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Determining the Efficacy of a Pressure Ulcer Prevention Program by Collecting Prevalence and Incidence Data: A Unit-Based Effort
Pressure ulcer prevention falls within the domain of nursing practice. Skin assessment and care is taught as a fundamental part of all nursing education curricula. Nurses assess the patient's skin, develop a plan of care to maintain the skin's integrity, and provide the preventative interventions. They are the primary caregivers for inpatients at risk for developing pressure ulcers.
At the bedside, nurses note subtle changes in a patient's condition that often lead to prevention interventions.1 Physicians have only a limited training in the prevention of pressure ulcers.2 It follows then that preventing pressure ulcers is a fundamental caring/nursing activity.3,4
Many surveyors of the healthcare industry believe that the incidence of pressure ulcers can be reduced simpl0y if the primary skin care provider cares enough to deliver quality care.5 Surveyors often equate pressure ulcers with neglect. The parameter of pressure ulcer occurrence is included as a national indicator of excellence in nursing and as a significant healthcare value that a facility provides its customers.6, 7,8
Similarly, patient healthcare satisfaction scores are linked to the development of pressure ulcers. Consumers of healthcare hold institutions accountable for quality healthcare at a low cost. The average hospital incurs $400,000 to $700,000 in direct costs to treat pressure ulcers annually. Most of that cost is not reimbursable.9,10 It is estimated that 20 minutes/day/patient of nursing time is related to services for pressure ulcers.11 Institutions are charged with providing economical skin care. Nurses operationalize that charge.
Prevention Program Development and Implementation
In a 500-bed Midwestern hospital, a quality improvement (QI) monitor demonstrating an increase in pressure ulcers, linked with a review of 10 core indicators for excellence in nursing care that included skin integrity, propelled the development of a pressure ulcer prevention program.8,12 The interdisciplinary skin team, including unit-based leaders, started the effort during their monthly meetings by implementing the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention.6,7,12,13 These evidence-based guidelines limit variability in care and promote quality standards. The guideline provided the research base for risk prediction tools, support surfaces, skin care, ulcer classification, professional, and patient and family or caregiver educational content.
The skin team identified particular areas of concern: pressure ulcer assessment, documentation, and patient and staff education. During inservices for the nursing staff, the team outlined the prevention program, highlighting skin anatomy and function, use of the Braden Scale, the importance of turning and positioning, documentation changes, and the use of skin care products.
Measuring program effectiveness. During the development of the pressure ulcer prevention program, one of the biggest hurdles the team faced was developing goals and measuring outcomes. The literature supports identifying outcomes by collecting prevalence and incidence data.3,4,7-10,13,15 Prevalence data reflect patients admitted with ulcers as well as nosocomial pressure ulcers; the figure is calculated by dividing the number of people with an ulcer by the total number of people in the population of interest at that time.
Prevalence data provide a snapshot in time of the number of pressure ulcers in a given facility. An increase in prevalence may reflect an unusually high admission rate of those in the community most vulnerable to pressure ulcers, such as the elderly or disabled. Prevalence data are not a sensitive measure of nursing care within the facility. The best indicator of the effectiveness of prevention strategies to reduce nosocomial pressure ulcers is incidence data.10,13
Pressure ulcer incidence reflects the number of patients who acquire pressure ulcers while receiving nursing care; it is calculated by dividing the number of people developing new pressure ulcers by the total number of people in the population at the beginning of the time period.4 It is a more accurate and sensitive measure of nursing intervention.13
National reports such as the National Pressure Ulcer Advisory Panel (NPUAP) monograph reviewed prevalence and incidence studies from 1990 to 2000. The lowest reported acute care prevalence rate was 10.1% and incidence was 7%.15 The VHA Mid-American organization reports that < 4% is an "acceptable" incidence rate for acute care facilities (personal correspondence). The skin team set incidence as the measurable marker for reduction in pressure ulcers and efficacy of the prevention program.
The team began to collect prevalence and incidence (P + I) data by participating in the 1998 Novations/KCI National Prevalence and Incidence Study.10 This annual program provides an external benchmark that compares data from approximately 180 facilities and 24,000 patients. Because the average length of stay is 4.8 days in this institution, recording the incidence of pressure ulcers after a 5-day hospital stay is an appropriate timeframe that reflects nursing care.
Data are collected at the beginning and end of a 5-day time period. Prevalence is determined by noting the number of pressure ulcers found on day 1. Incidence is determined by noting the number of new pressure ulcers found on day 5.13 All patients who do not have a pressure ulcer on day 1 and remain hospitalized are reexamined on day 5.
The KCI/Novations Executive Summary, provided to participating institutions from results submitted during the study, is particularly useful to nursing administration, QI leaders in the institution, and the executive board. However, the team felt that a more frequent outcome measurement was needed. Effective nursing interventions affect incidence on a daily basis and need to be encouraged. Waiting 12 months to fix problem areas decreases daily accountability for skin care. Annual review also has a tendency to shift the focus to the "bad apple," labeling units instead of focusing on process improvement.14 Another obvious benefit of more frequent measurement is the opportunity to make changes that will improve care in a timely manner and facilitate teachable moments.14 For these reasons, the team began looking at internal benchmarking measures that compared the institution's data against its own past performance.16
In addition, routinely completing facility-wide P + I surveys is impractical, and chart reviews may be inaccurate. Stage I and Stage II ulcers are considered the most nurse-sensitive skin injury, and yet often they are not documented.10,13 Staff assigned to collect data must have accurate skin care assessment skills to correctly differentiate pressure ulcers from other skin injuries.13 Team members with those skills provided the most valid and reliable data. However, it is prohibitive for team members to participate in frequent day-long surveys.
