Prevalence of pressure ulcers in three university teaching hospitals in Ireland

Journal of Tissue Viability (2008) 17, 103e109

www.elsevier.com/locate/jtv

Basic research

Prevalence of pressure ulcers in three university teaching hospitals in Ireland Paul Gallagher a,*, Pat Barry a, Irene Hartigan b, Pat McCluskey c, Kieran O’Connor d, Mike O’Connor a a

Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland School of Nursing and Midwifery, University College Cork, Ireland c Department of Wound Care, Cork University Hospital, Wilton, Cork, Ireland d South Infirmary Victoria University Hospital and Mercy University Hospital, Cork, Ireland b

KEYWORDS Pressure ulcer; Prevalence; Prevention; Teaching hospital

Abstract Aim: Pressure ulceration is a significant, but preventable, cause of morbidity and resource utilisation in hospital populations. Data on pressure ulcer prevalence in Ireland are limited. This study aims to determine (i) the pointprevalence of pressure ulcers in three teaching hospitals in Ireland and (ii) risk factors for their development. Methods: Eight teams of one doctor and one nurse visited 672 adult patients over a 2-day period in three teaching hospitals. Each patient was examined and pressure ulcers graded with the European Pressure Ulcer Advisory Panel system. Mental test score, Barthel index, type of support surface, length of stay, documentation of risk assessment and serum albumin were recorded. Results: Point-prevalence of pressure ulceration was 18.5%. Seventy-seven percent of pressure ulcers were hospital-acquired, 49% grade 1, 37% grade 2, 11% grade 3 and 3% grade 4. Reduced mobility, urinary incontinence, cognitive impairment, low serum albumin and length of stay were significantly associated with pressure ulcers. Multivariate logistic regression analysis found reduced mobility (odds ratio 8.84; 95% CI 5.04e15.48, p < 0.0001) and length of stay (odds ratio 1.02; 95% CI 1.01e1.02, p < 0.0001) to be predictive of the presence of pressure ulcers. Age, gender and risk assessment documentation were not associated with pressure ulcers. Sixty-five percent of patients with pressure ulcers were positioned on appropriate support surfaces. Discussion: Point-prevalence of pressure ulceration was 18.5%, similar to international data. Regular audit of prevalence, prevention and management strategies may raise awareness, influence resource allocation and ultimately improve patient care. ª 2008 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ353 21 4922396; fax: þ353 21 4922829. E-mail address: [email protected] (P. Gallagher). S0268-0009/$34 ª 2008 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jtv.2007.12.001

104

P. Gallagher et al.

Introduction

Methods

A pressure ulcer can be defined as an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and/or a combination of these [1]. Though usually preventable, pressure ulcers are common adverse events and represent a very serious health problem, not only in terms of patient morbidity and mortality but also in terms of health resource utilisation [2e5]. The incidence of pressure ulcers (the number of new cases expected annually) is up to 5% in acute care hospitals [6,7] and as high as 13% in long-term care facilities [8e11]. However, the reported prevalence of pressure ulcers (the number of cases within a population during a defined period of time) varies extensively [12e17]. The European Pressure Ulcer Advisory Panel (EPUAP) reported an overall pressure ulcer prevalence rate of 18.1% from a sample of 5000 hospitalised patients in five European countries, ranging from 8.3% in Italy to 22.9% in Sweden [12]. Bours et al. reported a 13.2% prevalence rate of pressure ulcers in university teaching hospitals in the Netherlands (range: 7.8e21%) [13]. Data on the prevalence of pressure ulcers in acute hospitals in the Republic of Ireland are few, with only two studies in the literature reporting prevalence rates of 15% and 12%, respectively [16,17]. However, it is difficult to accurately compare the results of such studies because of variations in methodology. The risk factors and preventative strategies for development of pressure ulcers are wellestablished [18]. Consequently, the prevalence of pressure ulcers is fast becoming a quality of care measure both in hospital and long-term care settings. It is important to regularly audit practice in terms of prevention, treatment and prevalence of pressure ulcers [1,19]. However, to accurately interpret and compare results it is essential that consistent methodologies be employed. The EPUAP has proposed that a minimum data-set be incorporated into prevalence study methodology so that results can be interpreted in the context of similar studies from different populations [1,12]. We aimed to determine the point-prevalence of pressure ulcers in a sample derived from three separate university teaching hospitals in Ireland, using the EPUAP standardised methodology. We also aimed to determine which of the following variables were associated with pressure ulcers: age, gender, urinary incontinence, mobility, cognition, length of stay and documentation of risk assessment.

