Pressure ulcer audit data gathered in England and Wales was used to detect trends and compare implementation of guidance with clinical outcomes
Phillips, L., Buttery, J. (2009) Exploring pressure ulcer prevalence and preventative care. Nursing Times; 105: 16, early online publication.
A clinical audit was undertaken across a number of NHS trusts to establish the prevalence of pressure ulcers among hospital patients over a three-year period. The audit also recorded patient profiles and the provision of preventative pressure area care. The findings were analysed to compare pressure ulcer prevalence with implementation of NICE guidelines on managing pressure ulcers. The audit uncovered areas where care appears to fall below expected standards, which may partly explain continuing high prevalence rates.
Keywords: Pressure ulcer prevalence, Guidelines, Seating
Lyn Phillips, BSc, RN, is clinical director; Jill Buttery, BSc, RGN, is group systems support manager; both at ArjoHuntleigh, Luton, Bedfordshire.
We have been counting pressure ulcers for decades and, while there are certainly local success stories, data from the US and Europe suggest that pressure ulcer rates have failed to respond to prevention strategies (Gallagher et al, 2008; Van Gilder et al, 2008; Schoonhoven et al, 2007; Vanderwee et al, 2007). Many countries continue to report double-figure percentage results - for example, a European pilot survey noted that up to one in five acute care patients suffered some degree of tissue damage (Vanderwee et al, 2007), while others report that as many as three in four patients with pressure ulcers develop them in hospital (Gallagher et al, 2008).
How does the UK fare? The truth is we do not know for sure. England and Wales do not conduct a national pressure ulcer survey. For this reason, data that could be used to illustrate important trends in practice and clinical outcome is not available.
The lack of contemporary data also means that an accurate assessment of the costs and benefits of implementing the NICE (2005) pressure ulcer guidelines is difficult.
Until a national survey is established, a possible substitute is the comprehensive data that arises from routine audits conducted by commercial-client partnerships. This data can be pooled and analysed, provided the audit methodology is standardised across all hospitals. One such database, held by Huntleigh UK, collates data annually from up to 44 acute NHS trusts in England and Wales with from 250 to over 2,000 beds, and covers up to 30,000 patients annually.
As outcomes are likely to be most strongly influenced by local practice, including local care protocols, resource allocation and nursing intervention, the audit takes the degree to which the NICE guidelines have been implemented as a standard marker of preventative care, and measures the rate of both inherited and hospital-acquired pressure ulcers.
This inclusive approach to audit gives an insight into the pressure ulcer problem across a wide geographical area of England and Wales. More importantly, it can highlight areas of practice that might be worth further scrutiny and identify hot spots that would benefit from strategic action. This is particularly relevant given that more than half of all the ulcers recorded in the UK during 2005-2007 were acquired in hospital (Phillips, 2008). Vanderwee et al (2007) point out that where pressure ulcer prevalence was higher than expected fewer than 10% of patients were receiving optimal preventative care.
The analytical process
Data was collected during a three-year period from up to 44 acute hospitals in England and Wales using a standardised methodology. It was collected by trust employees, usually nominated clinical nurses, working with an auditor from the company. All inpatients present at 2am on the day of the audit were included.
The primary aim of these audits was to establish the overall number of patients with pressure ulcers and assess the vulnerability of the population.
Pressure ulcers are divided into wounds that are present on admission and those that occur during an episode of care, this latter group are increasingly considered to be a direct marker of quality. More in-depth analysis of the wound, the patient profile and the implementation of preventative care gives clinicians a clear indication of areas that deliver best practice and those where preventative care is lacking. This information is important in order to effectively target resources in the future.
To protect patient confidentiality, the nurses gathered relevant clinical information through assessment and nursing records, while the auditor entered the anonymous data directly into an electronic data entry form.
This electronic record has been designed to capture the minimum data set while reducing the likelihood of ‘missing fields’, which is a common problem with manual data collection tools. Data analysis and report preparation was automated to reduce the likelihood of user error.
