost half (n = 28) of patients were found to have grade 2-4 ulcers. Gender was not associated with presence or severity of PU (Table 1). One-third of the PUs were present on admission to hospital; and one-third were hospitalacquired. It is not known when the ulcer developed in the remaining third. The most frequent locations for PU were the sacrum (n = 15) followed by the heel (n = 10) and the ear (n = 8) (Figure 1). If grade 1 PUs were excluded, the most common locations were the heel (n = 6) followed by the sacrum (n = 5) (Figure 1). The most common principal diagnosis leading to hospital admission among patients with grade 2-4 PU (n = 28) was cardiovascular diseases (n = 8; 29%), followed by infection-related diseases (n = 6; 21%). Diabetes mellitus was a comorbid condition in 25% (n = 7).
PU Prevalence and MNS Score Modified Norton Scale scores identified 64 patients (25%) as being at risk of developing a PU. Logistic regression analysis revealed a significant association between MNS score and the presence of PU. The lower the MNS score, the higher the probability (P < .001) of PU (Figure 2). The likelihood that preventive measures were being used increased as the MNS score decreased (P < .001) (Figure 3). Nevertheless, we observed multiple patients with low MNS scores without preventive measures. We also observed a number of patients who had no ulcers and a high MNS score and yet underwent preventive measures (Figure 4). Logistic regression analysis showed a significant (P = .007) association between advancing age and PU prevalence (Figure 5). Forty percent (n = 104) of all 258 patients with and without PUs were deceased 21 months after this quality improvement project was conducted. In patients with PUs, 66% (n = 40) had died. If grade 1 PUs are TABLE 1.
Gender Breakdown of Ulcer Incidence Based on the most Severe Ulcer (n = 60) Grade
Women
Men
Total
1
16
16
32
2
9
10
19
3
5
2
7
4 Total
1
1
2
31
29
60
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FIGURE 1. Frequency and location of the patient’s most severe
pressure ulcers.
excluded, 68% (n = 19) had died. A logistic regression analysis (age-adjusted) showed that the relative risk of dying within 21 months was 3.6 times higher (P < .001) for patients with a PU compared to those without.
■ Discussion We measured a point prevalence of 23.3%; this statistic describes PU of all grades, including grades I and II. This finding is consistent with previous studies in Sweden using similar methodologies, in which PU prevalence rates between 18.1% and 23.9% have been reported.14,35,36 Our findings were also comparable to other Swedish-based studies regarding PU grade and location.11,14,18,35,37-39 Our results also confirm the association between age and prevalence of PUs shown by other studies.9,11,36
FIGURE 2. Probability of pressure ulcer based on the MNS scores (cutoff score for risk = 20) (constant = 3.78; β value for MNS score = −0.223; SE = 0.038; P < .001).
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FIGURE 3. Probability of preventive measures, depending MNS scores (cutoff score for risk = 20) (constant = 3.731; β value for MNS score = −0.191; SE = 0.35; P < .001).
Findings from research are consistent with previous studies suggesting that a validated risk assessment instrument is indicated as part of an effective prevention program.21-23,36 Nevertheless, we also recognize that some patients may have an increased risk for PU development that is not detected by these instruments. Examples might include patients with arterial insufficiency of the lower extremities. Therefore, we recommend combining PU risk assessment, using a validated instrument such as the MSN scale with clinical assessment based on the patient’s underlying medical history. There was an association between advancing age and PU; this may indicate that PU is a sign of an overall fragility.
FIGURE 4. Distribution of preventive measures between
patients with and without ulceration, associated with the MNS scores (cutoff score for risk = 20).
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■ Conclusions We found a point prevalence rate of 23%. However, we also found that PU risk assessment tools such as the MNS are not consistently used. Our results further suggest that some patients at risk of PU may receive few preventive measures. Findings also show that patients with ulcers had a higher probability of dying within 21 months. The implications of these results are that procedures for PU risk assessment should include all patients and include a risk assessment instruments, for example MNS. Special attention should be given to older patients.
■ References FIGURE 5. Probability of pressure ulcers, depending on age (constant = −3.461; β value for age = 0.031; SE = 0.011; P = .007).
However, when controlling for age when association between PU and mortality was analyzed using logistic regression, this showed that patients with a PU had an increased risk (3.6 times higher) of dying within the next 21 months compared to those without a PU. This indicates that advancing age may increase the risk of PU, but also that occurance of a PU increases the risk of dying, regardless of age. Previous studies that evaluated the association between PU and mortality reported mixed results.7,40 For example, Thomas and colleagues report that developing a PU during acute hospitalization was not associated with reduced 1-year survival. In contrast, Berlowitz and Wilking7 reported that patients in longterm care with PU had a 2- to 3-fold increased risk of dying within 6 weeks of admission. However, they also observed that the PU was not identified as the direct cause of death. Instead, they noted that the PU was a sign of an underlying disease, resulting in an increased risk of complications and thus increased mortality.
■ Limitations Data collection was based on data collected from 81% of the target population. For example, we anecdotally note that ambulatory fitter patients were more likely to decline to participate than were patients with higher acuity illnesses. It is not known whether findings from patients not included in the study may have influenced outcomes. The EPUAP protocol for measuring PU prevalence recommends the use of the Braden Scale for Pressure Sore Risk, but we elected to use the MNS because this instrument is more familiar to Swedish nurses.14 In addition, the MNS is recommended by the Swedish Association of Local Authorities and Regions21 and has proved to have high interrater reliability.33,34 Nevertheless, the influence of this substitution on project outcomes is unknown.
