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A Brief History of Pressure Ulcer Measurement in England: the Last 20 Years

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A Brief History of Pressure Ulcer Measurement in England: the Last 20 Years EDITORIAL A brief history of pressure ulcer measurement in England: the last 20 years ressure ulcers (PU) have long been Measuring pressure ulcers: recognised as a challenge to healthcare, are prevalence and incidence a cause of significant pain and distress for During this time, the most reported forms of Ppatients and are costly for healthcare providers measurement have been prevalence and incidence. in term of finances and use of human resource Prevalence is the proportion of a population (Guest et al, 2020). who have a specific characteristic in a given This paper, the first in a series of three, describes time period. Therefore, the prevalence of PUs is the predominant methods that have been used to the proportion of a defined patient population JACQUI FLETCHER OBE capture the prevalence of PUs in England over the with pressure damage during a specified time Clinical Lead Pressure Ulcer last 20 years. The second paper will describe the period. Incidence is the number of specified new Workstream National Wound proposed system for national PU measurement events, during a specified period in a specified Care Strategy Clinical Editor, Wounds UK in England and the third paper will outline population. Therefore, the incidence of pressure proposals for implementing this system to drive damage is the number of people in a defined quality improvement. patient population who develop a new PU during a specified time period. BACKGROUND Prevalence of pressure damage is a good Measurement of the occurrence of PUs (also indicator of the overall burden and clinical known as pressure sores, decubitus ulcers, workload related to pressure damage but does pressure injury and bed sores) has been a part of not identify when and where the PU occurred, nursing activity for many years. The first paper how long it had been present, probability on the epidemiology of what were then called of healing or the cost of care (International ANN JACKLIN pressure sores was published by Petersen and Guidelines, 2009). As incidence only identifies Lead for Digital, Data and Infor- mation Workstream, National Bittmann in 1971. These initial audits aimed to new occurrences within the specified time Wound Care Strategy, identify the size of the problem to focus efforts frame, it provides a measure of the quality of on reducing occurrence through implementing care and can be used to help identify possible the seminal work of clinicians such as Norton patterns relating to interventions such as quality et al (1962). Since then, there have been many improvement initiatives such as the introduction publications on this topic, seeking to identify the of new equipment or education (International number of PUs occurring in specific organisations Guidelines, 2009). (Barbenel et al, 1977; Stevenson et al, 2013) as Although there are many publications well as studies on specific populations such reporting the results of audits and similar studies, as intensive care (Chaboyer et al, 2018; Jacq unfortunately, these use a range of reporting et al, 2021), palliative care (Ferris et al, 2019), approaches and definitions. (Box 1; Fletcher, UNA ADDERLEY paediatrics (Delmore et al, 2020; Marafu et 2001). This lack of a consistent, systematic, Director, National Wound Care al, 2021), spinal injuries (Chen et al, 2020). Strategy Programme There have also been larger scale studies across Box 1. Examples of inconsistencies countries (Barrois et al, 2008, Gunninberg et al, • Data may be collected by reviewing patients notes, 2013), or continents (O’Dea, 1995; Vanderwee asking ward staff if damage is present or by inspecting et al, 2007; Moore et al, 2019). Recently, because patients’ skin for evidence of pressure ulcers. of the COVID-19 pandemic, studies have been • Some audits include category 1 pressure ulcers, others published reporting the pressure damage in do not. health professionals related to personal protective • Inclusion/exclusion of ‘avoidable’ pressure ulcers. equipment (Abiakam et al, 2020; Jiang et al, 2020). • Inclusion/exclusion of device related pressure ulcers. 