If has been estimated that in Canada 25% of patients admitted to acute care hospitals will develop a pressure ulcer. Furthermore, estimates suggest that for those people in acute care hospitals assessed for enhanced level of care and awaiting placement, 48% will develop pressure ulcers (Foster, 1992). The cost of treating pressure ulcers in Canada has not been adequately documented. This is due in part to a lack of adequate and accessible data bases, and to the method of payment to hospitals through global budget Financing, which makes it difficult to conduct accurate cost analysis of daily treatments associated with pressure ulcers.
Evidence from the United States, in terms of product and labor costs and patients' length of hospitalization indicates that the cost of treating pressure ulcers is high. Estimates of the cost to treat a pressure ulcer can range form $5,000 to $60,000 annually and the estimated median cost per hospital admission of patients with pressure ulcers was $27,000, compared with $7,000 for all patients hospitalized in 1984 (Fowler, 1990).
The increased death rates associated with pressure ulcers is shocking. Powell (1989) found that during the first year of admission to a nursing home, the death rate was 129% higher for those patients who develop ulcers. Kennedy (1989) found that 55.7% of patients died within 6 weeks of the onset of pressure ulcers. It has been estimated that the risk of death among the geriatric population who develop a pressure ulcer increases 4 times the norm and increases to 6 times the norm in those patients whose pressure ulcers do not heal (Burd, 1992). Research has clearly demonstrated the link between pressure ulcers and increased mortality; however, the amount of suffering associated with these ulcers remains an intuitive judgment. Clearly, the total costs associated with pressure ulcers is high.
The purpose of this article is to describe the impact of a wound and skin team education initiative within a chronic care hospital. The current study had two objectives:
* to determine the prevalence of pressure ulcers in a chronic care hospital; and
* to determine the impact of an educational program designed to heighten nursing staff awareness of the significance of pressure ulcers.
It was hypothesized that nursing staff education would promote early nursing prevention/intervention strategies which would significantly reduce the prevalence of pressure ulcers.
St Mary's of the Lake Hospital is a 248-bed accredited teaching hospital in Kingston, Ontario, which offers both inpatient and outpatient services. A multidisciplinary team approach is used in specialized programs which includes geriatrics, rehabilitation, and continuing care medicine, as well as palliative and respite care. It is the largest chronic care facility in southeastern Ontario. Within St. Mary's, a multidiscipline Wound and Skin Care Team (WSCT) was initiated with the mandate to provide educational inservices for nursing staff. The team's objective was to increase general knowledge and awareness relevant to the prevention and treatment of pressure ulcers. Team membership included a physician, a dietitian, an occupational therapist, a nursing administrator, and a nursing representative from each of the hospital's six nursing units.
The WSCT members were provided with monthly inservices, and each nurse representative was encouraged to keep an information binder with inservice materials on his or her unit which was accessible to the rest of the nursing staff. Topics included the pathogenesis of pressure ulcers, risk assessment using the Braden Risk Assessment tool, and nursing interventions associated with the indicated risk factors. Wound assessment using the National Pressure Ulcer Advisory Panel (NPUAP) Staging System was also covered. A different product was highlighted by sales representative from various wound-care product companies at least every 3 months. These included inservices regarding mattress overlays and foam; skin-care products, such as cleansers and creams; and specialty beds and mattresses. Special focus was placed on the appropriate use of dressings, specifically the use of hydrocolloid dressings to provide a moist wound-healing environment, Educational materials were circulated to the units for staff to use, if they wished. This material was also used by the nursing administrator as the basis for staff inservices. In addition, nursing staff were encouraged to view the members of the WSCT as resources who could be consulted on issues relating to pressure ulcers.
Prior to the start of the education initiative, a patient survey was conducted to establish a prevalence baseline of pressure ulcers within the hospital. This survey would be repeated on an annual basis, as it offered the opportunity to assess the efforts of the WSCTs educational program in the prevention and treatment of pressure ulcers.
The charts of all patiente who participated in the survey were reviewed to collect data pertinent to the study. These data included demographics; dates of admission; physicians responsible; and risk factors associated with skin breakdown, including mobility, activity levels, and continence status. Where applicable, the type of incontinence system that the patient used was also recorded. Where pressure ulcers were identified, the assessment team recorded the etiology, stage, location, and the type of treatment the ulcer was receiving. If the patient had been admitted within the prior 6 months, the patient chart was reviewed to record whether the ulcer was present upon admission. Two nurse classifiers conducted a physical assessment of all patients included in the study. When a reddened area was noted, finger blanching was conducted to determine a stage I pressure ulcer. All pressure sores were staged according to classification criteria endorsed by the NPUAP (1989):
* Stage 1: Nonblanchable erythema of intact skin; the heralding of skin ulceration.
* Stage 2: Partial-thickness skin loss involving the epidermis and /or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
* Stage 3: Full-thickness loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
* Stage 4: Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures (such as tendons or joint capsules).
A formal assessment tool was used on all patients to maintain consistency in the data collection (Figure). Each patient was given a number to assure confidentiality. No formal consent was obtained because it was felt that a skin assessment of this nature was a routine part of daily nursing care, and the results of this survey were to be used to maintain patient-care qualityassurance standards. The period of the assessment was 2 weeks.
Year 1 survey
Demographics Of the 210 patients surveyed, 140 patients (66.7%) were female. The age range in the population was 28 to 106, with a mean age of 74.8 years. Although the age range was broad, the population was primarily elerly, with 166 (79%) being 65 years or older.
Within the survey, 68 patients (32%) were observed to have pressure ulcers. A total of 96 pressure ulcers were noted and staged. Of those patients who were admitted within the prior 6 months, 18 of these had pressure ulcers present upon admission. Forty-seven of the patients had one ulcer, 14 had two, and 7 had three. The most frequent pressure ulcer location was the coccyx/ sacrum area.