Gathering monthly data. A mechanism to gather P + I data/unit/month was developed.7 Registered nurses on the committee go in pairs to units other than their own to survey the skin of 10 patients. Length-of-stay and Braden score on admission are used as criteria for choosing the patients to survey each month (see Figure 1). Beginning with criteria 1, the nurses choose as many patients who fit the parameters of length-of-stay and Braden score as possible, followed by criteria 2 through 4 until the sample size equals 10 patients. The number of pressure ulcers one patient may have is not a factor.
All pressure ulcer(s) found on examination of the patient's skin are noted. Admission documentation of a pressure ulcer(s) is used to determine whether the ulcer is included as prevalence data only or as both prevalence and incidence data. For example, if the ulcer(s) is documented on admission, it is included as prevalence data only. If the ulcer(s) is not documented on admission, it is included as prevalence and incidence data. The administration allows the nurse pairs 3 to 4 indirect care hours per month for data collection.
Because the nurses use a sample gathered in one 4-hour period each month, the traditional P + I equation was revised to reflect that not all nosocomial ulcer occurrences or patients admitted with pressure ulcers on each unit are included in the P + I data.
Prevalence = (Number of persons surveyed with a pressure ulcer(s) when admitted)/ [Number of persons surveyed (10)]
Incidence = (Number of persons surveyed developing a pressure ulcer(s) after admission)/ [Number of persons surveyed (10)]
Patients may be admitted with ulcers and discharged before the survey, or they may develop and resolve Stage I or even Stage II ulcers before the survey. Although probably an underestimate, this monthly survey provides data helpful to nurses concerned about quality nursing care.
Results of the P + I survey are disseminated monthly to each unit and quarterly to nursing administration and the QI committee (see Figures 2 and 3). Unit-based data help those with the highest incidence focus on prevention strategies. Nurses often "tune out" opportunities to attend conferences that could increase their knowledge base about skin care. They consider themselves competent and that receiving instruction on skin care education is an insult to their practice.2 However, sharing the personal, unit-based data serves to maintain awareness and heightens attention to skin care issues in a non-threatening manner, especially on units with elevated P + I rates.
For example, one unit with high incidence rates decided to use a turning clock to help staff routinely reposition the patient. Other units needed to stress the link between a low Braden score and implementing prevention strategies. Nurses are often more motivated to take pressure ulcer precautions based on visible damage due to pressure than to respond to the warning provided by the presence of specific risk factors.3,17
The survey format also encourages nurses to do a thorough skin assessment and documentation on admission. Using this survey tool, pressure ulcers not noted on admission may indicate an assessment or documentation deficit rather than a true reflection of a nosocomial pressure ulcer.10
Outcomes
Each unit is able to track its individual P + I data. Since this tracking mechanism was instituted, most units have decreased their incidence rate by 10% to 20% over baseline. The second annual KCI/Novations facility-wide survey demonstrated a decrease in incidence from 14% to 9% overall. The goal is to further reduce the incidence to less than 4%.
Efforts to maintain skin care awareness continue, highlighting prevention strategies based on the Braden scale. Creating unit-based skin care resource nurses from the members of the skin care committee is also a focused effort. Members are encouraged to attend wound-care conferences and bring skin care dilemmas and problems to the monthly meetings for discussion. Other agenda items include instruction by the enterostomal nurse on specific wounds such as diabetic and stasis ulcers. Vendors are frequently invited to demonstrate their products. Most committee members are the recognized unit authority on skin care; they say they are comfortable in that role.
Ongoing Challenges and Recommendations
High census and staff shortages continue to plague nurses' ability to provide quality care. Insufficient time often makes providing desired skin care an unnecessarily difficult challenge for staff. Attention to turning, positioning, and other prevention strategies is often delayed. Frequently, finding time to merely complete the survey is difficult for nurses from different units and shifts.
Maintaining awareness calls for creativity to keep the program fresh and applicable to daily nursing care. The key is to recruit nurses to the skin care committee who are interested in skin care and committed to decreasing the incidence of pressure ulcers on their units.
Developing unit-based skin care resource nurses also has proven to be a strategy that produces results. The nurses delivering the care can discuss skin care dilemmas at the unit level and devise a plan of care that is meaningful to them. Unit-based skin care resource nurses promote learning about skin care and prevention and treatment of pressure ulcers.
The major strength of the program is the monthly unit-based survey. The data are fresh and usable. Effective interventions and outcome data can be shared with nursing administration and QI staff in the institution. Units can set individual goals and compete against themselves or other units for improved incidence data. More importantly, collecting and sharing prevalence and incidence data clarifies the relationship between skin care assessment, documentation, early intervention, and outcomes.
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