1. Allman RM. Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med. 1997;13(3):421-436. 2. Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patient stories of living with a pressure ulcer. J Adv Nurs. 2006;56(4): 345-353. 3. Langemo DK, Melland H, Hanson D, Olson B, Hunter S. The lived experience of having a pressure ulcer: a qualitative analysis. Adv Skin Wound Care. 2000;13(5):225-235. 4. Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age Ageing. 2004;33(3):230-235. 5. Bertov K, Nordin A. Synliggöra Ekonomiska Konsekvenser av Förbättringsarbeten [Making visible the economic impact of the improvement works] (in Swedish). Jönköping; Utvecklingskraft: 2006. 6. Haalboom JR. The Dutch experience of pressure ulcers—a personal view. J Wound Care. 2000;9(3):121-122. 7. Berlowitz DR, Wilking SV. The short-term outcome of pressure sores. J Am Geriatr Soc. 1990;38(7):748-752. 8. Thomas DR. Issues and dilemmas in the prevention and treatment of pressure ulcers: a review. J Gerontol A Biol Sci Med Sci. 2001;56(6):M328-M340. 9. Lindgren M. Pressure Sores, Risk Assessment and Prevention [Medical Dissertation No. 784]. Lindköping: Faculty of Health Sciences, Linköping University; 2003. 10. Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy Wound Manage. 2004;50(10):22-24, 26, 28, 30, 32, 34, 36-38. 11. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs. 2000;27(4):209-215. 12. Tubaishat A, Anthony D, Saleh M. Pressure ulcers in Jordan: a point prevalence study. J Tissue Viability. 2011;20(1):14-19. 13. European Pressure Ulcer Advisory Panel. Summary report on the prevalence of pressure ulcers 2002;4(2). 14. Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T. Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract. 2007;13(2):227-235. 15. Gunningberg L, Carlsson S, Willman A. EPUAP-protokollet en europeisk metod för mätning av trycksårsförekomst [EPUAP-protocol—a European method to survey pressure ulcers] (in Swedish). Vård i Norden. 2006;26(2):48-51. 16. Gunningberg L. Risk, prevalence and prevention of pressure ulcers in three Swedish healthcare settings. J Wound Care. 2004;13(7):286-290. 17. Gunningberg L. EPUAP pressure ulcer prevalence survey in Sweden: a two-year follow-up of quality indicators. J Wound Ostomy Continence Nurs. 2006;33(3):258-266. 18. Lindholm CPPrag. Students learn about pressure ulcers, research methodology and to perform major quality audits—
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29. Beeckman D, Schoonhoven L, Boucque H, Van Maele G, Defloor T. Pressure ulcers: e-learning to improve classification by nurses and nursing students. J Clin Nurs. 2008;17(13): 1697-1707. 30. Pressure Ulcer Classification: ePuclas2 [computer program]. Version 8.VI.2006: EUCAP; 2006. 31. Socialstyrelsen. Klassifikation av Sjukdomar och Hälsoproblem. [Classification of diseases and related health problems] (in Swedish). Stockholm: Socialstyrelsen; 1997. 32. Lindholm C. Professor. In: PANEL EPUA, ed 11/22/2010. 33. Bååth C, Hall-Lord ML, Idvall E, Wiberg-Hedman K, Wilde Larsson B. Interrater reliability using Modified Norton Scale, Pressure Ulcer Card, Short Form-Mini Nutritional Assessment by registered and enrolled nurses in clinical practice. J Clin Nurs. 2008;17(5):618-626. 34. Lindgren M, Unosson M, Krantz AM, Ek AC. A risk assessment scale for the prediction of pressure sore development: reliability and validity. J Adv Nurs. 2002;38(2):190-199. 35. Lindholm C. Prevalence, prevention and grading of pressure ulcers in a variety of populations—utilizing the EPUAP minidata-sheet. 36. Gunningberg L, Stotts NA. Tracking quality over time: what do pressure ulcer data show? Int J Qual Health Care. 2008;20(4): 246-253. 37. Gunningberg L, Dahm MF, Ehrenberg A. Accuracy in the recording of pressure ulcers and prevention after implementing an electronic health record in hospital care. Qual Saf Health Care. 2008;17(4):281-285. 38. Källman U, Suserud BO. Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment—a survey in a Swedish healthcare setting. Scand J Caring Sci. 2009;23(2):334-341. 39. Clark M, Benbow M, Butcher M, Gebhardt K, Teasley G, Zoller J. Collecting pressure ulcer prevention and management outcomes: 1. Br J Nurs. 2002;11(4):230, 232, 234 passim. 40. Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospitalacquired pressure ulcers and risk of death. J Am Geriatr Soc. Dec 1996;44(12):1435-1440.
Call for Authors: Wound Care • Continuous Quality Improvement projects, research reports, or institutional case studies focusing on innovative approaches to reduction of facility acquired pressure ulcers. • Original research or literature review on causes and management of refractory wounds. • Case studies, case series, review articles, or research reports on management of wound-related pain. • Case studies, case series, review articles, or research reports on matrix dressings, human skin substitutes, growth factors, or other advanced wound therapies. • Research reports or literature review on pathology, prevention, and management of biofilms. • Literature review and current guidelines on skin and wound care in neonates and infants.
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