Explaining the national differences in pressure ulcer prevalence between the Netherlands and Germany – adjusted for personal risk factors and institutional quality indicators

Background Pressure ulcers have a known impact on quality of life as well as on morbidity and mortality of the persons affected. Remarkable differences in pressure ulcer prevalence between the Netherlands and Germany have been found during the last 6 years. This study explores to what extent the individual risk of the population and quality indicators of the institutions can explain the variation in national prevalence. Methods Data of a binational multi‐centred cross‐sectional study in 103 hospitals (n = 21 378 patients) and 129 nursing homes (n = 15 579 residents) were analysed using random effects regression models to calculate the differences in national prevalences within the nursing homes and hospitals, adjusted for personal risk for pressure ulcer and quality indicators. Results The prevalence of pressure ulcers among the at‐risk group (Bradenscore ≤20) in nursing homes was 30.8% in the Netherlands and 8.3% in Germany [OR: 4.9 (CI 95%: 4.2–5.7)]. In hospitals, the prevalence among the at‐risk group was 26.1% in the Netherlands and 21.2% in Germany [OR: 1.3 (CI 95%: 1.2–1.5)]. After adjusting for individual risk factors (age, gender, Bradenscore) as well as for quality structures (use of prevention and treatment protocols, experts groups, information leaflets, nurses training, central pressure ulcer statistics and regular updating of protocols), the chance of developing a pressure ulcer was 6.05 times higher (CI 95%: 4.0–9.2) in a Dutch nursing home than in a German nursing home. Within the hospitals, the OR for Dutch patients was 2.03 (CI 95%: 1.4–3.0). Conclusion A remarkable national variation exists in pressure ulcer prevalence and nursing practice. Neither the populations vulnerability for pressure ulcers nor pressure ulcer management as measured in this study could explain this national variation. Therefore, other risk factors should be taken into consideration. Additionally, it is possible that quality indicators are implemented in differing ways with varying levels of effectiveness. Therefore, further research is needed to examine prospectively and in more detail the reality of care within facilities in both countries.     

Pressure ulcer: Prevention protocols and prevalence

Aims and objectives The aim of this paper is to analyse the protocols used in German hospitals and nursing homes for the prevention of pressure ulcers with regard to their contents and accordance with the national standard of the Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (DNQP) and the European Pressure Ulcer Advisory Panel (EPUAP) and Royal College of Nursing (RCN) guidelines. Additionally, it is to show the relation between the existence and contents of the protocols of pressure ulcer prevention and pressure ulcer prevalence in the institutions. Methods On a fixed date trained nursing staff gathers data regarding the frequency of pressure ulcers during a prevalence survey. The existence of a pressure ulcer is established by physical examination after the risk assessment with the Braden‐Scale. The patient’s or resident’s informed consent is a precondition for his or her participation in the survey. The protocols are available as hard copies on paper or electronic files. Results Only two out of the 21 protocols developed in‐house are completely concurrent with the expert standard. The EPUAP and RCN guidelines include the aspect of training and further education that is missing in the in‐house protocols and the DNQP expert standard. Evaluation of the data reveals that there is no relation between the availability of protocols and pressure ulcer prevalence. Neither is there any relation between the contents and pressure ulcer prevalence. The institutions currently developing protocols have the lowest prevalence rates. Conclusion It is obvious that, while developing in‐house protocols, the discussion about pressure ulcer prevention has led to a higher problem awareness in nurses and thus to an increased attentiveness in daily nursing practice which then results in improved outcomes. Two years after its publication, the expert standard is still not very well known, therefore this concentrated form of the most up‐to‐date knowledge is not available to all nursing staff as a basis for evidence‐based practice. In addition, the sometimes outdated knowledge of nursing staff impedes the implementation of evidence‐based practice guidelines. A systematic implementation strategy that assists guidelines being applied in practice is therefore required.     

