The Effect of a Simple 3-Step Pressure Relieving Strategy for Preventing Pressure Ulcers: An Explorative Longitudinal Study From 2002-2011

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.^1,2 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.³ Severens et al⁴ 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.⁴ 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.⁵ 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.⁴

  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.⁶

  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.⁶ 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.^7-10 If this measure does not meet the needs of the patient, use of an alternating mattress is advised.^4,9 When using another type of mattress, additional repositioning must be taken in consideration.^7-9

  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.¹¹ 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,¹⁰ 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,¹¹ 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^12,13 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.¹⁰

  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,¹⁰ Van Leen et al,^12,13 and Sideranko et al,¹⁴ 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:
    1) 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?
    2) 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?
    3) 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?

Design of the study. This study aimed to investigate the effect of a 3-step prevention protocol. Longitudinal data was collected starting in April 2002. The study followed a longitudinal design with annual measurements (2002-2011) of the nosocomial PU prevalence and the use of preventive measures. An annual comparison with figures from the national nursing home sector was also made.

  Participants. The participants were all patients at risk of developing PUs (Braden ≤ 20) in the Avoord Zorg en Wonen nursing homes. In the Netherlands, all patients living in nursing homes participate in the LPZ without need for specific informed consent. The medical ethical committee of the Maastricht University decided, in cooperation with the government, that specific consent is not necessary for collecting this data. In practice, the authors inform their patients that they collect the data by a yearly letter. All patients at risk of developing PUs in Dutch nursing homes who participated in the annual LPZ measurements were also included in the study, with the exception of patients who received palliative care, short term rehabilitation, or who stayed in the nursing homes for less than 30 days.

  Instruments. Data about gender, age, prevalence of PUs, type of mattress, and repositioning were derived from the LPZ measurements from 2002 to 2011. The LPZ uses a standardized questionnaire to register data on matters such as the risk of and the prevalence of PUs, and the preventive and therapeutic measurements undertaken in daily PU care, including the type of preventive mattresses used. The risk of PUs is measured with the full Braden scale score.¹⁵ Braden scores range from 1 to 4 based on 6 items concerning sensory perception, moisture, activity, nutritional intake, and friction and shear. The maximum score is 23 (no risk at all). A score lower than 20 indicates the patient is at risk of PUs.¹⁶ The original PU grading system of the EPUAP was used to classify the PUs.^4,9

  Overall cost was calculated using the mean price of a leasing contract for the 7 most commonly used alternating mattress systems; the actual cost for the static air overlay mattresses was used. Prices for leasing alternating systems ranged between €7 and €16 per day. Based on information gathered by the authors from 4 large companies that lease 80% of the alternating mattress systems in the Netherlands, a mean price of €10 per day was used for the cost estimation. Static air mattresses are not available for leasing in the Netherlands, and the cost per mattress was €175. The authors’ experience with the static air overlay mattresses shows that 1.4 mattresses are generally needed per patient each year. The mean cost for 100 patients was calculated.

  Interventions. In 2002 patients at the Avoord nursing homes all received a visco-elastic foam mattress as a standard prevention measure. In January 2005, the new 3-step model (ie, basic visco-elastic foam mattress, static air overlay, repositioning) was introduced. The nursing staff was trained and subsequently coached by a specialist wound nurse for 3 months.

Statistical Analysis
All statistical analyses were performed using the statistical package for social science version 20.0 (IBM SPSS Statistics for Windows, Armonk, NY). Logistic regression analyses were used to test the differences in the prevalence of pressure ulcers developed in the Avoord clinics and in the other participating nursing homes.

As shown in Table 1, there is a large fluctuation in the number of patients who participated in the LPZ at a national level. This is largely because of the voluntary nature of participation in the LPZ and because not all nursing homes participated during the whole study period. The increase of Avoord patients is based on its organizational increase of available beds. As shown in Table 1, the mean age of the participating patients was approximately 80 years, and there was no statistical difference between the participating patients at a national level and those residing at the Avoord nursing homes.

  The results of the national nursing home sector show a linear reduction of the nosocomial prevalence of category 2-4 PUs from 8.7% in 2005 to 3.7% in 2011 (Table 1). After the introduction of the new 3-step model at the Avoord nursing homes in 2005, the PU nosocomial prevalence dropped to 0.5% within 1 year. This level was maintained at a rate of between 1.2% and 2.6% (category 2-4) throughout the rest of the study period. In the period since the implementation of the new 3-step protocol in 2005, the PU prevalence rate has been significantly lower in the Avoord nursing homes than in the overall national nursing home sector.

  Although the national PU guidelines recommend that patients should be repositioned, this is not a standard procedure in Dutch nursing homes, as shown in Figure 1. The national annual data show a small fluctuation in repositioning percentages between 10% and 17%. The data from Avoord nursing homes show a decline from 22% in 2005 to 7% in 2006, and a trend of stabilization in the years following that.

  Figure 2 shows data for the most commonly used types of mattresses for patients who did not receive enough pressure relief from a visco-elastic mattress and/or repositioning, a standard measure in the current national guidelines.⁷ In Dutch nursing homes during the study period, an average of 11.7% (ranging from 9.7%-14.3%) of the patients at risk received an alternating mattress and 9.2% (ranging from 6.8%-12.4%) a static air mattress, indicating that about 20% of the patients received these 2 types of additional mattresses (alternating or static air) for extra PU prevention. Comparable data for the Avoord nursing homes show an average of 2.3% (ranging from 0.4%-5.4%) received alternating mattresses and 13.1% (ranging from 0%-25.4%) received static air mattresses in addition to a visco-elastic foam mattress. This means that 15.4% of the patients received these 2 types of mattresses. Differences in the use of alternating systems and static air overlay mattresses between national and Avoord nursing homes were all significant (P < 0.001).