Each hospital received an individual report and, with their agreement, the audit data was merged in order to facilitate benchmarking and trend analysis.
Data covering the nine-month period before the NICE guidelines (2005) were introduced, through the post-guideline period and into 2007 were analysed. The primary focus for the analysis was on recommendations in the guidelines that are directly related to patient assessment, care planning and the use of nursing practice related to immobility. These include repositioning, limited sitting and the use of specialist pressure-redistributing equipment. For this last point, given that more than 118 products from 30 different suppliers were in use, products are described under the definitions in the guidelines: non pressure-redistributing; pressure-redistributing and ‘advanced’ (powered) support surfaces.
Simple descriptive data was reported to illustrate emergent trends associated with implementation of the guidelines and to highlight areas that may influence the persistence of double-figure ulcer rates.
Overall prevalence and hospital-acquired ulcers
Despite increased awareness and new guidelines, the three-year audit data indicates a relatively static overall prevalence of 10.2%-10.3%.
There were fluctuations in the number of patients who developed pressure ulcers while under clinical supervision in an acute hospital, and this hospital-acquired figure has failed to drop below 50% of all ulcers encountered (Table 1).
Table 1. Reflection on clinical practice and ulcer outcomes 2005-2007
|Based on the key recommendations of the NICE pressure ulcer guidelines||Pre-NICE||Post-NICE||2007|
|% of ‘vulnerable’ patients on non-Pressure Redistributing (PR) mattress||13.8||2.0||0.5|
|% of ‘elevated patient risk’ on non-PR mattress||8.7||1.0||0.3|
|% of patients with grade 1-2 ulcers on non-PR mattress||2.9||1.3||0.4|
|% of patients with grade 3-4 ulcers not on ‘advanced’ mattress/bed||29||19||22|
|% of patients who have specialist mattress but sit out without a cushion||80||79||73|
|% patients with grade 3-4 sacral wounds, no cushion and sat out for up to 7 hours or more||55||71||59|
|Overall prevalence (all grades of wound)||10.3%||10.3%||10.2%|
|% of all ulcers encountered which were hospital-acquired (nosocomial)||62||57||59|
The data did not indicate a significant shift over time towards a higher risk or less mobile population (Fig 1), so increasing population acuity (increasing risk factors such as immobility, co-morbid disease) does not, on the face of it, seem to explain the persistent and/or rising rate of hospital-acquired ulcers, at least in terms of risk and dependency, for example, immobility, poor nutrition and incontinence, which are the traditional benchmarks for ulcer vulnerability.
Using NICE guidelines
The NICE guidelines make a series of evidence-based recommendations that focus on the holistic care of the patient. However, guidelines have little chance of having a positive impact if they are implemented in a piecemeal and inconsistent manner and, again, only if they are implemented as soon as a risk to health becomes apparent.
While the data suggests that one recommendation from the NICE guidelines - the allocation of pressure-redistributing mattress against need - has been largely adopted (Table 1), other significant gaps in preventative care are emerging.
The first cornerstone of prevention is to assess and manage the risk before an injury occurs. This principle is clearly identified by Schoonhoven et al (2008) whose in-depth study concluded that: ‘It would appear that any preventive measures can only be effective if taken timely.’
NICE suggests that assessment is carried out within six hours of admission, yet just four (<10%) of the hospitals routinely audited whether this actually happened.
The second principle, once risk has been identified, is to initiate a holistic plan of care. However, just six hospitals (<15%) audited the presence of a preventative care plan for those with identified risk or with existing ulcers; the hospitals that did audit this criteria reported that 60% of patients who should have had a plan did not.
Are seated patients exposed to additional risk?
There is a third and, possibly, more critical area which, from audit data at least, appears to be important - the care of patients when they are seated.
Patients are at risk of skin breakdown for 24 hours a day, yet the findings would appear to suggest a disparity in the management of seated patients compared with when they are nursed in bed.