Effect of non-response bias in pressure ulcer prevalence studies

AIM: This paper reports a study to determine the prevalence of pressure ulcers in German hospitals and nursing homes for national and international comparison, and analyses the influence of non-response bias. BACKGROUND: Outcome rates are often used to evaluate provider performance. The prevalence of pressure ulcers is seen as a possible parameter of outcome healthcare quality. However, the results from different pressure ulcer prevalence studies cannot be compared, because there is no standardized methodology and terminology. Observed and published prevalence rates may reflect variations in quality of care, but differences could also relate to differences in case-mix or to random variation. METHODS: A point prevalence survey was carried out for 2002 and 2003 using data from 21,574 patients and residents in 147 different kinds of institutions throughout Germany. Participation rates and reasons for not participating in the study were documented. Non-responders were considered in different calculations to show the range of possible prevalence rate for a hypothetic 100% participation. RESULTS: In 2002 and 2003, the calculated prevalence rate (among participating persons at risk) in hospitals was 25.1% and 24.2% respectively, while in nursing homes it was 17.3% and 12.5% respectively. Non-response varied from 15.1% to 25.1%. The majority of non-responders in hospitals and nursing homes had not been willing to participate in the study. Based on different assumptions about the characteristics of the non-responders, we calculated minimum and maximum prevalence rates as if 100% participation was achieved. CONCLUSIONS: Calculating the non-response bias of prevalence rates is an inconvenient but necessary thing to do because its influence on calculated prevalence rates was high in this study. High participation rates in clinical studies will minimize non-response bias. If non-response cannot be avoided, the formula provided will help researchers calculate possible minimum and maximum prevalence rates for the total sample of both the responding and non-responding groups.     

The prevalence of pressure ulcers in four paediatric institutions

Aim and objective. Pressure ulcers are a common nursing care issue in hospitals. They are associated with psychological and physical suffering, an increased morbidity and mortality rate and higher overall health care costs. The aim of the current study is to describe the frequency of pressure ulcers in a paediatric care setting and to identify the population at risk, as well as to assess the factors predisposing to the development of pressure ulcers. Design. A point prevalence study. Methods. The study was conducted in four paediatric hospitals in the German‐speaking part of Switzerland and included children from the age of 0–18 years. The method of data collection was a direct systematic inspection and assessment of the skin, taking into account the clinical condition of the patient for risk assessment. A valid risk assessment and data collection instrument was used and, each patient was assessed by a previously instructed rater pair. Results. Of all possible patients, 81% (n = 155) were included. An overall pressure ulcer prevalence of 27·7% (including grade 1) was registered. Thirty‐six patients (84%) had grade 1 ulcers, including many caused by external medical devices. Sixty‐five per cent (n = 100) of all patients were considered at risk (Braden score ≤ 20) of developing a pressure ulcer. Thirty‐five per cent of patients in the risk group were afflicted with one or more pressure ulcers. Conclusions. The prevalence of pressure ulcers in paediatric patients is greater then previously appreciated and the problem requires further exploration. The high percentage of grade 1 pressure ulcers caused by medical devices requires nursing interventions to prevent lesions for these patients. Relevance to clinical practice. The high prevalence rate in paediatric patients is disconcerting and requires further exploration in terms of interventions needed to improve outcomes for this patient group.     

Variation in pressure ulcer prevalence and prevention in nursing homes: A multicenter study

AimTo estimate the prevalence of pressure ulcers in nursing homes and its variability, the frequency of use of preventive measures and treatment.BackgroundPressure ulcer is a frequent pathology across healthcare settings. Most pressure ulcers are preventable and are considered an important quality of care indicator.MethodsAssessments were done on a single day of November 2015 in nursing homes in Geneva, Switzerland. Of the 51 institutions (3824 patients) eligible, 33 homes agreed to participate, representing 2671 patients (69.8%).One referent nurse per nursing home received training on pressure ulcer detection. To estimate the residual variability in prevalence and in number of prevention measures, adjusted multilevel logistic regressions were used.ResultsPatients were on average 85.6 years old, with a median length of stay of 2.1 years. The overall prevalence was 5.7% but varied considerably, from 0% to 19.6%.The variability across nursing homes decreased slightly when taking into account patient-level and institution-level characteristics.In the adjusted models, pressure ulcers prevalence was significantly associated with Braden risk; number of preventive measures was significantly associated with nursing home size, and Braden risk, and marginally associated with length of stay.ConclusionsOverall prevalence of pressure ulcers was relatively low. While several prevention measures for patients at risk were taken, the correct use of all of them was rare.The variability in prevalence and in number of preventive measures across nursing homes was very high. Programmes focusing on the correct use of all recommended prevention measures could help reducing pressure ulcers prevalence.     