14 Wounds UK | Vol 17 | No 2 | 2021 EDITORIAL and valid approach to data collection makes injury to patients and share many underlying meaningful comparison problematic, either within factors relating to fundamental patient care (e.g., or between organisations. mobility, medication management, nutrition, hydration). This QUIPP programme led to the Policy approaches to measuring development of a measurement tool – the NHS pressure ulcers Safety Thermometer and to the development of In the 1980s and 1990s, organisations began the Commissioning for Quality and Innovation to appoint specialist tissue viability nurses (CQUIN) payment framework (DH, 2010d) which and measurement of PU prevalence became enabled commissioners to reward excellence in increasingly common. Some organisations care delivery. undertook extensive audits, repeated annually, The NHS Safety Thermometer aimed to collect 6-monthly or even quarterly (Hibbs, 1988). These accurate nationally comparable data with low audits tended to focus on negative outcomes (e.g., burden to staff that could be used to support number of PUs, severity, size, location, and origin), quality improvement work (Power et al, 2016). but rarely captured information about clinical The Safety Thermometer was a voluntary system, care or concordance with key measures within but financial incentives meant that most NHS preventative care protocols (Phillips and Clark, organisations participated. Data collection was 2010). It was rare for audits to capture healing data undertaken locally on one specific day of each or for audit data to be linked with robust quality month by front line nursing teams, for all NHS improvement programmes so repeat prevalence funded patients. Anonymised data was then audits identified the same challenges year on year. uploaded to the national database, providing In 1993 the Department of Health (DH) a point prevalence of existing PUs, presented identified PUs as a Key Quality Indicator (DH, as the percentage of all in-patients with a PU 1993). As more and more organisations began to on the survey date. The data were presented as collect PU data, there was national recognition overall totals, by type of organisation (Hospital, that support was required to standardise and community, nursing home) and for each individual improve data collection practice. organisation. At best the Safety Thermometer In 1996, the European Pressure Ulcer Advisory information represented the prevalence of patients Panel (EPUAP) was founded with the aim of in the organisation with PUs on that given day. reducing the burden of pressure ulcers across The methodological limitations meant it was not Europe (https://www.epuap.org/organisation/) possible to capture incidence data. through education, research and by developing a Alongside Safety Thermometer reporting, minimum data set for PU prevalence monitoring organisations were encouraged to also report (Vanderwee et al, 2007). pressure ulcers via Incident Reporting Systems In 2010 the Department of Health classified (IRS) (such as Datix and Ulysses). The aim was PUs as an avoidable harm (DH, 2010a) and tasked to support the National Reporting and Learning organisations with reducing their frequency as System (NRLS) and NHS England’s web based part of the Quality Innovation, Productivity and serious incident management system, the Strategic Prevention (QIPP) programme (DOH, 2010b). Executive Information System (StEIS) for the The responsibility for PU prevention was placed reporting of serious incidents (SIs). squarely on the shoulders of nurses and midwives when PU prevention was included in the High Stop the Pressure Programme Impact Actions for Nursing and Midwifery To support the introduction of the Safety (DH, 2010c). Thermometer in 2011 the Stop the Pressure The QUIPP Programme covered four high-cost, programme was launched as a short-term high volume harms (venous thromboembolism regional initiative in the East of England (and (VTE), PUs, urinary tract infection in patients later the Midlands and East Strategic Health with urinary catheters and falls) selected because Authority) with a clear ambition to eliminate all they account for a large proportion of all avoidable avoidable category II, III and IV PUs by December Wounds UK | Vol 17 | No 2 | 2021 15 EDITORIAL 2012. The Stop the Pressure Programme (StPP) trust to trust comparisons of PU prevalence focussed on quality improvement using the Safety (Smith et al, 2016) and made recommendations Thermometer data to give a base line prevalence for improvement (Coleman et al, 2016). They figure for PU numbers. Organisations were concluded that the systems used to monitor PU invited to participate in quality improvement patient harm lack standardisation, are characterised collaboratives and resources were developed to by high levels of under-reporting and, despite their encourage standardisation of approaches. This limitations, have been unfairly used to compare and approach led to a significant reduction in the sometimes financially penalise trusts. prevalence of PUs from 5.59% in July 2012 to 4.4% In April 2020, following a public consultation in 2015 and 2016 (Power et al, 2016). as part of proposed changes to the NHS Standard The StPP workstream ceased in April 2012 with Contract, all data collection for the ‘classic’ the reorganisation of the NHS and dissolution Safety Thermometer and the ‘next generation’ of the regional Strategic Health Authorities but Safety Thermometers
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