Pressure ulcer prevalence across Welsh orthopaedic units and community hospitals: surveys based on...

ORIGINAL ARTICLE

Pressure ulcer prevalenceacross Welsh orthopaedicunits and communityhospitals: surveys basedon the European PressureUlcer Advisory Panelminimum data setJane James, Julie A Evans, Trudie Young, Michael Clark

James J, Evans JA, Young, T, Clark M. Pressure ulcer prevalence across Welsh orthopaedic units and communityhospitals: surveys based on the European Pressure Ulcer Advisory Panel minimum data set. Int Wound J 2010;7:147–152

ABSTRACTThe survey used the European Pressure Ulcer Advisory Panel (EPUAP) methodology for the collection of pressure ulcerprevalence data. The orthopaedic survey was conducted across all National Health Service Trusts in Wales between2 and 6 July 2007 while the community hospital survey covering 25% of all community hospital beds was conductedbetween 21 April 2008 and 2 May 2008. Data were gathered upon 1196 patients (581, 48·6% within orthopaedicunits with 615 located in community hospitals). Of these patients, 81 (13·9%) and 162 (26·7%) had pressure ulcersin orthopaedic and community hospitals, respectively. Where patients presented with multiple pressure ulcers, themost severe pressure ulcer was recorded. Across both surveys, most pressure ulcers were reported to be eithercategory I or II with 91 category I wounds (33 in orthopaedic units and 58 in community hospitals). Severe (categoriesIII and IV) pressure ulcers affected 78 patients (19 in orthopaedic units and 59 in community hospitals). Adoption ofthe EPUAP pressure ulcer prevalence methods can help achieve consistent data upon pressure ulcer prevalence indifferent health care organisations and specialities. The adoption of a consistent data collection capture methodologyis a clear prerequisite for the compilation of meaningful pressure ulcer prevalence data sets at a national level.

Key words: Community hospitals • Orthopaedics • Pressure ulcer prevalence

Authors: J James, MSc, Hywel Dda Health Board, Haverford-west, Pembrokeshire, UK; JA Evans, Post Graduate Certificatein Advanced Clinical Practice, Tissue Viability Service, AbertaweBro Morgannwg Health Board, Swansea, UK; T Young, MSc,School of Healthcare Sciences, Bangor University, UK; M Clark,PhD, Department of Dermatology and Wound Healing, Schoolof Medicine, Cardiff University, Cardiff, UKAddress for correspondence: M Clark, PhD, Departmentof Dermatology and Wound Healing, School of Medicine, CardiffUniversity, Cardiff, UK CF14 4XNE-mail: [email protected]

INTRODUCTIONDespite investment in pressure ulcer pre-

Key Points

• data were gathered upon 1196patients (581, 48·6% withinorthopaedic units with 615located in community hospi-tals). Of these patients, 81(13·9%) and 162 (26·7%) hadpressure ulcers in orthopaedicand community hospitals,respectively

• in clinical practice, 11/13 healthcare organisations across Walesroutinely collect pressure ulceroccurrence data

• surveys of pressure ulcerpoint prevalence were reportedacross nine organisations withthe majority (n = 6) collectingthese data on an annual basis.Continuous prevalence record-ing was noted in a singleorganisation as was infrequentdata collection (defined as beingmore than 12 months betweensurveys)vention practices and interventions, pressure

ulcers remain common (1–10). Part of thisapparent contradiction stems from confusionover appropriate methods for recording pres-sure ulcer occurrence (11) while the lack ofrobust baseline data against which changesin pressure ulcer occurrence can be comparedalso prohibits examination of any trends in the

© 2010 The Authors. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines.com Inc • International Wound Journal • Vol 7 No 3 147

Pressure ulcer prevalence across Welsh orthopaedic units and community hospitals

number of people affected by pressure ulcers.Within the UK, the only national (England)data on pressure ulcer prevalence is over25 years old (12) and is largely unpublished.Within this early survey, 6·67% of adult hos-pital in-patients was reported to have pressureulcers while many of these wounds involveddamage to tissues below the dermis [n = 939,62·3% of all surveyed pressure ulcers were cat-egories III and IV pressure ulcers (13)]. Giventhe lack of national or extensive regional pres-sure ulcer occurrence data post-1983 within theUK, it is unsurprising that there remains uncer-tainty over trends in the number of people withpressure ulcers and potentially any changesin the characteristics of these wounds overtime.