Differences in prevalence of pressure ulcers between the Netherlands and Germany--associations between risk, prevention and occurrence of pressure ulcers in hospitals and nursing homes

Aim. This study compares pressure ulcer prevalence and prevention activities in nursing homes and hospitals within two European countries. Background. Over three years stable differences have been found between the Netherlands (NL) and Germany (GER) with higher pressure ulcer rates in the NL. As previous analyses have shown, the differences cannot be entirely explained by differences in the population’s vulnerability to pressure ulcers because they still remain after risk adjustment. Therefore, the differences in prevalence must be caused by other factors. The purpose of this study is to analyse if any potential differences in preventive activities can account for the varying occurrence of pressure ulcers. Method. In both countries, nation-wide surveys were conducted annually using the same standardised questionnaires. Trained nurses examined all consenting patients of the voluntarily participating facilities. This examination included a skin assessment of the entire body. Data regarding risk factors, prevention and details about wounds were then collected. Results. In-patients of 29 German (n = 2531) and 71 Dutch (n = 10 098) nursing homes and 39 German (n = 8515) and 60 Dutch (n = 10 237) hospitals were investigated. The use of pressure-reducing devices was more common in the NL than in GER, but all other interventions were more frequently provided to German risk patients than to their Dutch counterparts. The pressure ulcer prevalence was significantly higher in the Dutch sample. After adjusting for gender, age, Braden Score and prevention, the probability of having a pressure ulcer was 8·1 times higher for Dutch nursing home residents than for German residents. Conclusion. Some of the variance in pressure ulcer prevalence between the two countries can be explained by varying pressure ulcer prevention. However, some remarkable differences still remain unexplained. Relevance to clinical practice. The extent of pressure ulcer prevention, especially repositioning and nutrition intervention provided to patients at risk, is not in accordance with international guidelines.     

The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers

Aims and objective. The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2–4) in nursing home patients with non‐blanchable erythema. Background. No studies could be found that identify risk factors for further development of pressure ulcer in patients with non‐blanchable erythema. For some patients with non‐blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention. Design. Secondary data analyses of a previously conducted randomised controlled trial were performed. Methods. Eighty‐four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non‐blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system. Results. The cumulative pressure ulcer incidence was 18·7% (44/235). Hypotension (relative risk = 3·42, 95% CI = 1·56–7·49), a history of a cerebral vascular accident (relative risk = 1·94, 95% CI = 1·10–3·70) and contractures (relative risk = 2·02, 95% CI 1·03–3·95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%. Conclusions. In nursing home residents with non‐blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions. Relevance to clinical practice. Patients with non‐blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs.     

A comparison of pressure ulcer prevalence rates in nursing homes in the Netherlands and Germany, adjusted for population characteristics

Annual pressure ulcer surveys in the Netherlands and Germany have shown remarkable differences in prevalence rates. We explored the differences between the two populations, and the degree to which these differences were associated with differences in prevalence. To this end, data from 48 Dutch and 45 German facilities (n = 9772) from 2003 were analyzed. The prevalence of pressure ulcers (excluding grade 1) was 12.5% in the Netherlands and 4.3% in Germany. After adjusting for age, sex, and other risk factors, the probability of developing a pressure ulcer of stage 2 or higher in Dutch nursing homes was three times greater than in German homes.     

Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice

Aims and objectives. To investigate the pressure ulcer prevalence in home nursing patients and to evaluate guideline adherence of measures for the prevention of pressure ulcers and the participation of informal carers in pressure ulcer prevention. Background. Since 2002, the Belgian Guideline for the Prevention of Pressure Ulcers was published on the Internet, but no information was available on guideline adherence in home care. Methods. A cross‐sectional survey of pressure ulcer prevalence and guideline adherence was performed in a cluster randomized sample of 2779 clients of nine regional nursing departments in Flanders, Belgium. The Belgian Guideline for the Prevention of Pressure Ulcers was the reference standard for the evaluation of the guideline adherence. Results. There were 744 subjects at risk for developing pressure ulcers. The overall prevalence of pressure ulcers for the total sample population was 6·8%. The age‐, sex‐ and risk‐standardized prevalence per regional department varied between 4·9% and 9·1%. Of the 744 subjects at risk, 33 (4·4%) received preventive measures, which were in adherence to the Belgian Guideline for Prevention of Pressure Ulcers, 482 persons (64·8%) were administered measures, which did not adhere to the Belgian Guideline for Prevention of Pressure Ulcers and in 229 subjects (30·8%) at risk for developing pressure ulcers, prevention was lacking. For subjects with at least one pressure ulcer, the proportions were: 4·8% adherence, 76·6% no adherence and 18·6% no prevention. A proportion of 22·2% of the patients at risk and their informal carers were informed and motivated by the home care nurse to participate in the pressure ulcer prevention and their actual participation in the prevention was 21·4% of all risk cases. Conclusions. The adherence of nurses and clients to the guideline for pressure ulcer prevention was low. Relevance to the clinical practice. The study demonstrates a detailed evaluation of guideline adherence to pressure ulcer prevention in an individual patient situation, with special attention for materials and measures, which are not adequate and not recommended by the Belgian Guideline for the Prevention of Pressure Ulcers.     

Pressure ulcer prevention in nursing homes: views and beliefs of enrolled nurses and other health care workers

Background. In the Netherlands much attention has been paid to pressure ulcer prevention. National guidelines on pressure ulcer prevention were developed in 1985 and adapted in 1992 at the request of a national organization for quality assurance in health care. Several studies indicate that nurses seem to be insufficiently informed about pressure ulcer preventive activities. There is, however, no information available about the reasons why nurses seem to be insufficiently informed. Aims and objectives. This study was planned to elucidate the views and beliefs of health care workers (especially enrolled nurses) in Dutch nursing homes about pressure ulcer prevention and about issues related with pressure ulcer prevention. Design. A qualitative study with semi‐structured, tape‐recorded interviews. Method. Interviews were conducted with enrolled nurses, team leaders, head nurses, staff nurses and physicians. The interviews were coded and analysed. Results. Analysis of the interviews revealed that today's pressure ulcer preventive activities are very much based on old traditions in nursing. It also showed that enrolled nurses have no intention to change the care they deliver with regard to pressure ulcer prevention. Conclusions. It is concluded that a systematic approach is necessary to change nursing thinking and acting with regard to pressure ulcer prevention. Relevance to clinical practice. This study gives an overview of the views and beliefs of health care workers (especially enrolled nurses) in Dutch nursing homes about pressure ulcer prevention. These views and beliefs can be used as a starting point for effective implementation of guidelines regarding the prevention of pressure ulcers.     

Pressure ulcer incidence in Dutch and German nursing homes: design of a prospective multicenter cohort study

Background

Pressure ulcers are a common and serious health care problem in all health care settings. Results from annual national pressure ulcer prevalence surveys in the Netherlands and Germany reveal large differences in prevalence rates between both countries over the past ten years, especially in nursing homes. When examining differences in prevalence and incidence rates, it is important to take into account all factors associated with the development of pressure ulcers. Numerous studies have identified patient related factors, as well as nursing related interventions as risk factors for the development of pressure ulcers. Next to these more process oriented factors, also structural factors such as staffing levels and staff quality play a role in the development of pressure ulcers. This study has been designed to investigate the incidence of pressure ulcers in nursing homes in the Netherlands and Germany and to identify patient related factors, nursing related factors and structural factors associated with pressure ulcer development. The present article describes the protocol for this study.