Figure 3

The main aim of this study was to evaluate the clinical efficacy of the introduction of the 3-step PU prevention protocol in Avoord nursing homes. The results showed a sustained decrease of PU prevalence after the implementation of the new protocol, which indicates the effectiveness of the 3-step protocol. However, a prospective and randomized incidence study is needed to confirm these results. The data from the national nursing home sector also showed a decline in PU prevalence, but was less pronounced than in the Avoord nursing homes. This can be explained by the growing attention for PU prevention in the Netherlands over the past decade.

  The 3-step protocol also resulted in a decrease of repositioning from 22% to 7.8% in the Avoord nursing homes.

  Patients are generally repositioned to reduce the duration and magnitude of pressure on vulnerable areas of the body and also to contribute to comfort, dignity, and functional ability.⁴ However, repositioning is very expensive for nursing homes because almost 50% of the patients in the authors’ clinics who are repositioned have to be turned by 2 people. The task of repositioning patients also causes a considerable physical burden on the nurses and often interrupts patients’ privacy and causes them discomfort (interruption of daily rhythm and sleep).

  Current guidelines still incorporate repositioning as an essential and ethical preventive measure. In addition, a relevant question remains whether there is enough evidence-based data to make repositioning a standard measure. Defloor,¹⁰ Vanderwee,¹⁷ and Moore et al¹⁸ showed that even when 100% of patients are repositioned and receive a visco-elastic foam mattresses, 9%-16.4% still develop a category 2 or higher PU.

  The prevalence data from Avoord nursing homes show that after the 3-step PU prevention protocol was introduced, repositioning declined to 7.8% from 2006 to 2011, and only 2% of the participating patients had a category 2 through 4 PU on the days of measurement. Based on 2 earlier studies in the same population that led to the introduction of the 3-step protocol, the authors decided that in this protocol, standard repositioning combined with a high quality mattress was not basic prevention.^12,13

  Figure 1 clearly shows that repositioning is not always used for patients at risk in the Netherlands and that, as a result of the 3-step protocol, repositioning was used significantly less in the study nursing homes than in other nursing homes from 2006 on. This may imply that not all patients need repositioning for prevention of PUs. This study also reveals that using the 3-step protocol (with repositioning only taking place in step 3) may lead to a considerable improvement of PU prevalence.

This study had a number of limitations. Because the methodology involved a prevalence study, no causal conclusions could be made. Unfortunately, no incidence data are available in Dutch nursing homes concerning nosocomial PUs, so to monitor the effect of the 3-step protocol the authors chose to use data from the annual LPZ, which follows an internationally accepted methodology.¹⁹ Furthermore, only the Avoord nursing homes used the integrated prevention strategy (3-step protocol). No information was available on whether specific prevention strategies were used by the other Dutch nursing homes that participated in the LPZ; it was only known that these nursing homes followed the national guidelines.

  Nevertheless, this study indicates that, thanks to the prolonged measurements over the period 2006-2011, the 3-step strategy may be more effective than the prevention strategy based on the 2002 national guidelines. Also, no revisions have been made to prevention strategies in the most recent national guidelines on PU prevention, based on the guidelines of the NPUAP/EPUAP since 2002.^4,20 There are no changes in the strategy of prevention in later guidelines and all the preventive strategies in this study are based on the 2002 guideline.

  The 3-step model uses the total Braden scale score. For the best chance of detecting all patients at risk, all patients with an overall score of less than 20 were included.15 A limitation of using a score of less than 20 is the fact that patients who are more active or mobile may be included as being at risk, which may introduce some bias to the data. Coleman et al²¹ suggests that using specific items from the scale concerning activity and mobility might provide a better risk score. Although in theory the main cause of a PU is pressure, and PUs cannot develop without pressure, the development of PUs in real-life conditions is much more complicated. Other factors, such as malnourishment and sensory perception, also play a role. For instance, a malnourished patient with no mobility or activity limitations can develop a PU when the patient’s sensory perception is limited, resulting in not enough position changes overnight. The Dutch guidelines therefore recommend the use of the full-scale score.

  A final limitation in this study is that the calculation of costs is based on the costs of measurements taken during the day. A prospective cohort study is needed to give a more reliable statement of costs.

  The overall conclusions of this study show the implementation of the new 3-step prevention protocol in the Avoord nursing homes resulted in a sustained reduction of the prevalence of PUs; a considerable cost reduction in the use of preventive mattresses when not following the national PU guidelines (which may be followed at the discretion of individual facilities); and a considerable reduction of the workload for the nursing staff because fewer patients need repositioning with a secondary cost reduction resulting from a safe decrease of the application of repositioning.

Affiliations: Martin W.F. van Leen, MD is from Avoord Zorg en Wonen, Etten-Leur, the Netherlands; and Faculty of Health, Medicine and Life Sciences, Caphri/Department of Family Medicine, Maastricht University, Maastricht, the Netherlands. Jos M.G.A. Schols, MD, PhD is from the Faculty of Health, Medicine and Life Sciences, Caphri/Department of Family Medicine, Maastricht University, Maastricht, the Netherlands. Steven E.R. Hovius, MD, PhD is from the Department of Plastic Surgery, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands. Ruud J.G. Halfens, PhD is from the Faculty of Health, Medicine and Life Sciences, Caphri/Department of Health Services Research, Maastricht University, Maastricht, the Netherlands.

Address correspondence to:
Martin W.F. van Leen, MD
martin_van_leen@zonnet.nl

Disclosure: The authors disclose no financial or other conflicts of interest.