This publication describes the use of theEuropean Pressure Ulcer Advisory Panel(EPUAP) pressure ulcer prevalence minimumdata set (4) to structure pressure ulcer data col-lection in a timely, consistent manner wherelimited resources (data collectors and funding)were available. While the data were collectedfollowing the then current EPUAP pressureulcer classification tool, the data have beenreported using the new system of categoriesintroduced in 2009 by the International Pres-sure Ulcer Guidelines (13) on the basis that themajor descriptions of grade (EPUAP) and cate-gory (International Guidelines) remain broadlyconsistent.

Wales has a population of 2·98 million peo-ple and a relatively simple health care systemwith, at the time of the project’s initiation,13 National Health Service (NHS) organisa-tions. Given that extensive funding to recruitdata collectors was not available, a key require-ment for the successful gathering of pressureulcer prevalence data was access to a cohortof clinicians with the necessary experienceto identify and classify pressure ulcers accu-rately. Across Wales, there are 27 specialisttissue viability nurses and these individu-als cooperate through the All-Wales TissueViability Nurses Forum (AWTVNF). Whileproviding a platform for sharing informationand experience between the specialist, nurseshave also undertaken discreet project work,for example in 2007, the AWTVNF devel-oped documentation to describe, assess andrecord competencies in tissue viability (http://www.agored.org.uk/default.aspx?id=1). Thisis an example of the collaborative working

between AWTVNF members and served as afoundation for the present study. All AWTVNFmembers agreed to participate and supportthe collection of pressure ulcer prevalencedata using a consistent methodology in thisstudy.

The report provides for the first time com-parable data upon pressure ulcer prevalenceacross selected specialities (orthopaedics andcommunity hospitals) across all NHS settingswithin Wales. These specialities were selectedfollowing discussion within the AWTVNF andwere considered to reflect areas where the high-est numbers of people with pressure ulcerswere expected. Information was also collectedupon the methods currently used to iden-tify pressure ulcer vulnerable patients and theextent of pressure ulcer occurrence. This infor-mation was gathered using an online surveyconducted in September 2009 with data gath-ered across the 13 health care organisationswithin Wales.

Pressure ulcer data collection methodsused across WalesIn clinical practice, 11/13 health care organi-sations across Wales routinely collect pressureulcer occurrence data. In the two organisationsthat did not collect such data vulnerabilityto pressure ulcer development was assessedusing the Waterlow (14) or Pressure Sore Pre-diction Scale (PSPS) (15) risk assessment tools.Where pressure ulcer occurrence data were col-lected, risk of developing pressure ulcers wasassessed most commonly using the Waterlowscale (n = 8) with two organisations using thePSPS tool and the final using a risk assessmenttool not described in the literature (Maelortool). National guidance had been issued inWales in 1999 (16) upon pressure ulcer pre-vention and the recommended national riskassessment tool was the PSPS scale. Surveys ofpressure ulcer point prevalence were reportedacross nine organisations with the majority(n = 6) collecting this data on an annual basis.Continuous prevalence recording was notedin a single organisation as was infrequentdata collection (defined as being more than12 months between surveys). Where pressureulcer prevalence was recorded infrequently, itwas noted that period prevalence collectionwas also undertaken. One organisation col-lected pressure ulcer prevalence data monthlyin medical units and quarterly across the rest

148 © 2010 The Authors. Journal Compilation © 2010 Blackwell Publishing Ltd and Medicalhelplines.com Inc


of the organisation with an overall annualsurvey also conducted. Across Wales, fourorganisations depended upon wound productsuppliers to undertake the prevalence surveyswhile most used a mix of direct observation ofpatients’ skin and reporting of pressure ulcersby ward staff to obtain their prevalence data.Two organisations relied exclusively on directobservation of skin and one depended uponstaff reports of pressure ulcers alone. In only4/12 organisations, pressure ulcer prevalencewas collected across all patients, with the mostcommon excluded specialities being learningdifficulties (n = 3), paediatrics (n = 3), mater-nity (n = 2) and mental health (n = 2). In sevenof nine organisations with routine pressureulcer prevalence surveys, data were reportedupon all encountered pressure ulcers whiletwo organisations excluded category I pressureulcers.

The collection of pressure ulcer incidencedata was restricted to five organisationswith the frequency of recording reported forthree (continuous n = 2 and annual n = 1).All organisations which provided details oftheir incidence monitoring noted that datawere gathered from a mix of direct skinobservation and reports from clinical staff.No commercial supplier appeared to organisepressure ulcer incidence data collection. Onlyone organisation collected pressure ulcer inci-dence data across all patients with paediatrics(n = 1), mental health (n = 1) and learning dif-ficulties (n = 1) excluded from this data collec-tion. Category I pressure ulcers were excludedfrom one organisation’s incidence reportingwhile the remaining organisations who col-lected incidence data reported all encounterednosocomial pressure ulcers.