Even in the absence of specific guidelines on this subject, there are some well-established precedents to guide best practice. Traditionally, these arise from the fields of physiotherapy, occupational therapy and the care of people with spinal injury. Patients who are seated require:
- Limited sitting times;
- A pressure-redistributing cushion;
- Regular repositioning.
More recently, attention has been turned toward the importance of the height and dimension of the chair in the management of seated patients. However, as the availability of variable-height chairs was limited in the hospitals audited, this has not been considered alongside seat cushions for the purpose of this report, although it should be in the future.
The audit analysis revealed that three out of four patients who are deemed to be at sufficient risk of developing pressure ulcers need a specialist mattress to sit in a chair without any form of pressure-redistributing cushion. At the same time, approximately half of the patients with existing pressure ulcers or total immobility/dependency sat for in excess of two hours (Table 2).
Table 2. Management of seated patients
|Management of seated patients|
|% of patients who are fully dependent/completely immobile and sit out for between 2 and 7+ hours||49%
|% of patients with active ulcers on the sacral-coccygeal or ischial region who sit out for between 2 and 7+ hours||56%
Of the patients who:
% who did not have a pressure redistributing cushion
Implications for practice
This snapshot of clinical practice, provided through clinical audit, has uncovered three critical areas where patient care appears to fall below the expected standards:
- Risk assessment on admission - and a failure in most cases to include this critical activity in the audit process;
- A prescribed plan of care which documents interventions, assessment schedules and outcomes - and a failure in most cases to include this measure in the audit process;
- The allocation of resources as soon as risk is identified - particularly lacking for the seated patient.
Although audit alone cannot establish a causal link, it does point to areas that may need to be addressed if hospitals are to realise the full potential of their investment in preventative care.
There is little evidence of early assessment or care planning - or at least no record of its implementation - yet assessment is a vital step toward timely intervention and is therefore worthy of more attention.
There is also a clear lack of provision for seated patients, particularly those who are most vulnerable because of a risk that has been identified, those with existing ulcers or those who are completely dependent on their carers.
The development of existing guidelines has been frustrated by a lack of published evidence in this area, particularly for acute and primary care patients. However, the Tissue Viability Society and a panel of experts have developed new seating guidelines and it will be interesting to track their adoption through the audit process (see ‘Guidelines for seating in pressure ulcer prevention and management’). Whether this is the missing link and will have a tangible impact on overall outcomes is yet to be seen.
Unless gaps in care provision are addressed - this audit has highlighted clear areas for investigation - the issue of patient safety will remain a concern. To echo the sentiment from Olshansky (2008): ‘The time has now come that we must raise our expectations… with few exceptions, pressure ulcers are unacceptable.’
Gallagher, P. et al (2008) Prevalence of pressure ulcers in three university teaching hospitals in Ireland. Journal of Tissue Viability; 17: 4, 103–109.
NICE (2005) Pressure Ulcer Management.
Phillips, L. (2008) Cushions or Casualties? Are Patients with Full-time Needs Getting Part-time Care? European Wound Management Association Conference, Lisbon, 13–16 May. Oral presentation. Abstract number 20.
Olshansky, K. (2008) The 10 most important questions concerning pressure ulcers and quality of care. Advances in Skin and Wound Care; 21: 11, 505–506.
Schoonhoven, L. et al (2007) The prevalence and incidence of pressure ulcers in hospitalised patients in the Netherlands: a prospective inception cohort study. International Journal of Nursing Studies; 44: 6, 927–935.
Van Gilder, C. et al (2008) Results of nine international pressure ulcer prevalence surveys: 1989–2005. Ostomy and Wound Management; 54: 2, 40–54.
Vanderwee, K. et al (2007) Pressure ulcer prevalence in Europe: a pilot study. Journal of Evaluation in Clinical Practice; 13: 2, 227–235.