European Pressure Ulcer Advisory Panel

TILDA, Tool for Interactive Learning and Daily Assistance. A way of education and quality control regarding treatment and prevention of pressure ulcers

S.I. Harden¹, C. Monsen²

1. Intensive Care Unit,
2. Vascular Surgical Ward, Malmö University Hospital, Malmö, Sweden. (Grant Acknowledgement: Kinetic Concepts, Inc. (KCI))

Introduction

During 2004, the Malmö University Hospital (UMAS), Sweden, compiled an quality indicator to decrease the frequency of pressure sores among patients. A point prevalence study was carried out in March 2004 according to EPUAP’s protocol. 635 patients in 33 wards were included. The study showed that knowledge regarding pressure sores-prevention and treatment needed improvement and a hospital-wide guideline needed implementation. Intensive education of all personnel was carried out during 2007. A repetitive point prevalence study will be done on 16 April 2008.

Methods

To prepare and educate all staff at UMAS, the ulcer advisory panel at the hospital introduced pressure sore education in a Swedish application called TILDA (Tool for Interactive Learning and Daily Assistance). TILDA is available through the Internet. The education module and the study material are all built and secured by the ulcer advisory panel at the hospital. TILDA can quickly be extended to a large number of users. It is individual based and user adapted, with education modules tailored to professional needs (e.g., doctors, nurses, nurses-aides, physiotherapists). Competency certificates are issued after required reading and a multiple-choice test.

Results

TILDA consists of two main units. With the administrative unit of TILDA, interactive training of ulcer care, methods for wound dressing, operator certification and specific ulcer training issues are addressed. Training courses are fast and easy to create by means of TILDA’s training course templates. Users taking part in the interactive training courses are guided through theoretical and practical knowledge and exercises. The theoretical, practical parts and the exercises are finished with a test and can be sandwiched with practical reviews.

The second unit deals with quality control. The competency certificate is a confirmation that the user has taken part in the training course and attained sufficient knowledge, and hence acts as a quality control and safety tool for the caregivers and caretakers. The certificates also make it possible for administrative users to get a general view of the results of the training course in the department. TILDA is available on the Internet 24 hours a day, making it easily accessible. Each user is given a personal account. Individual competencies are stored and a user may return to his account at any time. TILDA is recommended by The National Board of Health and Welfare for training within the medical service.

Conclusion

During times of personnel shortage, there is also a lack of learning and it is difficult to ensure the professional knowledge within the ward. An interactive learning application available 24 hours, guarantees a consistent level of learning for all staff. The application is individual based and adapts to the users level of knowledge. Up to date TILDA has been adopted by at least 50 units and 20 hospitals in Sweden and is recommended by The National Board of Health and Welfare for training within the medical service.

Pressure ulcer prevalence as a valid indicator of the quality of care

J.C. (Christiaan) Both

Academic Medical Centre (AMC), Postbox 22660, 1100 DD, Amsterdam, The Netherlands

Introduction

Since 2004 pressure ulcer prevalence is used by the Dutch Health Care Inspectorate (Inspectie voor de Gezondheidszorg, IGZ) as an indicator of the quality of care in hospitals. In this context pressure ulcer prevalence is defined as the percentage of the in-patients with one or more hospital-acquired (‘nosocomiaal’) pressure ulcers grade two or worse. Children younger than eighteen years and patients with a very short length of stay are excluded.¹

As hospitals differ with respect to (a) the percentage of patients at risk and (b) the mean length of stay, differences between hospitals with respect to pressure ulcer prevalence are difficult to interpret. The higher the percentage patients at risk and the longer the length of stay, the more effort must be done to generate a low pressure ulcer prevalence. Consequently, to be a valid quality indicator, pressure ulcer prevalence should be measured in relation to risk group and length of stay.