Nine of the organisations routinely reportedpressure ulcers as critical incidents. One organ-isation appeared to report all pressure ulcers,two reported categories III and IV pressureulcers only as critical incidents while theremaining six reported all pressure ulcersfrom category II. At the time of the onlinesurvey, two organisations had under 10 pres-sure ulcer cases as active adverse incidents,one had under 20 while three had over20 active adverse incidents related to pres-sure ulcers. The remaining three organisa-tions did not identify how many pressureulcer-related adverse incidents were currentlyactive.

SURVEY METHODOLOGYTwo serial point prevalence surveys were con-ducted following the methods described byVanderwee et al. (4) when using the EPUAPpressure ulcer minimum data set to gatherprevalence data. The minimum data set com-prises data upon patients’ age, gender andcurrent care location; their perceived level ofvulnerability to pressure ulcer developed asassessed using the Braden scale (17); incon-tinence was assessed using the appropriatesubscale from the Norton pressure ulcer riskassessment tool (18); the severity and anatomi-cal location of encountered pressure ulcers wasrecorded along with the provision of pressureredistribution in bed and while seated througheither the provision of pressure redistributingdevices or through manual repositioning andspecified time intervals. No attempt was madeto combine the Braden and continence scoresinto a single indicator of possible vulnerabil-ity to pressure ulcers. The use of the Bradenscale, an integral part of the EPUAP minimumdata set, provided the single largest challengeto the participating data collectors, none ofwhom used this tool in their daily practice, andto overcome this, the educational tools devel-oped by the EPUAP were used to inform datacollectors upon the correct use of this tool. Noformal pilot was undertaken given that datacollection was based on a pre-existing tool (4).Nor was there any formal testing of inter-raterreliability between observers.

The identification of pressure ulcers wasmade following visual inspection of the skin ofeach patient by one member of the AWTVNFwith verification of the presence and extent ofthe pressure ulcer made by a second, inde-pendent assessment by a second AWTVNFmember. The EPUAP provided permission toreproduce their pressure ulcer prevalence min-imum data set data collection form. Formalresearch ethics committee approval was notsought given that pressure ulcer prevalencesurveys were a common feature of tissue viabil-ity practice, although conducted using variousmethodologies that precluded collation of pre-existing data to provide an overall summary ofthe occurrence of pressure ulcers in Wales.

Ideally the pressure ulcer prevalence surveywould have covered all hospital and com-munity care patients across Wales; however,this was unrealistic given constraints upondata collector time and numbers. Accordingly

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two areas of perceived high pressure ulcerprevalence were selected which were com-mon to all health care organisations acrossWales – orthopaedic units in acute care andcommunity hospitals. These areas were sur-veyed serially with the first survey restrictedto orthopaedic units. While the data collectionmethods remained constant across the two sur-veys, there was one key difference betweenthe two surveys. It was possible to survey allorthopaedic in-patients within the confines ofthe study resources; however, the number ofcommunity hospital beds across Wales pre-cluded complete coverage of this area. A 25%convenience sample was taken across all Welshcommunity hospital beds and formed the basisfor the present survey population. Betweenthe orthopaedic and community hospital sur-veys, minor modification of the response cat-egories describing the frequency of manualrepositioning and explicit recording of whetheran individual was bedfast or chairboundwere included in the data collection form toremove perceived ambiguities in data collectorresponses during the orthopaedic unit survey.

Prior to the first survey, training in the cor-rect use of the Braden risk assessment toolwas provided; in addition, all data collec-tors completed the self-directed module uponpressure ulcer classification (PUCLAS 2) avail-able on the EPUAP website (www.epuap.org).All data collection forms were returned to acentral point (Department of Wound Heal-ing, Cardiff University) for compilation intoan SPSS database (SPSS Inc, version 16.0) forsubsequent descriptive analysis.

RESULTSPressure ulcer prevalence data were gatheredacross orthopaedic units between 2 and 6 July2007 while the survey within the communityhospital occurred between 21 April and 2 May2008. Data were gathered upon 1196 patients(581, 48·6% within orthopaedic units with 615located in community hospitals).