Chi-square analyses revealed that neither sex had a greater proportion of pressure ulcers (Chi-square = .01, p = .92). The proportion of females who had intact skin was 68% (n = 95), while 67% (n = 47) of surveyed males also had intact skin. Similarly, there was no significant difference in the prevalence of pressure ulcers among the older patients compared to younger ones. (Chi-square = .66, p =.41). The proportion of patients over 65 years of age who had intact skin was 66% (n = 110), compared to 72% (n = 32) of those under 65 years of age.
The ranking of risk factors in order of those seen with greatest frequency was patient activity restricted to a bed or chair (86%; n -179), limited limb mobility (79%; n = 107), and incontinence (74%; n = 135).
Each risk factor was analyzed to determine its relationship with skin breakdown. The prevalence of pressure ulcers was not found to be significantly associated with each of the three selected risk factors; restricted activity (Chi-square = .55, p = .46), limited limb mobility (Chisquare =1.14, p = .56), and incontinence (Chi-square - .01, p = .91).
Year 2 survey
In the second year, 202 patients were surveyed; 124 patients (64%) were female. The age range in the population was 17 to 101, with a mean age of 73.7 years. The population was primarily elderly, with 144 (71%) being 65 years or older.
Within the survey, 45 patients (22%) were observed to have pressure ulcers, a significantly lower number than the previous year (Chisquare =5.28, p<.05). Similarly, the 64 pressure areas which were noted and staged were significantly lower than the previous year (Chisquare = 5.60, p< .05). Twenty-eight of the patients had one ulcer, 15 had two, and 2 had three. Eleven of the patients admitted within 6 months of the survey had pressure ulcers upon admission, an admission ulcer rate which was equivalent to the previous year (Chi-square = .06, p = .80). Similar to the first survey, the most frequent pressure ulcer location was in the coccyx/sacrum area.
There was no significant relationship found between gender and skin integrity (Chi-square = .07, p = .79). Neither sex was more likely to develop pressure ulcers. However, a strong but nonsignificant relationship was found between age and skin integrity (Chi-square = 3.38, p = .06), where 26% (n = 37) over 65 years of age had pressure sores, as opposed to 13% (n = 8) under 65 years of age.
In order of observed frequency, patient activity restricted to the bed or chair was 82% (n = 160), limited limb mobility was 81% (n = 157), and incontinence was 71% (n = 138).
Unlike the finding in the first survey a significant proportion of patients who had pressure ulcers where immobile (Chi-square 11.26, p<.01). Similarly, a strong but nonsignificant relationship was found between pressure ulcers and both incontinence (Chi-square = 3.50, p = .06), and activity (Chi-square = 3.50, p = .06).
The prevalence survey conducted prior to the implementation of the WSCT indicated a prevalence rate equivalent to what has been noted in extended care settings in Canada (Foster, 1992). The second prevalence survey recorded both a significantly lower number of pressure ulcers and a lower number of individual patients who had pressure ulcers one year after the WSCT education initiative.
The decrease in the prevalence of pressure ulcers after the development of the WSCT initiative suggests that this approach to wound-care management is a valuable model for use in the development of effective strategies for prevention and treatment of pressure ulcers. These findings are consistent with what has been reported elsewhere in the literature on the contribution of wound and skin education (Arikiaon, 1990; Moody, 1988). It was of interest to note that in the second survey, unlike the first, strong associations were found between pressure ulcers and risk factors associated with pressure ulcers including limited patient mobility, incontinence, inactivity, and age. This observation suggests that over the course of the year, the quality of skin care that patients received improved and that patients who were not at risk were receiving the care they needed to prevent ulcers.
As wound care is a topic "near and dear" to nurses, the monthly inservices provided by the WSCT were well attended. Team representatives made a special effort to send a replacement from their units when they were unable to attend. Each month at least one representative or alternate was present from each of the six units. While no formal staff evaluations of the inservices were conducted, informal reports from the nursing staff indicated an increase in the confidence to manage pressure sores, as well as to advocate for necessary treatments.
The clinical implications of a WSCT education initiative are apparent; it worked by increasing nursing staff awareness of effective prevention and management strategies of pressure ulcers. In the case at St. Mary's, the interest and enthusiasm that the nursing staff demonstrated by their regular attendance and participation in monthly meetings kept wound care and ulcer prevention a topic of interest and discussion on the nursing units.
While the analysis in the present study is associative in nature, the study conditions encourage an interpretation where changes in the prevalence of pressure ulcers were due to the WSCT initiative. A large proportion of the patients surveyed constituted a stable group in long-term care. The presence of a stable group encourages the interpretation that prevention and wound-management strategies contributed to the decrease in the ulcer prevalence between the two surveys. The decrease in the prevalence of pressure ulcers contributes to the significance of a WSCT education initiative in promoting effective prevention and management strategies of pressure ulcers.
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- Fowler, E. Chronic wounds: An overview. In D. Krasner (Ed.), Chronic wound care: A clinical source book for health care professionals. King of Prussia, PA: Health Management Publications, 1990, 12-18.
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- Moody, B., Sanale, M., Thompson, D., Vaillancourt, D., Symonds, G., Bonasoro C. Impact of staff education on pressure sores developing in elderly hospitalized patients. Arch Intern Mcd 1988; 2241-2243.
- National Pressure Ulcer Advisory Panel. Pressure ulcer prevalence, cost, and risk assessment: Consensus development conference statement. Decubitus 1989; 2(2):24-28.
- Powell, J. W. Increasing acuity of nursing home patients and the prevalence of pressure ulcers: A ten year comparison. Decubitus 1989; 2(2):56-58.