Effect of a 3-Step Strategy for Preventing Pressure Ulcers
Effect of a 3-Step Strategy for Preventing Pressure Ulcers
Objective Pressure ulcers (PUs) still form an important and distressing problem in Dutch nursing homes. Pressure ulcer prevention protocols are generally based on current guidelines. The authors developed an alternative 3-step protocol to help prevent pressure ulcers. The effects of this new 3-step protocol on the prevalence of pressure ulcers in patients at risk of developing PUs in the Avoord nursing homes in Etten-Leur/Zundert (Netherlands) were calculated. In addition, the protocol's general cost effects were explored.
Method Data on the prevalence of PUs and the use of preventive measures were derived from the annual independent International Prevalence Measurement of Care Problems of Maastricht University (Landelijke prevalentiemeting Zorgproblemen [LPZ]). This annual measurement was implemented in 1998 and measures care problems such as the prevalence of PUs and related preventive measures. Data on patients at risk of developing PUs at the Avoord nursing homes in Etten-Leur/Zundert (Netherlands) were analyzed and compared with national data between 2002 and 2011.
Results The introduction of the 3-step protocol resulted in a significant reduction of the nosocomial prevalence of category 2–4 PUs. The prevalence was reduced from 8.7% to 0.5% during the first year and remained stable at about 2% throughout the rest of the study period. The prevalence at the national level also decreased during this period, but not as much, and was still significantly higher in 2011. The use of alternated systems decreased to almost 1%. Use of static air mattresses showed an almost linear rise in the Avoord nursing homes from the start of the implementation of the protocol, while the trend for both types of mattresses remained stable on a national level. Introducing the static air mattress instead of the more expensive alternating mattresses helped to reduce the mean daily costs of mattresses at the Avoord nursing homes by more than 70% compared to national figures. The workload of the nursing staff decreased as well due to the reduction of repositioning.
Conclusion The introduction of the 3-step protocol showed to be effective. The prevalence of PUs and the mean daily costs were reduced to, and have been sustained at, a significantly lower level.
A pressure ulcer (PU) is a localized injury to the skin and/or underlying tissue, usually over a bony prominence that results from pressure, including pressure associated with shear. Pressure ulcers are an important and distressing care problem in nursing homes, leading to suffering and loss of residents' quality of life. Pressure ulcers are also associated with considerable extra health care costs.
The prevalence of category 1–4 PUs in Dutch nursing homes is more than 20%, which indicates the relevance of the problem. Severens et al calculated that the costs of PU care in nursing homes related to extra hours of nursing and medical care, pressure relieving mattresses, and prolonged stays in the nursing home, amounts to more than 500 million euros a year. Another study calculated the mean costs for the treatment of category 2–4 PUs to be €750 per ulcer in 2001, based on materials and activities of nurses and doctors. The mean costs are currently €1,670 per ulcer, based on the price level of 2012. No cost analyses have been conducted in nursing homes in the Netherlands in the past 10 years.
In addition to the main causative factors, a number of contributing or confounding factors have been associated with the occurrence of pressure ulcers. These include mobility problems, neurological diseases, perfusion/oxygenation, skin moisture, body temperature, general health, and nutritional status.
Pressure-relieving systems play an important role in the daily practice of PU prevention. Physicians and nurses often apply additional support surfaces to redistribute pressure over a larger surface area of the patient's body. Although there is little scientific evidence to support the use of these systems, they are widely used.
A higher specification foam mattress should be used for patients with a high risk of developing a PU rather than a standard hospital foam mattress. Since 2002, guidelines on PUs, such as the Dutch Institute for Healthcare Improvement (CBO) guidelines, have recommended as a primary step that a visco-elastic foam mattress be used in combination with repositioning in bed every 3 hours during the day or every 4 hours during the night. If this measure does not meet the needs of the patient, use of an alternating mattress is advised. When using another type of mattress, additional repositioning must be taken in consideration.
Every year since 1998, Maastricht University has conducted a national prevalence measurement (Landelijke prevalentiemeting Zorgproblemen [LPZ]) in hospitals, nursing homes, and home care organizations. The LPZ is a cross-sectional, multicenter prevalence measurement that uses a standardized questionnaire to record data such as the prevalence and risk of pressure ulcers and the preventive and therapeutic measurements taken in daily PU care. Participation in the LPZ enables nursing homes to compare their PU prevalence, PU prevention, and PU policy with national data from the entire nursing home sector.
The Avoord Zorg en Wonen nursing homes (Etten-Leur/Zundert, the Netherlands) participate in these annual LPZ measurements and PU prevalence data are available from 2002 to the present. In 2002, 2003, and 2004, the prevalence of category 1–4 PUs in the Avoord Zorg en Wonen nursing homes was 30.7%, 26.6%, and 22.2%, respectively. These data are comparable with the mean national prevalence data from 2002, 2003, and 2004. The decrease from 30.7% to 22.2% was probably the result of all basic mattresses being replaced by visco-elastic foam mattresses in 2002, the first step recommended by the Dutch national guidelines. In 2002, the Avoord nursing homes also started using a standard protocol for PU prevention, based on the CBO 2002 guidelines, that includes repositioning patients every 3–4 hours.