Methods/design

A prospective multicenter study is designed in which a cohort of newly admitted nursing home residents in 10 Dutch and 11 German nursing homes will be followed for a period of 12 weeks. Data will be collected by research assistants using questionnaires on four different levels: resident, staff, ward, and nursing home.

Discussion

The results of the study will provide information on the incidence of pressure ulcers in Dutch and German nursing homes. Furthermore, information will be gathered on the influence of patient related factors, nursing related factors and structural factors on the incidence of pressure ulcers. The present article describes the study design and addresses the study's strengths and weaknesses.     

Pressure ulcer prevention in intensive care patients: guidelines and practice

Background  Pressure ulcers are a potential problem in intensive care patients, and their prevention is a major issue in nursing care. This study aims to assess the allocation of preventive measures for patients at risk for pressure ulcers in intensive care and the evidence of applied pressure ulcer preventive measures in intensive care settings in respect to the European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention.
Design  The design of this study was a cross-sectional study (point prevalence).
Setting  The study setting was intensive care units. The sample consisted of 169 patients – 60 patients from surgical wards, 59 from interdisciplinary wards and 50 from medical intensive care wards.
Results  The study results revealed that pressure reducing devices like mattresses (alternating pressure air, low air loss and foam) are applied for 58 (36.5%) patients, and all of these patients are at risk for pressure ulcer development. Most patients receive more than one nursing intervention, especially patients at risk. Nursing interventions applied are skin inspection, massage with moisture cream, nutrition and mobility (81.8%, 80.5%, 68.6% and 56.6%) respectively. Moreover, all applied pressure ulcer preventive measures in this study are in line with the guidelines of the EPUAP and AHCPR except massage which is applied to 8.8% of all patients.
Conclusions  The use of pressure reducing devices and nursing interventions in intensive care patients are in line with international pressure ulcer guidelines. Only massage, which is also being used, should be avoided according to the recommendation of national and international guidelines.     

Pressure ulcer development in older residents in nursing homes: influencing factors

Title. Pressure ulcer development in older residents in nursing homes: influencing factors. Aim. This paper is a report of a study assessing pressure ulcer incidence and factors affecting pressure ulcer development among older nursing home residents. Background. Previous researchers have shown that demographic, clinical, health status, risk and human resources factors affect pressure ulcer development among older people in various healthcare settings, but none has investigated their interactive effects among older nursing home residents. Method. This was a prospective cohort study involving 346 residents aged 65 years or over from four private nursing homes in Hong Kong. We collected information on participant demographics and assessed their clinical characteristics, health status and pressure ulcer risk factors. Subsequently, we assessed their skin condition every 2 days for 4 weeks to detect pressure ulcers that developed after the initial assessment. The data were collected between December 2006 and September 2007. Results. The pressure ulcer incidence was 25·16%. The model in which the factors of clinical characteristics, health status, pressure ulcer risk and human resources were controlled was more reliable in predicting pressure ulcer development than the other two models. It showed that bedfast or chairfast residents, especially those with co‐morbidities (renal failure and stroke) and living in nursing homes where there were no nurses but more nursing assistants, were at higher risk for pressure ulcer development. Conclusion. Evidence‐based interventions should be adopted to minimize the possible problems of pressure, malnutrition, friction and shear force, and the decreased pain perception of bedfast or chairfast residents in nursing homes, especially those with renal failure or stroke.     

