PREVENTION OF PRESSURE ULCERS
Denmark
State of the art
AAR H U S U N I V E R S I T Y
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Background
Pressure ulcer
 Are caused by




Localised pressure ->
Deformation of skin and soft tissues ->
Distorting cells, reducing blood flow ->
Inducing ischemia and necrosis.
Takahashi M, Wounds International,
2010
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Background
what is going on?
Tissue distortion due to pressure
Roaf R, J Tissue Viability 2006
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Background
what is going on?
 Pressure and duration that
are likely to result in
tissue damage.
Takahashi M, Wounds International,
2010
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Background
Are pressure ulcers still a challenge in Danish Hospitals?
 Six resent Danish cross sectional, in hospital, studies have
shown a pressure ulcer prevalence of 14 – 66%
 More than 5% of these were category 3 – 4 ulcers.
 Nationwide this correspond to the use of ap. 1.500 manyears on treating pressure ulcers.
Bermark, S, vol2: 2010 EWMA J
Dumiel-Peeters I, 2006; J Clin Nurse
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Challenges
 Identifying persons at risk
 How, when, how often?
 How to monitor the frequency of pressure sores?
 Prevalence / incidence?
 Effective evidence-based prevention strategy?
 Clinical guidelines? Generic or disease specific
 Implementation of strategies
 How
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Challenges
 Adoption of the strategies (guidelines)
 Who is responsible?
 Education and equipment?
 How to maintain?
 Documentation of risk and preventive actions
 How?
 When?
 What is sufficient?
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art
Risk assessment = Identifying persons at risk
 Many different risk assessment instruments have been
develop and used during the past 20 years
 Their ability to indentify persons at risk of having
pressure ulcers have though not been convincing
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Pancorbo-Hidalgo PL et al. Journal of Advanced Nursing 2006; 54(1):94-110.
Schoonhoven L et al . Medical Journal 2002; 325(7368):797-800.
Seongsook RNJ et all. Journal of Nursing Studies 2004; 41(2):199-204.
Defloor T, Grypdonck MF. Journal of Clinical Nursing 2005; 14(3):373-382.
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art
Risk assessment = identifying persons at risk

Vogelsang AB, 2004, research
 Purpose
 To conduct a valid prognostic index/risk assessment instrument
(Adhoc)
 To evaluate the prediction validity of Adhoc versus the Braden
assessment scale
Vogelsang AB, Bladet SÅR, 2004
AAR H U S U N I V E R S I T E T
Aarhus University Hospital
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art: Risk assessment
Adhoc
 Considered at risk are only persons who are not selfreliant
 Exception: Persons with diabetes
 Score and risk category

0 point

1 - 4 points

5 - 8 points
 10 - 11 points
No risk
Low risk
Moderate risk
High risk
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art: Risk assessment
Adhoc
 State the degree of limitation in activity performance





0
1
2
3
4
NONE or negligible limitation
SLIGHTLY limited
MODERATE limited
STRONGLY limited
Activity CAN NOT be performed
( 0–
4%)
( 5 – 14%)
(15 – 49%)
(50 – 94%)
(95 – 100%)
 Do the person have both the ability and consent to
mobility?
 0
 1
 2
Yes
Yes, partly
No
AAR H U S U N I V E R S I T E T
Aarhus University Hospital
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art: Risk assessment
Adhoc
 Is friction reducing material used when moving or
repositioning the person?
 0
 1
 2
Yes
Yes, in average every second time
No
 Has the person been exposed to pressure at the same part
of the body for more than 1½ running hour during the
past 24 hours?