National and international guidelines often include repositioning as a structural part of preventive measures. However, in daily practice in the Netherlands compliance is lax, with very few patients actually repositioned every 3–4 hours; in fact, only 15%-30% of the patients at risk were repositioned in the years 2002–2004 (Figure 1). Around 2002, following the findings of Defloor, many guidelines on PUs, including the CBO guidelines, based their advice for repositioning on a visco-elastic foam mattress. The current international guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the European Pressure Ulcer Advisory Panel (EPUAP) and Verpleegkundigen & Verzorgenden Nederland (V&VN) also based the use of repositioning on these studies, because other studies before December 2007 were analyzed as methodologically insufficient. The guidelines also specify that repositioning should be considered when patients have other types of mattresses. However, 2 studies by van Leen et al that involved patients at high risk for PUs, as measured with the Norton and Braden scales, showed the incidence of pressure ulcer development was approximately 4% for patients using a static air mattress without repositioning, while the findings of Defloor showed a 15% incidence.
(Enlarge Image)
Figure 1.
Effect of 3-step pressure ulcer (PU) prevention protocol on PU prevalence in Avoord nursing homes compared to the national nursing home sector and the effects on the percentage of repositioning (2002–2011).
The original PU prevention protocol of Avoord Zorg en Wonen was revised to implement a more effective guideline. The revisions were based on studies by Defloor, Van Leen et al, and Sideranko et al, who studied the effects of static air.
The new PU protocol contains 3 main steps: 1) All patients receive a standard visco-elastic mattress, with no repositioning; 2) patients who develop signs of a possible category 1 PU (nonblanchable redness) receive a static air overlay (Repose, Frontier Therapeutics Ltd, Blackwood, South Wales UK) in addition to the visco-elastic foam mattress, again with no repositioning; 3) patients who still develop a PU are repositioned every 3 hours during the day and every 4 hours during the night. If this 3-step protocol is insufficient because a patient develops a more severe PU (ie, category 4) the patient's mattress will be swapped for a low-air loss system.
The yearly participation in the LPZ measurements between 2002 and 2011 allowed for the evaluation of patient outcome effects and the cost effectiveness of using this new protocol, and an ability to compare the PU prevalence figures with the national prevalence figures in the nursing home sector.
The authors aimed to address the following research questions in this study:
Abstract and Introduction
Abstract
Objective Pressure ulcers (PUs) still form an important and distressing problem in Dutch nursing homes. Pressure ulcer prevention protocols are generally based on current guidelines. The authors developed an alternative 3-step protocol to help prevent pressure ulcers. The effects of this new 3-step protocol on the prevalence of pressure ulcers in patients at risk of developing PUs in the Avoord nursing homes in Etten-Leur/Zundert (Netherlands) were calculated. In addition, the protocol's general cost effects were explored.
Method Data on the prevalence of PUs and the use of preventive measures were derived from the annual independent International Prevalence Measurement of Care Problems of Maastricht University (Landelijke prevalentiemeting Zorgproblemen [LPZ]). This annual measurement was implemented in 1998 and measures care problems such as the prevalence of PUs and related preventive measures. Data on patients at risk of developing PUs at the Avoord nursing homes in Etten-Leur/Zundert (Netherlands) were analyzed and compared with national data between 2002 and 2011.
Results The introduction of the 3-step protocol resulted in a significant reduction of the nosocomial prevalence of category 2–4 PUs. The prevalence was reduced from 8.7% to 0.5% during the first year and remained stable at about 2% throughout the rest of the study period. The prevalence at the national level also decreased during this period, but not as much, and was still significantly higher in 2011. The use of alternated systems decreased to almost 1%. Use of static air mattresses showed an almost linear rise in the Avoord nursing homes from the start of the implementation of the protocol, while the trend for both types of mattresses remained stable on a national level. Introducing the static air mattress instead of the more expensive alternating mattresses helped to reduce the mean daily costs of mattresses at the Avoord nursing homes by more than 70% compared to national figures. The workload of the nursing staff decreased as well due to the reduction of repositioning.
Conclusion The introduction of the 3-step protocol showed to be effective. The prevalence of PUs and the mean daily costs were reduced to, and have been sustained at, a significantly lower level.
Introduction
A pressure ulcer (PU) is a localized injury to the skin and/or underlying tissue, usually over a bony prominence that results from pressure, including pressure associated with shear. Pressure ulcers are an important and distressing care problem in nursing homes, leading to suffering and loss of residents' quality of life. Pressure ulcers are also associated with considerable extra health care costs.
The prevalence of category 1–4 PUs in Dutch nursing homes is more than 20%, which indicates the relevance of the problem. Severens et al calculated that the costs of PU care in nursing homes related to extra hours of nursing and medical care, pressure relieving mattresses, and prolonged stays in the nursing home, amounts to more than 500 million euros a year. Another study calculated the mean costs for the treatment of category 2–4 PUs to be €750 per ulcer in 2001, based on materials and activities of nurses and doctors. The mean costs are currently €1,670 per ulcer, based on the price level of 2012. No cost analyses have been conducted in nursing homes in the Netherlands in the past 10 years.