Distinguishing risk groups

As part of the yearly national survey of health problems (Landelijke Prevalentiemeting Zorgproblemen, LPZ), organised by the University Maastricht, the risk of developing pressure ulcers is assessed by measuring the Braden score. The range of the Braden score is between 6 and 23, the lower the Braden score, the higher the risk. In the definition used by the LPZ, patients with a Braden score of 20 or less are regarded to be at risk.² However, the relation between Braden score and pressure ulcer prevalence of the patients that participated in the LPZ of 2007, showed a large variation of pressure ulcer prevalence within this group of patients (2-25%). In consequence of this finding from now on in the LPZ-reports three risk groups will be distinguished: high to moderate risk (Braden score 6-14), mild risk (Braden score 15-20) and not at risk (Braden score 21-23).³ The distinction between high to moderate and mild risk patients matches the recent definitions of risk groups based on the Braden score.⁴

The effect of length of stay

For each patient that is screened in the scope of the LPZ survey the length of stay is registered. This parameter gives insight in the effect of the length of stay on the pressure ulcer prevalence. For each of the three risk groups the increase of pressure ulcer prevalence with length of hospital stay was calculated. In the patient population of the Academic Medical Centre (AMC) the overall nosocomial pressure ulcer prevalence of the adult patients in the period 1998-2007 amounts to 7.6%. The mean prevalence within the group of high to moderate risk patients is much higher (21.6%). This value increases rapidly with length of stay until it levels at 36% at a length of stay of about three weeks. The mean pressure ulcer prevalence of the mild risk patients is 6.5%, consequently the same magnitude as the overall mean. Within this risk group the prevalence also increases with length of stay. However, the rate of increase is much less and the prevalence levels at about 10%. Finally, within the group of patients that are not at risk, the mean pressure ulcer prevalence is low (1.3%) and shows little variation with length of stay.

Pressure ulcer guideline development and dissemination in Europe

Esther Meesterberends¹, Ruud J.G. Halfens¹, Rianne de Wit1,² and Christa Lohrmann³

1. Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands.
2. University Hospital Maastricht, the Netherlands.
3. Institute of Nursing Science, Medical University of Graz, Austria.

Introduction

Pressure ulcer prevalence rates show a large variance between European countries. In nursing homes prevalence rates seem to be the highest of all institutions. Studies throughout Europe have found pressure ulcer prevalence rates in nursing homes varying from 7.9% up to 83.6%. Few studies have been done on the reason for these differences, but it is known that the onset of pressure ulcers is caused and influenced by many factors. This study will focus on one of these factors, namely the development and dissemination of the pressure ulcer guideline. The aim of this study is to explore the current state of pressure ulcer guideline development and dissemination in six European countries including; England, Germany, Italy, the Netherlands, Portugal and Sweden.

Methods

A literature search and semi-structured interviews.

Results

In Portugal and Sweden there are no national guidelines for pressure ulcer prevention or treatment available, although there is an organization in Sweden that does systematic literature reviews on which pressure ulcer guidelines are based. Furthermore, in Sweden there are persons working at regional level who are responsible for developing guidelines for the region and for disseminating them to the nursing homes in the region. The interviews in the nursing homes revealed that all nursing homes use pressure ulcer guidelines except the nursing homes in Portugal where no pressure ulcer guidelines are available. Moreover, the interviews revealed that in all countries but Portugal and Sweden the nursing homes have a commission that is responsible for disseminating the pressure ulcer guideline in the nursing home. The literature search has shown that attention for pressure ulcer care, like developing a pressure ulcer guideline decreases pressure ulcer prevalence and that nurses’ knowledge regarding pressure ulcer prevention and treatment is lacking in some countries.

Conclusion

This study has pointed out factors that seem to facilitate the development and dissemination of pressure ulcer guidelines; the existence of a national organization that is responsible for pressure ulcer guideline development, dissemination and revision and the availability of a commission at regional level or within the nursing home that is responsible for adjusting the national pressure ulcer guideline to the situation in the nursing home and for disseminating it within the nursing home.

