Pressure Ulcers
As part of an analysis of the effectiveness of existing medical services (the ’126 list’), a Health Council committee evaluates in this advisory report the current level of knowledge with regard to pressure ulcers. Pressure ulcers (also known as pressure sores or bedsores) are degenerative changes in the skin and underlying tissue which are caused by pressure, shear or friction, or a combination of these forces. Whether — and in what stage — pressure ulcers form, is also dependent on patient-related factors. The most important of these are: age, neurological condition, dietary status, blood circulation and how moist the skin is.
A recent nationwide prevalence survey in the Netherlands revealed the prevalence of pressures sores to be 14 per cent among patients in university hospitals, 20 per cent in general hospitals, 29 per cent in residents of nursing homes and 12 per cent in residential care homes. In the home-care setting, a prevalence of 17 per cent has been established. The committee estimates the annual direct costs of pressure sores in the Netherlands to be at least NLG 1 billion. This is more than one per cent of the total cost of health care in 1998.
The committee notes that the level of knowledge about pressure ulcers is meagre. The lack of results from proper scientific research is especially marked with regard to wound care and anti-pressure ulcer devices. Also, it remains unclear whether the use of risk assessment scales in the current way leads to appropriate care for pressure ulcers. Nevertheless, clear guidelines have been established, based on the current level of knowledge. The committee endorses these guidelines.
Several Dutch studies have revealed that the measures taken to combat pressure ulcers vary greatly. Compliance with existing guidelines is inadequate. It is not always possible to prevent pressure ulcers, but the prevalence figures can be reduced. This applies especially in relation to general hospitals and nursing homes. The committee therefore also advocates that such institutions should employ nurses specifically trained for pressure-ulcer management (’pressure-ulcer consultants’).
According to the committee, one of the reasons why existing guidelines are not always followed is the lack of knowledge about pressure ulcers on the part of (district) nurses, general practitioners and specialists. Pressure ulcer management deserves more attention both in basic training and in the context of further training and postgraduate courses.
Secondly, pressure ulcers are seldom viewed as a major problem in institutions. It is frequently unclear who is responsible for the management of pressure ulcers, with the quality of care often depending too much on an individual, motivated care-giver. Frequently this person neither has the time nor the overview to consider which devices are the best in any given case.
As its third point, the committee notes the problems associated with research into the effect of interventions. There is a great deal of variation in the measurement of wound healing and of the pressure-reducing effect of mattresses and cushions. Consequently, research results are difficult to compare and interpret. There is a need for well-designed, patient-based research into the effectiveness of these devices. What is important here is uniformity with regard to measurement procedures, outcome measurement and the staging of pressure ulcers. A system is required — as is proposed before in the Netherlands — that would allow for an evaluation of the quality and effectiveness of anti-pressure ulcer devices: i.e. a quality mark for anti-pressure ulcer devices.
The committee advocates the following three parallel approaches to training: the training of ’pressure ulcer consultants’ within the nursing profession and a greater emphasis on pressure ulcers both in the basic training of nurses and doctors and in the further training and postgraduate training that is given to qualified care-givers. What is needed in order to achieve this is a coordination point around which a network of knowledge about pressure ulcers can be organised. Here, information from real-life situations and from scientific research would be gathered at national level, analysed and exchanged with the training colleges. It would be possible to link up with the initiatives that have been set in motion by the National Pressure Ulcer Steering Group in association with the National Institute for Health Promotion and Disease Prevention (NIGZ). In collaboration with this coordination point, pressure ulcer consultants can coordinate the dissemination and implementation of knowledge and pressure ulcer management at an institutional level.