In addition to the main causative factors, a number of contributing or confounding factors have been associated with the occurrence of pressure ulcers. These include mobility problems, neurological diseases, perfusion/oxygenation, skin moisture, body temperature, general health, and nutritional status.
Pressure-relieving systems play an important role in the daily practice of PU prevention. Physicians and nurses often apply additional support surfaces to redistribute pressure over a larger surface area of the patient's body. Although there is little scientific evidence to support the use of these systems, they are widely used.
A higher specification foam mattress should be used for patients with a high risk of developing a PU rather than a standard hospital foam mattress. Since 2002, guidelines on PUs, such as the Dutch Institute for Healthcare Improvement (CBO) guidelines, have recommended as a primary step that a visco-elastic foam mattress be used in combination with repositioning in bed every 3 hours during the day or every 4 hours during the night. If this measure does not meet the needs of the patient, use of an alternating mattress is advised. When using another type of mattress, additional repositioning must be taken in consideration.
Every year since 1998, Maastricht University has conducted a national prevalence measurement (Landelijke prevalentiemeting Zorgproblemen [LPZ]) in hospitals, nursing homes, and home care organizations. The LPZ is a cross-sectional, multicenter prevalence measurement that uses a standardized questionnaire to record data such as the prevalence and risk of pressure ulcers and the preventive and therapeutic measurements taken in daily PU care. Participation in the LPZ enables nursing homes to compare their PU prevalence, PU prevention, and PU policy with national data from the entire nursing home sector.
The Avoord Zorg en Wonen nursing homes (Etten-Leur/Zundert, the Netherlands) participate in these annual LPZ measurements and PU prevalence data are available from 2002 to the present. In 2002, 2003, and 2004, the prevalence of category 1–4 PUs in the Avoord Zorg en Wonen nursing homes was 30.7%, 26.6%, and 22.2%, respectively. These data are comparable with the mean national prevalence data from 2002, 2003, and 2004. The decrease from 30.7% to 22.2% was probably the result of all basic mattresses being replaced by visco-elastic foam mattresses in 2002, the first step recommended by the Dutch national guidelines. In 2002, the Avoord nursing homes also started using a standard protocol for PU prevention, based on the CBO 2002 guidelines, that includes repositioning patients every 3–4 hours.
National and international guidelines often include repositioning as a structural part of preventive measures. However, in daily practice in the Netherlands compliance is lax, with very few patients actually repositioned every 3–4 hours; in fact, only 15%-30% of the patients at risk were repositioned in the years 2002–2004 (Figure 1). Around 2002, following the findings of Defloor, many guidelines on PUs, including the CBO guidelines, based their advice for repositioning on a visco-elastic foam mattress. The current international guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the European Pressure Ulcer Advisory Panel (EPUAP) and Verpleegkundigen & Verzorgenden Nederland (V&VN) also based the use of repositioning on these studies, because other studies before December 2007 were analyzed as methodologically insufficient. The guidelines also specify that repositioning should be considered when patients have other types of mattresses. However, 2 studies by van Leen et al that involved patients at high risk for PUs, as measured with the Norton and Braden scales, showed the incidence of pressure ulcer development was approximately 4% for patients using a static air mattress without repositioning, while the findings of Defloor showed a 15% incidence.
(Enlarge Image)
Figure 1.
Effect of 3-step pressure ulcer (PU) prevention protocol on PU prevalence in Avoord nursing homes compared to the national nursing home sector and the effects on the percentage of repositioning (2002–2011).
The original PU prevention protocol of Avoord Zorg en Wonen was revised to implement a more effective guideline. The revisions were based on studies by Defloor, Van Leen et al, and Sideranko et al, who studied the effects of static air.
The new PU protocol contains 3 main steps: 1) All patients receive a standard visco-elastic mattress, with no repositioning; 2) patients who develop signs of a possible category 1 PU (nonblanchable redness) receive a static air overlay (Repose, Frontier Therapeutics Ltd, Blackwood, South Wales UK) in addition to the visco-elastic foam mattress, again with no repositioning; 3) patients who still develop a PU are repositioned every 3 hours during the day and every 4 hours during the night. If this 3-step protocol is insufficient because a patient develops a more severe PU (ie, category 4) the patient's mattress will be swapped for a low-air loss system.
The yearly participation in the LPZ measurements between 2002 and 2011 allowed for the evaluation of patient outcome effects and the cost effectiveness of using this new protocol, and an ability to compare the PU prevalence figures with the national prevalence figures in the nursing home sector.
The authors aimed to address the following research questions in this study:
What effect did the implementation of the 3-step PU prevention protocol have on the nosocomial PU prevalence in the Avoord nursing homes from 2005 to 2011?
How does the nosocomial PU prevalence in the Avoord nursing homes from 2005 to 2011 compare to national figures from the nursing home sector during those same years?
What indication can be given about the cost-effectiveness of the implementation of static air mattresses and the reduction of alternating systems between 2005 and 2011 per 100 patients, compared to national data?
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