Study population All patients aged 16 years and over admitted to the medical, surgical and intensive care units of three separate university teaching hospitals serving a mixed urban and rural population were eligible for inclusion in the study (see Table 1). Patients in the psychiatry units were excluded so that our results could be interpreted in the context of similar studies of acute general hospital populations. The local clinical research ethics committee approved the study protocol. All eligible patients were issued with an information sheet describing the study aims and procedures. Consent for inclusion was sought from each patient prior to data collection.

Data collection tool We designed a data collection tool to obtain the following information: (i) standard socio-demographic details; (ii) duration of hospital stay up to the study date; (iii) abbreviated mental test score [20]; (iv) Barthel index of activities of daily living [21] (principally for measures of mobility and continence); (v) documentation of pressure ulcer risk using validated instruments such as the

Table 1 Study population (derived from three university teaching hospitals) Site

Eligible (n)

Recruited (n)

Hospital 1 Medicine Surgery Intensive care

230 154 8

219 140 8

392

367

112 62 6

107 56 6

180

169

85 55 4

79 53 4

144

136

716

672

Total Hospital 2 Medicine Surgery Intensive care Total Hospital 3 Medicine Surgery Intensive care Total Total study population

Prevalence of pressure ulcers

105

Braden score [22], the Norton score [23] or the Waterlow score [24] as all three hospitals used different risk assessment scales; (vi) presence or absence of pressure ulcer; (vii) whether or not pressure ulcer was hospital-acquired; (viii) site and grade of pressure ulcer if present according to the EPUAP classification system [1] (see Table 2); (ix) type of support surface, i.e. standard foam mattress or pressure-relieving device; and (x) serum albumin as a marker of nutritional status. The inter-rater reliability of the EPUAP grading system has previously been documented as excellent with a kappa co-efficient of >0.8 [25,26].

Data were analysed using SPSS for windows version 14. Descriptive statistics for non-parametric data included the median and interquartile range. The ManneWhitney U-test was used for testing the independence of ordinal scale variables and the Chi square test was used to test for association between categorical variables. A multiple logistic regression model was used to evaluate the influence of variables associated with pressure ulcers. The goodness-of-fit of the model was tested using the HosmereLemeshow statistic. A probability value of less than 0.05 was considered statistically significant.

Data collection procedure

Results

Eight teams of one doctor and one nurse were formed. All doctors worked in the department of geriatric medicine and included consultants, registrars and senior house officers. All nursing staff were of senior grade and represented the departments of wound care, general medical and surgical wards as well as the nurse education centre. All data collectors were trained in the data collection procedures one week prior to and again on the morning of the study. Each team was provided with a pictorial representation and definition of the EPUAP grading system for pressure ulcers. For logistical reasons the study was performed over a 2-day period with data collection occurring in Hospital 1 on one day and in Hospitals 2 and 3 on a separate day. Each patient’s skin was carefully examined by the doctor and nurse and pressure ulcers, if present, were graded. The data collection tool, as described above, was completed at that point in time. Supplementary information was obtained from the clinical ward staff when required.

Patient characteristics

Table 2 ulcers [1]

EPUAP

grading

system

for

pressure

Grade Description I II III

IV

Non-blanchable erythema of intact skin Partial-thickness skin loss involving epidermis, dermis or both Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures

Seven hundred and sixteen patients were eligible for inclusion in the study, but 44 patients declined to participate. Therefore, data were prospectively collected from 672 patients, of whom 52% were female (see Tables 1 and 3). There were no significant differences in patient characteristics between the three hospitals and data were pooled for further analysis. There were no significant differences between male and female patients in terms of cognition (p ¼ 0.644), mobility (p ¼ 0.658), urinary incontinence (p ¼ 0.934) and hospital length of stay (p ¼ 0.640).

Pressure ulcer prevalence Pressure ulcers were identified in 124 of 672 patients giving an overall point-prevalence of 18.5%. Of these, 27 patients (21.8%) had a pressure ulcer on admission to hospital. The remaining 96 patients (76.6%) acquired a pressure ulcer in hospital. Seventy-nine patients (63.7%) had a single pressure ulcer. Forty-five patients (36.3%) had pressure ulcers at more than one site. The commonest sites of single pressure ulcers were sacrum (n ¼ 32), buttocks (n ¼ 23) and heel (n ¼ 5). The commonest sites for multiple pressure ulcers were sacrum with another site (n ¼ 17) and heels with another site (n ¼ 15). Almost 50% of pressure ulcers were grade 1 according to the EPUAP classification (see Table 4). The characteristics of patients with and without pressure ulcers are illustrated in Table 5. There were significant differences between the pressure ulcer group and the non-pressure ulcer group in terms of cognition, mobility, urinary incontinence, serum albumin concentration and length of hospital

106 Table 3

P. Gallagher et al. Principal characteristics of study population Male

Female

Total

Number of patients

322 (47.9%)