0
1
2
3
No
Yes, once
Yes, twice
Yes, more than twice
AAR H U S U N I V E R S I T E T
Aarhus University Hospital
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art: Risk assessment
Prediction
Risk at 1. registration compared to number of pressure ulcers at the 2. registration
AAR H U S U N I V E R S I T E T
Aarhus University Hospital
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art: Risk assessment
Prediction
 Braden vs. Adhoc
 Predicted presence of
pressure ulcers correctly
 Predicted absence of
pressure ulcer correctly
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art: Risk assessment
Conclusion
 If the high predictive validity for Adhoc could be repeated
in a new and independent population, Adhoc could be
considered a valid instrument to identify patients at risk
of developing pressure ulcer
 The result from this and other studies leads to the
conclusion that although the Braden scale predicts the
occurrence of pressure ulcers to some extent, routine use
of this scale has to be called into question
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art:
Monitoring frequency
 Up until now
 All Danish studies but one are prevalence studies
• We then do not know where and when the ulcers were produced!
• Do we really measure quality?
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art:
Implementation of strategies on equipment
 Mattresses
 Around 50% are placed on adequately pressure relieving mattresses
 No one knows when the patient actually was located on the
mattress.
 Cushions
 In average 30% of the patients are placed on adequately relieving
cushions
 Heal
 One hospital did practice this procedure, the rest did not.
Bermark, S, 2010 EWMA J
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Buttery J, 2010: EWMA J
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Conclusion:
Implementation of strategies on equipment
 Use of preventive equipment are insufficient and may be introduced
too late or perhaps not until the pressure ulcer is visible on the skin
 Conversely, the use is not reduced as the need for preventive action
decreases
 Even the most simple recommendations are inadequately
followed.
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
State of the art:
Documentation of risk and actions
 Preventive efforts
 We do not know the degree of documentation, but the percentage is
low
 Categorising pressure ulcers
 Less than 50% are registered in the nursing journal
 Treatment plan???
Bermark, S 2010 EWMA J
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Buttery J, 2010: EWMA J
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Conclusion:
Documentation of risk and actions
 Conclusion
 Planned preventive actions is rarely documented and evaluated.
 This all most certainly leads to staff spending to much time on the
same process.
 No one really knows if the most simple general recommendations
are follow
 The preventive effort is for certain not individualize corresponding
the individual patient risk.
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Future recommendations:
Prevention of pressure ulcers
 National guidelines should be defined and cleared
 Local instructions should be available on the intranet and
signed by the department leaders
 Learning programs should be defined and available on the
intranet
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Future recommendations:
Prevention of pressure ulcers
 Support/education should be well organized
 National indicators should be defined
 Audit should be made on:
 Pressure ulcer Incidence and Category
 Percentage of E-learning passed
 Percentage of patients placed on the right equipment at the right time.
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Future
”Forebyggelse af liggesår vha. standardiseret screeningsmetode og
sensorlagner”
 To ensure that appropriate preventive actions are
documented and provided to the right patient in time
 The effect of a simple implementation strategy will be tested in a
new Danish project.
 The interventions are based on a Danish clinical guideline
for prevention of pressure ulcer including “Adhoc”.
(Aarhus Universitetshospital Skeby, EWMA, OHMATEX) Projektleder Anne-Birgitte Vogelsang
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Screening og indsats
”Forebyggelse af liggesår vha screeningsmetode og sensorlagner”
SCREENING FOR
Risiko
Er personen oppegående og selvhjulpen?
1
0 Ja
1 Nej (Hvis nej eller diabetes, udfyld da resten af skemaet)
Selvhjulpen og oppegående
JA
Angiv dato
NEJ
2
3
Ikke yderligere tiltag
Angiv initialer
Screening for trykskade risiko og trykskader
Diabetes patienter skal
Foretages ved hjælp af screeningsinstrumentet ”Adhoc” .
screenes.
 Vanskelighed ved aktivitet generelt
Klokkeslæt
SCORE
 Vilje og evne til bevægelse
 Anvendelse af friktionsnedsættende hjælpemidler
 Eksternt tryk mere end 1½ samme sted på kroppen
 Trykskader og grad
1. Angiv graden af vanskeligheder ved udførelsen af aktivitet generelt.
INGEN eller ubetydelige aktivitetsbegrænsninger
0 – 4%
LETTE eller nogle aktivitetsbegrænsninger
5 – 14%
MODERATE aktivitetsbegrænsninger
15 – 49%
SVÆRE aktivitetsbegrænsninger
50 – 94%
Aktivitet kan IKKE UDFØRES
95 – 100%
0
1
2
3
4
4
Verifikation af risiko for trykskade
 Risikoscore 1 - 4 point
=
 Risikoscore 5 - 8 point
Lav risiko
=
Middel risiko
 Risikoscore 9 - 11 point
2. Har personen vilje og evne til mobilitet?
=
Høj risiko
0=
1=
2=
Ja
Ja, delvist
Nej
5
Lav risiko 1 - 4 point
3. Er personen ved stillingsændring og forflytning placeret på
friktionsnedsættende hjælpemiddel?
0=
1=
2=
Ja
Ja, i gennemsnit hver 2. gang
Nej
Ingen yderligere tiltag
6
7
Middel risiko 5 – 8 point eller trykskade
grad 1 - 2
Høj risiko 9 – 11 point eller trykskade
grad 3 - 4
1. Dokumenteret trykskadeforebyggende
skummadras placeres i patientens seng
1. Dokumenteret trykskadeforebyggende
low airloss eller (vekseltrykmadras)
placeres i patientens seng
De resterende handlinger er ens for middel og høj risiko patienter
2. Der anvendes friktionsnedsættende hjælpemiddel ved enhver forflytning og stillingsændring.
4. Har personen været eller vil personen blive udsat for tryk samme sted
mere end 1½ time i træk over 24 timer?
0
1
2
3
=
=
=
=
3. Der stillingsændres således patienten maksimalt er udsat for eksternt tryk, samme sted på
kroppen i 1½ time i træk.
4. I siddende stilling placeres patienten på trykskade forebyggende sædepude af skum.
Nej
Ja, en gang over 24 timer
Ja, to gange over 24 timer
Ja, mere end to gange over 24 timer
5. Mentalt bevidste patienter inddrages aktivt i egne forebyggende muligheder.
6. Ved trykskade oprettes individuel plejeplan.
Samlet point score
8
Fornyet screening hver 4. dag
0 point:
Ingen risiko
5 – 8 point: Middel risiko
24
8
eller ved ændring i tilstanden.
Risiko inddeling
1 – 4 point: Lav risiko
9 – 11 point: Høj risiko
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Effect parameters
”Forebyggelse af liggesår vha screeningsmetode og sensorlagner”
 Independent measurements of




Number of new pressure ulcers (incidence)
Degree of documentation
Staff time spent
Staff satisfaction
 Monitoring three times over a 4 weeks period :
1. Baseline
2. After education of the hole staff in: The screening method and
how pre-specified preventive actions should be performed
3. Added censoring seats, visualizing pressure in a time perspective
and added patient individual risk profile
25
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010
Succes criteria
”Forebyggelse af liggesår vha screeningsmetode og sensorlagner”






Time spent
Pressure frequency
Revalidated risk assessment “Adhoc”
Revalidated national clinical guideline
Cost Benefit analyses
User statements:
 Patient
 Staff
 Interested parties
AAR H U S U N I V E R S I T E T
Aarhus University Hospital, Skejby
Department of Cardiology
Anne-Birgitte Vogelsang, MPH, PhD-stud.
Stockholm 2010