EUROPEAN PRESSURE ULCER ADVISORY PANEL

What do we mean by quality in pressure ulcer prevention and treatment?
A Physician’s Perspective

Denis Colin, MD, PhD
Rehabilitation Hospital L’Arche, 72650 Saint Saturnin, Le Mans, France

Despite the considerable improvements of medical knowledge and it’s positive impacts on the domain of health in the past thirty years, the problem of pressure ulcers is still very visible. They occur with a worrying frequency, they are expensive to treat and they are physically and psychologically as painful as they always were. Indeed pressure ulcers remain a relatively neglected subject and are often considered, depending on the countries, as the responsibility of the nursing staff and sometimes the physicians. However, it is widely recognized on the medical profession that the complexity of the pressure ulcers require a multidisciplinary approach. It is essential that this approach takes the form of a quality control approach.

The quality control approach has been developed and improved in recent years in numerous health fields, including that of pressure ulcers. This process is typical of a multi-professional process.

The first stage is often the creation of national or international guidelines. However, one has to recognize that the dissemination and the application of these guidelines is insufficiently organized. This dissemination must be a priority in all areas of care. The role of expert groups or international panels like EPUAP in achieving this objective is fundamental.
The second stage is the choice of quality’s indicators. While pressure ulcer prevalence and incidence are often viewed as indicators of the quality of care it is of the utmost importance to remember that neither can be employed as a strict measure of quality. It is difficult to make comparisons between institutions, or even within an institution over a certain period of time without a good measure of baseline risk or case mix. Nevertheless, the development of pressure ulcers is often considered to be an indicator of low quality care or to be a phenomenon that dramatically reduces a person’s quality of life. Admittedly, the prevalence and incidence surveys in each area of care represent a necessary step, even though their scientific level is not always well-demonstrated.

Quality in pressure ulcers depends on a multidisciplinary approach which includes:
• a high level of primary education and on going training in nursing schools and medical universities,
• the establishment and the diffusion of validated guidelines and educational programs across all areas of care,
• the capacity to measure the impact of the problem on patients on a continuous basis, and
• the ability to involve the health boards and the politicians at each level of responsibility.

The prevention and the treatment of pressure ulcers represent important issues in both the funding and quality of health care. Our responsibility is the development and the expansion of multi-professional groups, their mission being to acquire knowledge, understanding and awareness of pressure ulcers throughout Europe.

What do we mean by quality in pressure ulcer prevention and treatment?
A Nurse’s Perspective

Agnès Jacquerye, Quality Adviser
Erasmus Hospital, Free University of Brussels, 808 route de Lennik, 1070 Brussels (Study supported by the Ministry of Social Affairs,Public Health and Environment.)

The quality movement has existed for over fifty years. Does it mean that quality did not existed before? Evidently not, but at present we are in a context where we have to prove explicitly that the accomplished work shows quality. It guarantees patients, professionals, and stakeholders that the taking into care of patients is realised professionally and that the financial investment is justified.

Quality is defined and determined by indicators based on literature (medical evidence-based), by experts and by a consensus of professionals. Quality is not an individual matter but a multidisciplinary one based on indicators. They are measured on the spot by audits to determine the quality level obtained. From the results, a program of quality improvement is implemented with a coaching of personnel on the spot and with training courses. The cycle ‘measurement and improvement’ is then regularly introduced to keep abreast of the problem and to check in an objective manner if the taking into care of patients is realised professionally. The goal of the quality program is to progressively modify behaviour and clinical practice to improve the quality of care and services to the patients, giving to the personnel the means and an environment where they are encouraged to take up their responsibilities.

Since 1995, the quality movement has been implemented with the same philosophy and rigorous manner in pressure ulcer prevention and treatment in Belgium in more than 200 health institutions, thanks to the support of the Ministry of Social Affairs, Public Health and Environment. The reference framework for the audit is based on the Gosnell-Donabedian model. This framework consists of twenty-nine variables which are divided up into characteristics of the nursing units, characteristics of the patients and eighteen care quality indicators classified into resources, processes and outcomes.

The resources are the reference nurse, multidisciplinary dialogue, prevention protocols, treatment protocols, explicit heading of risk detection in the patient record, prophylactic equipment, and sheets and draw sheets. The process indicators are mobilisation, frequency of mobilisation, prophylactic material, nutritional supervision and education of the patient / the family. The outcomes indicators are the prevalence of patients with pressure ulcers by hospitalised patients and in particular, the prevalence of the patients developing pressure ulcer in the wards, the origin, the sites, the description and the colour.