350 (52.1%)

672

Age distribution (years) Median Range IQR

67 16e92 51e76

72 18e94 56e80.25

69 16e94 54e78

Cognition AMTS  7/10 AMTS  8/10

52 (16.1%) 270 (83.9%)

52 (14.9%) 298 (85.1%)

104 (15.5%) 568 (84.5%)

Mobility Independent Needs assistance Immobile

191 (59.3%) 62 (19.3%) 69 (21.4%)

192 (54.9%) 98 (28%) 60 (17.1%)

383 (57%) 160 (23.8%) 129 (19.2%)

Urinary continence Continent Incontinent

266 (82.6%) 56 (17.4%)

272 (77.7%) 78 (22.3%)

538 (80.1%) 134 (19.9%)

Length of stay (days) Median (IQR)

8 (3e17)

6 (3e16)

7 (3e17)

IQR ¼ interquartile range; and AMTS ¼ abbreviated mental test score (<7/10 indicates cognitive impairment) [20].

stay up to the study date. There were no differences between the pressure ulcer group and the non-pressure ulcer group in terms of age, gender or documentation of risk assessment. Fifty-one percent of patients had a risk assessment score documented (56.5% of those with pressure ulcers and 49.6% of those without pressure ulcers). There was no significant association between having a risk assessment score documented and the presence of a pressure ulcer (Chi square 1.877, df 1, p ¼ 0.171). There was no significant association between age and presence of pressure ulcers (Chi square 1.253, df 1, p ¼ 0.263). Appropriate pressure-relieving support surfaces were in place for 80 patients (64.5%) with pressure ulcers. Multivariate logistic regression was used to evaluate the influence of the significantly associated independent variables on the presence of pressure ulcers (see Table 6). Patients who required assistance with mobilisation were eight

Table 4 Grade I II III IV Total

times more likely to have a pressure ulcer than those who were independently mobile (OR 8.84; 95% CI 5.04e15.48, p < 0.0001). Patients who were completely immobile were three times more likely to have a pressure ulcer than those who were independently mobile (OR 3.25; 95% CI 1.84e5.75, p < 0.0001). Patients with pressure ulcers were significantly more likely to have been in hospital for longer than those without pressure ulcers (OR 1.02; 95% CI 1.01e1.02, p < 0.0001). Poor cognition and urinary incontinence did not significantly influence the presence of pressure ulcers in the regression model.

Discussion The point-prevalence of pressure ulcers was 18.5% in this study of 672 patients from three university teaching hospitals in Ireland. This is higher than

Grades of pressure ulcer Ulcer present on admission 8 13 4 2 27 (21.8%)

Ulcer acquired in hospital 52 34 9 1 96 (77.4%)

Unknown

Total, n (%)

1 0 0 0

61 (49.2) 47 (37.9) 13 (10.5) 3 (2.4)

1

124

Prevalence of pressure ulcers Table 5

107

Characteristics of patients with and without pressure ulcers Pressure ulcer

Total, n (%)

No pressure ulcer

124 (18.5)

548 (81.5)

Gender Male, n (%) Female, n (%)

59 (47.5) 65 (52.5)

263 (47.9) 285 (52.1)

Age distribution (years) Male, median (IQR) Female, median (IQR)

70 (47e79) 74 (61e81)

Risk assessment Documented Not documented

70 (56.5%) 54 (43.5%)

272 (49.6%) 276 (50.4%)

Cognition AMTS  7/10 AMTS  8/10

40 (32.3%) 84 (67.7%)

64 (11.7%) 484 (88.3%)

Urinary continence Continent Incontinent

79 (63.7%) 45 (37.3%)

459 (83.8%) 89 (16.2%)

Mobility Independent Need assistance Immobile

30 (24.2%) 35 (28.2%) 59 (47.6%)

353 (64.4%) 125 (22.8%) 70 (12.8%)

Length of stay (days) Median (IQR)

15.5 (5e38.75)

Serum albumin (g/l) Median (IQR)

27.5 (22e32)

Difference between groups

p-Value

No

0.934

No

0.784

No

0.171

Yes

<0.0001

Yes

<0.0001

Yes

<0.0001

Yes

<0.0001

Yes

<0.0001

67 (51e76) 70 (53.5e80)

6 (3e14.75) 32 (27e37)

IQR ¼ interquartile range; and AMTS ¼ abbreviated mental test score [20].

the 15% and 12% prevalence rates reported in previous studies from Ireland [16,17] but similar to the 18.1% prevalence rate identified by Clark et al. in the EPUAP European study [12]. Urinary incontinence, cognitive impairment, reduced mobility and longer length of hospital stay were associated with the presence of pressure ulcers in this study, the latter two variables significantly influence the presence of pressure ulcers on multivariate analysis. While the identification of such risk factors is not a new discovery, and the differences between association and causality must be