Project based learning to improve PU care

Dulce Cabete

Escola Superior de Saude do Instituto Politecnico de Setubal Portugal

Introduction

It is widely recognized that education is an important tool to increase clinical practice. However it is also known that having the knowledge and using that knowledge is not as simple as that and long life education still relies in traditional methods of ‘delivering contents’. Thus we believe that active learning is needed to improve best practice. Hence a project based learning post-graduate programme on wound management was built over an academic year. We wanted to know in what extent project based learning would change practice in clinical students placements.

Methods

A post graduate education programme was designed over an academic year. Tutorial education was part of the program as well as theoretical lectures. Students were free to them to choose the field they want to in depth through a project based learning process. From a group of 33 nurses 11 choose pressure ulcers related issues. Each student set his own goals and presented a planning to accomplish in a six-month term supported by tutorial sessions. Each student should also negotiate the expected outcomes, defining measuring criteria.

Results

As students were free to choose their own way and aims, different outcomes came out of this process:

• 100% success in educational program;
• 110 nurses involved;
• over 600 patients assessed;
• 11 papers published;
• over 20 oral presentations so far reporting nurses’ achievements in their places of work, namely:

Reduction of prevalence of pressure ulcers from 20% to 13.1% in a acute medical ward and reduction of incidence from a 13% to 5.9% (401 patients assessed).

A first study of pressure ulcer prevalence in a general emergency room was done on the district, showing that 22% of patients staying over 48 hours in the emergency room had grade 1 or 2 pressure ulcers; 96% of his ulcers were developed in ER. In one ward a study of PUCLAS was conducted. From an initial failure of 60% in the on-line testing system the team moved up to a 75% success; 23 nurses involved; two intensive care units started to work with PUCLAS and reduced in 50% PU incidence.

One hospital developed the informatics application to document nursing care on pressure ulcers in order to keep systematic assessment and research.

Conclusion

We find these results encouraging and supportive to go on further with project based learning.

Pressure ulcers and malnutrition in hospitals and nursing homes

Shahin E¹, Dassen T¹, Halfens R²,Lahmann N¹, Schols J M G A³, Tannen A ¹and Meijers J²

1. Charité Universitätsmedizin Berlin, Germany, Department of Nursing Science.
2. Universiteit Maastricht, The Netherlands, Department of Health Care and Nursing Science.
3. Universiteit Maastricht, The Netherlands, Department of General Practice.

Background

Pressure ulcers remain a major health care problem throughout the world. Malnutrition is one of the risk factors that is associated with pressure ulcer development. This study aims to assess the relationship between malnutrition and pressure ulcers in hospitals and nursing homes.

Design and setting

A Cross sectional study was carried out in 22 hospitals and 29 nursing homes in Germany.

Sample

A total of 8934 patients (6117 from hospitals and 2817 from nursing homes) was included. The overall response rate to participate in this study was 72.5% (6473) participants (2393 (84.9%) participants from 29 nursing homes and 4080 (66.7%) participants from 22 hospitals).

Method

Pressure Ulcers were measured according to the grading system of the EPUAP, while the presence of malnutrition was assessed by measuring the following nutritional indicators: weight loss in the last six months, body mass index, nutritional intake during the last five days, amount of nutritional intake and also the level of dependency regarding eating and drinking.