The most important results of these five years of audits (1995, 1996, 1997, 1998, 2000) are as follows. The quality indicators in resources show real progress over these years and particularly the first two. Eventhough, they improved during this period of time, two criteria are still difficult to implement: multidisciplinary dialogues (55%), and the detection of patients at risk (74%). The process indicators of quality show important progress but improvement has still to be made for nutritional supervision (45%) and for education of the family (29%). Concerning the outcome, the pressure ulcer prevalence has decreased from 14% to 11%. One of the best indicators of quality is, for us, the prevalence of pressure ulcers developed in the care unit considered as nosocomial pressure ulcers. This prevalence fell from 7.7% to 5.3%.

Each year, each institution carried out to the data collection on the same day. Frequently, they measured data on other dates to obtain a representative sample in order to implement a plan of action between measurements. The health institutions also participated in to the national action plan. National coordinators and the Ministry created guidelines and a booklet for patient education. The national quality program on pressure ulcers not only allowed for the creation of a scientific and professional awareness of the problem but it has also reduced nosocomial pressure ulcers. The quality objectives were reached though there still is a lot of work to be done.

What do we mean by quality in pressure ulcer prevention and treatment?
A health economist’s perspective

Laszlo Gulacsi
Hungary

There are many competing demands for health care resources, of which pressure ulcer prevention and treatment is only one. This is not free of charge, expenditures have an opportunity cost which cannot be ignored. In the long run, the investment of scarce resources in pressure ulcer prevention and treatment activities has to be justified by their results.

Evidence shows that quality of PU prevention and treatment can be improved through appropriate implementation of various quality tools. Literature on the effects of quality improvement on cost is relatively limited in number; however, the relation between cost and quality is an issue of universal interest.

Despite considerable interest in improving the prevention of pressure ulcers, measuring the success of prevention continues to rely upon indicators such as changes in the prevalence or incidence of these wounds. However the selection of appropriate indicators remains confused, with little attempt to consider alternative outcomes such as changes in Health Related Quality of Life (HRQoL). Fundamental questions remain unanswered, for example when have the limits of pressure ulcer prevention been achieved, and when should health care organisations decide to invest, and withdraw from quality improvement initiatives directed towards pressure ulcer prevention.

These fundamental issues are raised in this presentation, with theoretical economic issues addressed to indicate that there is value in preventing pressure ulcers, but it is likely that all quality improvement initiatives will be subject to the law of diminishing returns.

Health-related quality of life in patients with pressure damage

P. Price
Wound Healing Research Unit, University of Wales College of Medicine, Wales UK

The development of pressure ulceration is a problem associated with a number of concomitant conditions and a range of symptoms, and although little research has been completed on the impact on everyday life, there is an assumption that it affects health-related quality of life. Qualitative work has shown that the impact of pressure ulcers is wide ranging, with physical social and financial aspects affected, whilst changes in body image and the loss of independence /control are profound (Langemo et al, 2000). All eight patients in this study, with or without spinal cord injury, experienced a range of negative effects. Studies that have used validated health-related quality of life tools (Clark 2002, Franks et al 2002) have used the Short-Form-36 in conjunction with tests of physical function (such as the Bartel). Franks et al (2002), in a study with 75 patients and 100 controls, have shown that whilst there is a negative impact on health-related quality of life for patients with pressure ulceration, this is similar to other patients treated within the community setting. Clark (2002), reporting on a cohort of 2,507 patients, has highlighted the difficulties of using generic self-report tools with this patient population. There are a number of challenges that professionals in this area need to consider, for example, as a condition specific tool for pressure ulceration is not available to use alongside generic tools (such as the SF–36), then it is difficult to assess the impact of new treatments in terms of the direct impact on the patient. In addition, many patients in this group will not be able to complete a self-report of impact on health-related quality of life, which raises the issue of the use of proxy ratings for some patients. In addition to reviewing the current literature, this presentation will introduce some important aspects of health-related quality of life that health professionals may be able to incorporate into their everyday practice.

References
Clark M (2002) Pressure ulcers and quality of life. Nursing Standard. 16, 22, 74 – 80.
Franks PJ, Winterberg H, Moffat C. (2002) Health-related quality of life and pressure ulceration assessment in patients treated in the community. Wound Repair and Regeneration, June, 133 – 140.
Langemo D, Melland H, Hanson D, Olson B, Hunter S. (2000) The lived experience of having a pressure ulcer: a qualitative study. Advances in Skin and Wound Care: Sept/Oct: 225 – 235.