Table 6

acknowledged as a limitation of a cross-sectional study, the significant associations re-iterate the fact that those with such risk factors are more likely to develop pressure ulcers and should be the focus of preventative strategies [6,18]. Risk assessment tools such as the Braden [22], the Norton [23] and the Waterlow score [24] have been designed to identify patients at risk of developing pressure ulcers. However, the validity and inter-rater reliability of such tools have previously been questioned [27] and their role in preventing pressure ulcers may further be questioned by the

Multivariate logistic regression: factors associated with the presence of pressure ulcers

Variable

Odds ratio

95% Confidence interval

p-Value

Independently mobile Needs assistance to mobilise Immobile Length of stay (days) Urinary continence Cognitive impairment

1 8.836 3.254 1.017 0.722 0.802

5.043e15.482 1.841e5.753 1.010e1.023 0.436e1.197 0.461e1.396

<0.0001 <0.0001 <0.0001 0.207 0.436

108 fact that there was no significant association between having a pressure ulcer and having a risk assessment performed in this study population. Nonetheless, the lack of documentation of risk in almost 50% of hospital in-patients raises concerns over whether risk assessment is seen as a priority in hospital care. At the very least, documentation of pressure ulcer risk ensures that communication and transfer of information between clinical staff are optimised, particularly in times of rapid staff turnover or when patients are changing location either within (from ward to ward) or between care settings (from hospital to community). Pressure ulcer prevalence is fast becoming a quality of care measure and litigation over hospital and nursing-home acquired pressure ulcers is on the rise [28]. In the United States, health insurance companies no longer intend to cover the costs of hospital-acquired pressure ulcers as they are seen to be avoidable adverse events and their management is enormously expensive. It is estimated that pressure ulcer care costs $11 billion annually in the United States [29]. In the United Kingdom, pressure ulcer care has been estimated to cost £1.4e2.1 billion annually, the equivalent of 4% of National Health Service (NHS) expenditure [11]. In Ireland, the annual cost of pressure ulcer care has been estimated at V250 million, though this cost was extrapolated from the cost of treating one patient with multiple grade IV pressure ulcers [17]. These statistics should be seen as an incentive to improve vigilance and optimise pressure ulcer preventative strategies. However, such strategies require considerable investment for several areas. Firstly, more high quality randomised controlled trials are needed to broaden the evidence base on which traditional preventative strategies rest. In a recent systematic review, it was found that of 763 trials examining interventions to prevent pressure ulcers, only 59 were of sufficient methodological quality on which to base recommendations [30]. Secondly, education and training on pressure ulcer risk, prevention and treatment must be improved at undergraduate and postgraduate levels for both medical and nursing staff. Pressure ulcer care has traditionally been the domain of nursing staff, but should be the responsibility of all health care professionals as it impacts on recovery, rehabilitation, and length of stay. Thirdly, timely access to appropriate pressurerelieving devices and expert wound management teams is necessary [19]. Regular audit of pressure ulcer care must be performed so that performance can be assessed and, ultimately, patient care optimised [1,19].

P. Gallagher et al. However, such audit is time-consuming and labour intensive and perhaps could better be achieved by using electronic records as part of ongoing care. Again, this requires substantial investment and training, but is essential if guidelines such as NICE [19] and EPUAP [1] are to be adhered to. Finally, prevalence studies and regular audit using standardised data collection procedures should provide robust data at a local level on the extent of a particular problem. Such data can be used to raise awareness, influence policy and plan resource allocation with the ultimate aim of improving patient care and minimising hospital adverse events.

Conclusion The prevalence of pressure ulcers in a large sample drawn from three university teaching hospitals in Ireland was 18.5%. Over 75% of these pressure ulcers were hospital-acquired. The variables that were associated with the presence of pressure ulcers were poor mobility, poor cognition, urinary incontinence, low serum albumin and length of stay in hospital. Age, gender and documentation of risk assessment scale were not significantly associated with the presence of pressure ulcers. Multivariate regression analysis found length of stay and poor mobility to significantly influence the presence of pressure ulcers. Pressure ulcers are common, hospital-acquired adverse events. The risk factors for development of pressure ulcers are well-established. Preventative strategies are also well-recognised. However, implementation of such strategies must be addressed through ongoing education and training of all staff involved in patient care. Regular audit of pressure ulcer prevalence, prevention and management has a very important role to play in raising awareness about hospital-acquired pressure ulcers with the ultimate aim of optimising patient care.

Conflicts of interest The authors have no conflicts of interest to declare.

Acknowledgement We wish to thank all the data collectors who participated in this study.

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109

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