The surveyed patients tended to be elderlywith 223 (38·4%) and 401 (65·2%) of allorthopaedic and community hospital patients,respectively, aged at least 80 years old.Most patients were female in both surveys:orthopaedic units 371 (63·9%) and commu-nity hospitals 383 (62·4%). Patients appearedslightly more vulnerable to pressure ulcer

development within the orthopaedic units(mode Braden score 23, range 6–28) com-pared with the community hospital population(mode Braden score 19, range 8–28).

Across the orthopaedic wards of 12 hospi-tals, 81 patients (13·9%) had established pres-sure ulcers. The pressure ulcer status of 11patients was unreported with the availabledata derived from all, bar 1, hospital site withorthopaedic wards within Wales. The final siteonly returned data upon patients with pres-sure ulcers preventing any calculation of theprevalence of pressure ulcer within that loca-tion. Accordingly no data were included fromthe partial return site. Within community hos-pitals, 162 patients had pressure ulcers (26·7%)with the pressure ulcer status of eight commu-nity hospital patients unreported.

The most severe pressure ulcer was recordedfor all patients with pressure ulcers. Acrossboth surveys, most pressure ulcers werereported to be either category I or II (13) with 91category I wounds (33 in orthopaedic units and58 in community hospitals). Severe (categoriesIII and IV) pressure ulcers affected 78 patients(19 in orthopaedic units and 59 in communityhospitals).

In both audits, two independent observershad verified the presence and severity ofthe encountered pressure ulcers – in commu-nity hospitals, 22/162 (13·6%) of all pressureulcers were reported by a single observeronly (including three category III and six cate-gory IV wounds). In the surveyed orthopaedicunits, 23/81 (28·4%) of all encountered pres-sure ulcers were only seen by a single observer,including four category III and three categoryIV wounds.

DISCUSSIONPressure ulcers present major clinical andfinancial challenges to health care systemswhich are likely to remain unless regionaland national standardisation over their careand reporting occur. Wales, with only 13 localhealth care organisations (in 2008), exhibitedwidespread differences in care practices, forexample the selection of pressure ulcer riskassessment tools and the monitoring of pres-sure ulcer outcomes (primarily prevalence andclinical incidents). This is the first report at anational level of the often-assumed local vari-ations in pressure ulcer monitoring and risk



assessment methods. The results of the onlinesurvey conducted as part of the backgroundto the two pressure ulcer prevalence sur-veys highlight that comparison between healthcare organisations is restricted until commonmethodologies are adopted.

The two pressure ulcer prevalence surveysconducted across Wales identify that pressureulcers occurred within all surveyed care loca-tions with a mix of severity similar to that seenin other surveys (1). The prevalence propor-tions – 13·9% in orthopaedic units and 26·7% incommunity hospitals – are challenging to inter-pret given the lack of prior data collected specif-ically in these specialities using the EPUAPpressure ulcer prevalence minimum data set.However, that over 10% of Welsh orthopaedicpatients and over one quarter of communityhospital patients had pressure ulcers highlightsthat these wounds remain common. The exe-cution of the surveys using uniform methodsacross a wide number of health care organi-sations highlights that it is possible to beginto compile accurate information at a nationallevel (at least in a small country such as Wales)upon the size of the pressure ulcer populationthus allowing future comparison of trends inpressure ulcer occurrence to be monitored.

Despite the success of the two pressure ulceraudits being conducted nationally, the processwas not without its challenges. The EPUAPdata collection tool required completion of aBraden score for all patients; however, thistool was not in use within Wales prior to (orindeed after) the audits were performed with arequired lengthy training on the correct use ofthe Braden scale. While this additional trainingwas required prior to the surveys, this was thesole limitation to the conduct of the audits.

In an environment where collaborative effortin research and larger scale studies becomesthe norm, this survey has illustrated how theseobjectives can be obtained with limited or nofunding. While the AWTVNF were able toagree common data collection methods andto successfully collect data there were limita-tions upon the surveys. This is perhaps bestseen in the inability to survey all communityhospital patients while the single focus uponorthopaedic patients in acute care was itself aresponse to the lack of resource available tothe project team. While limited in nature, thesesurveys present clear benefits to health carein Wales through providing a focus for activity

among clinicians with interest in pressure ulcerprevention and treatment while the data serveas a baseline against which progress in pressureulcer prevention may be judged in future years.

ACKNOWLEDGEMENTSThe authors would like to thank all membersof the AWTVNF for their support in data col-lection during the two surveys. We would alsolike to thank the Welsh Wound Network forsupport in data entry and analysis.

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