Nurse Managers’ prerequisite for nursing development: a survey on pressure ulcers and contextual factors in hospital organizations

gunningberg l., brudin l. & idvall e. (2010) Journal of Nursing Management  18, 757–766
Nurse Managers’ prerequisite for nursing development: a survey on pressure ulcers and contextual factors in hospital organizations Aim To describe and compare pressure ulcer prevalence in two county councils and concurrently explore Nurse Managers’ perspective of contextual factors in a hospital organization. Background Despite good knowledge about risk factors and prevention of pressure ulcers, the prevalence of pressure ulcers remains high. Nurse Managers’ have a key role in implementing evidence-based practice. Methods The present study included five hospitals in two Swedish county councils: county council A (non-university setting) and county council B (university setting). A pressure ulcer prevalence study was conducted according to the methodology developed by the European Pressure Ulcer Advisory Panel. The Nurse Managers’ answered a (27-item) questionnaire on contextual factors. Results County council B had significantly less pressure ulcers grade (2–4) (7.7%) than county council A (11.3%). The Nurse Managers’ assessed only two out of the 27 general contextual items significantly differently. Some significant differences were observed in ward organization. Conclusions In county council B, the Nurse Managers’ seemed more aware of prevention strategies compared with Nurse Managers’ in county council A. The Nurse Managers’ should take more responsibility to develop the prerequisite for quality improvement in nursing. Implication for nursing management Nursing outcomes (e.g. pressure ulcers) should be incorporated into national quality registries for benchmarking and Nurse Managers’ competence in evidence-based practice and research methodology increased.     

Pressure ulcer prevention and care: a survey of current practice

The incidence and management of pressure ulcers in hospitalised patients is an ongoing concern for nurses. Efforts to prevent pressure ulcer development are plagued with inconsistencies and a general lack of best practice guidelines. Establishing current practice approaches to the assessment, prevention and management of pressure ulcers is a necessary first step in the implementation of evidence-based/best practice guidelines. Anecdotal evidence suggested a range of different approaches were being used in a Sydney metropolitan area health service (AHS) to assess patients to identify those at risk, to prevent pressure ulcers and to treat existing ulcers. A collaborative research project was undertaken to examine current practice and to explore the apparent clinical variance. It involved the distribution of a questionnaire to registered nurses working within the AHS (n = 2113) and a review of nursing policy documents in the various hospitals in the health service area. While the overall response rate was satisfactory (40%) many of the returned questionnaires were incomplete. Only 21% (n = 444) of the questionnaires were deemed suitable for analysis. The findings highlight a range of inconsistencies within and across nursing practice domains. Nurses generally do not use a tool to assess pressure ulcer risk potential, but rely on a range of practice procedures and risk indicators to determine risk potential of developing pressure ulcers. Repositioning patients is the most common approach used in an attempt to prevent the development of pressure ulcers, but additional measures are diverse. Most nurses seem to be familiar with modern wound dressings such as hydrocolloids, foams and alginates in the treatment of second and third stage ulceration. However, the care provided by some nurses reflects an adherence to outdated practices, including the use of water filled gloves, povidone iodine and gauze packing.     

Senior nurses' control expectations and the development of pressure ulcers

AIM: The aim of this research was to establish whether the attitudes and expectations of senior nursing staff might adversely affect patient outcomes in the prevention of pressure ulcers. The hypothesis was that nursing locus of control affects clinical outcomes in patients. In particular, it affects departmental prevalence of pressure damage. METHOD: A population of nurses (n = 439) in an acute and community NHS trust were surveyed to test knowledge, control beliefs and value of pressure ulcer prevention relative to prevalence. The research was designed to provide different data against which to test the hypothesis: first, to assess acceptability of nurses' knowledge of prevention and appropriate use of risk assessment and equipment; second, to calculate a mean departmental pressure ulcer prevalence; and third, to measure locus of control and value, which is the focus of this article. RESULTS: There were strong associations between departmental prevalence of pressure ulcers and attitudes of senior nursing staff. For example, the more that ward sisters believed they could control pressure ulcer prevention, the higher the prevalence of ulcers in their department. The more that sisters believed that they could not control prevalence, the lower the prevalence of ulcers. CONCLUSION: The study shows that failure to account for beliefs, values and expectations of staff could lead to patient harm. It is suggested that it might be counterproductive to put great effort into developing clinical guidelines and refinement of risk assessment methods. The findings have important implications for nursing, and challenge the assumption that nurse leaders are universally beneficial to patients.