Results

Pressure ulcer prevalence (grade 2 and greater) in hospitals was 9%, and in nursing homes 5.3%. The relationship between malnutrition and pressure ulcers is unclear. However, there are some significant and some non-significant relationships with the indicators for malnutrition.) Nevertheless, pressure ulcers grade 2 and greater related significantly (P = 0.01) with some possible indicators of malnutrition like body mass index, age, amount of nutritional intake, and level of dependency in eating and drinking. Moreover, the highest percentage of pressure ulcers was found in hospital patients who lost between 5 to 10% of their weight in the last six months. In nursing home patients the prevalence percentages of pressure ulcers were similar in patients who showed a percentage of weight losses of less than 5% and patients with weight losses between 5 and 10% in the last six months. The percentages of patients with a body mass index <18.5, 18.5 to <20 and <<24 kg/m² were all significantly (P = 0.01) higher in nursing homes than in hospitals. Weight losses between 5 and 10%, more than 10% in the last six months, as well as no nutritional intake for five days were significantly (P = 0.01) more prevalent in hospitals than in nursing homes, while there was no significant difference between hospitals and nursing homes regarding prevalence of pressure ulcers grade 2 and greater.

Conclusion

The relationship between malnutrition and pressure ulcer development has not become fully clear in this study. Therefore extra research is needed to provide more evidence based information regarding this relationship.

The effects of enteral nutritional support in the treatment of pressure ulcers: an overview of studies so far

Jos M.G.A. Schols¹, Hilde Heyman² and Erwin P. Meijer3³

1. Department of General Practice, Maastricht University, The Netherlands;
2. OCMW Antwerpen, Belgium;
3. Danone Research - Centre for Specialised Nutrition, Wageningen, The Netherlands.

Background

Pressure ulcers are a common and costly problem in geriatric facilities. Malnutrition, inadequate protein or poor protein and energy intake and recent weight loss have been identified as independent risk factors for the development of pressure ulcers. Providing oral nutritional supplements (ONS) in addition to regular food intake seems a logical way to replenish body shortages of macro- and micronutrients as well as to supply extra nutrients for the preservation of skin tissue, strengthening of tissue resistance, and promoting tissue repair. To examine the effect of a specific nutritional intervention in pressure ulcer care, clinical studies performed with a specific ONS enriched with arginine, vitamin C and zinc on the healing of pressure ulcers were reviewed.

Methods

Four clinical studies performed with the ONS (Cubitan(r), Nutricia) were included. The ONS provides 250 kcal, 20 g protein of which 3 g arginine, 250 mg vitamin C, 38 mg vitamin E and 9 mg zinc, and other micronutrients per 200 ml serving.

Results

The first study¹ in a small number of patients with severe cognitive impairment, examined the effects of pressure ulcer healing between three groups that received standard hospital diet; a standard diet plus high-protein formula or the specific ONS for 15 days. A tendency for improved pressure ulcer healing was shown in patients supplemented with the specific ONS compared to a high protein formula or hospital diet. More recently, an open-label study found an improved rate of healing of advanced pressure ulcers following three-week supplementation with the specific ONS². Pressure ulcer area reduced from 23.6 cm² to 19.2 cm², a significant reduction of 29%. To examine the effects in a larger population and by a longer duration of the intervention, 245 patients with grade II, III or IV pressure ulcers were enrolled into an open intervention study at 61 long-term-care facilities in Belgium³. After nine weeks of treatment, pressure ulcer area significantly reduced from 15.8 ± 37.4 cm^± to 7.4 ± 18.1 cm². In addition, 8 out of 10 patients reported no complaints regarding the prescribed amount of three servings per day, which resulted in a high compliance of 2.3 ± 0.56 servings per day. Importantly, 9 out of 10 health care professionals reported they would continue to use the ONS as part of pressure ulcer care in their long-term care facility in the future.

Furthermore, a recent quasi-experimental study⁴ in 478 patients with a hip fracture showed a reduction in total number of patients with a hospital-acquired pressure ulcer when the ONS was given twice a day postoperatively compared to the control group.

Conclusion

The current practice-based studies with the ONS specifically designed for patients with pressure ulcers showed positive effects on pressure ulcer healing. The specific ONS is well tolerated resulting in a high compliance and is appreciated by health care professionals. Importantly, a large randomised controlled trial that is currently running with this ONS will provide more evidence-based data regarding the role of this disease targetted ONS in the healing of pressure ulcers.