Pressure Ulcer Prevalence

and Incidence
Measurements: What, When
and Why?
Jan Weststrate RN, PhD
Research Fellow
Graduate School of Nursing Midwifery and Health
Victoria University
Wellington
jan.weststrate@vuw.ac.nz

The views expressed in this article are not necessarily the ones held by the New Zealand Wound Care Society 1
Introduction

Pressure ulcer (PU) development is becoming a real threat to the considerable

advances made in medical science over recent years. Nowadays more diseases can
effectively be treated or managed improving both quality and quantity of life to
patients whom 20 years ago would not have survived. A real threat to this trend is the
development of complications during their rehabilitation time, (un)related to the
disease or illness for which they were admitted (adverse events). A US national report
“To Err is Human” highlights that preventable adverse events are a leading cause of
death (Kohn, Corrigan et al. 1999). It is estimated that between 44.000 and 98.000
patients die in the US each year as a result of preventable medical errors. These
results have triggered governments around the world to investigate if these figures are
also representative for their national healthcare institutions. In the Netherlands, with a
population of 16 million, it has been estimated that 6000 patients suffer each year with
preventable unintentional healthcare complications of whom 1735 die (Wagner and
De Bruijne. 2007).

Pressure ulcer development is a preventable adverse event. In the Netherlands it has

been calculated that 243 people die each year where the development of a PU is the
primary cause of death (Halfens, Schoonhoven et al. 2007). Prevalence studies have
shown that between 12% and 18% of hospitalized patients have a PU and for the
community this figure was 8.4% (Halfens, Meijers et al. 2007). US figures also show
an increase in the number of patients discharged from hospital with a PU. In 1994 this
was 17 patients per 1000 discharges. This increased to 26 discharges in 2004.

Pressure ulcer development is not only bad news for the patient, but also for the
nursing staff and for healthcare economics in general. It is estimated, the presence of a
PU increases the nursing workload by 50% (Clarke, Bradley et al. 2005). As pressure
ulcer wounds develop, wound dressings are needed in addition to other expenses such
as specialist support surfaces all adding extra and significant expenditure to the
already stretched healthcare budget. A study in the Netherlands estimated that a grade
4 pressure ulcer wound cost 148-262 US dollars per day (Severens, Habraken et al.
2002).

The views expressed in this article are not necessarily the ones held by the New Zealand Wound Care Society 2
Generally it is accepted that 95% of the PU’s that develop can be prevented (Audit
commission.1995). Therefore in many countries with advanced healthcare systems
the Ministry of Health or similar governmental body requires each healthcare
institution to provide data on PU prevalence on an annual or more frequent basis.

Methods

Point prevalence is the method that is used for measuring the presence of PU’s. This
requires that on a pre-determined day, all patients in the healthcare institution have
their skin integrity checked by trained staff for PU’s. The number of people with any
sign (grade 1-4) of a PU is then calculated against the total population in the
healthcare institution. The result is a percentage that reflects how many patients with a
pressure ulcer were present in the institution on that particular day.

However, the question arises if the results from PU point prevalence studies
effectively inform healthcare institutions about their standard of care in this area. Only
after 8 consecutive years of PU prevalence studies in the Netherlands did a general
decrease in PU prevalence become evident (Halfens, Meijers et al. 2007). If it takes
that long to change practice maybe prevalence is not the only method that should be
utilised. Often the problem is not the high PU prevalence but the reason why this is
occurring. Only a change of practice is able to solve the problem. But which practice
needs to be changed cannot be revealed solely by the results of a prevalence study.

In 2005 the European Pressure Ulcer Advisory Panel (EPUAP) produced a statement
about monitoring the prevalence and incidence of PU’s (Defloor, Clark et al. 2005).
Table I shows the characteristics served by prevalence and incidence. From this table
it is evident that prevalence studies are mainly designed to get an insight into the
magnitude of the problem and if staff are following guidelines. Incidence on the other
hand does all this but is also able to gain insight into what caused the PU’s to
develop. Therefore if institutions want to know what the cause of their increased
prevalence is, measuring the incidence is the thing to do.

The views expressed in this article are not necessarily the ones held by the New Zealand Wound Care Society 3
Table 1. Different purposes served by prevalence and incidence (Defloor, Clark et al.
2005)
Prevalence Incidence
Gain insight into the magnitude of the Gain insight into the magnitude of the
problem of pressure problem of pressure
Gain insight in the causation of
pressure ulcers
Planning for health resources and Planning for evaluation of health
facilities resources and facilities
Compliance with prevention and Compliance with prevention and
treatment protocols treatment protocols
Evaluation of effectiveness of
preventive measure and treatment

However the downside of measuring PU incidence is that it is a very intensive and

time consuming process. Therefore it should be carried out selectively. Less
demanding on these resources is a yearly PU prevalence study that can guide this
process if a closer look at the root cause of the problem is warranted.

How then should PU prevalence and incidence studies be conducted within healthcare
institutions in New Zealand?

Step 1

The first step is to participate in an annual ward/unit point prevalence study. Ideally
this should be done on one day within the whole institution. The clinical nurse
specialist for PU prevention and treatment often supervises the organization of such a
project. Attention should be given to the following:

• Patients should be informed in advance about the prevalence measurement and

what is expected from them. A letter with this information should be given to the
patient and/ or the family at least a day before. The patient always has the right to
refuse to participate. For a correct measurement, the numbers of patient that do
not want to participate should be known.

The views expressed in this article are not necessarily the ones held by the New Zealand Wound Care Society 4
• The point prevalence of PU is measured at ward/unit level. Data should therefore
be collected and analysed at this level. In order to be accurate it should be carried
out by two nurses of whom one is from another ward within the institution.
• Always remember that both prevalence and incidence are calculated upon the
number of people who have or develop pressure ulcers and not upon the number
of pressure ulcers they may develop! So a person who develops several pressure
ulcers over a period of time would only be counted once in calculations of
prevalence or incidence.
• Use a data collection sheet that is able to collect all the data that is needed. The
EPUAP has a minimal data collection sheet on their website (www.epuap.org)
which can be used for such purposes (EPUAP. 2002) .
• It is recommended to have a training session with the whole team involved in
performing the prevalence study. During this meeting the data collection
instrument is explained and discussed and pressure ulcer grading ability is
assessed. A tool called PUCLAS 2, available free from the EPUAP website
(www.epuap.org), can be used to check if team members are able to grade PU’s
accurately.
• On the pre set day of the PU prevalence study, two nurses assess the skin integrity
of every consenting patient present on the ward at a specific time. If there is any
disagreement about a patient assessment, a third nurse with advanced knowledge
in tissue viability would be required to decide. For each pair of assessing nurses, a
note is made of the number of instances this third person was required to make a
decision.
• On completion of data collection all information requires input into a
computerised database and the PU prevalence quality indicators are calculated for
each ward.

Step 2

The second step is to calculate the average point prevalence of grade 2 PU or higher
over the whole institution. This figure acts as a threshold. Wards/units that have a
higher PU prevalence compared to the average are selected for further investigation.

The views expressed in this article are not necessarily the ones held by the New Zealand Wound Care Society 5
If the threshold is set at grade 1, we might end up counting a large number of PU’s
that never develop towards a wound that needs treatment. On the other hand if we
decide grade 4 is the threshold we might come up with an artificially good result. For
quality assurance purposes it is effective to place the threshold at grade 2 or higher.
The rationale behind this is that a grade 1 lesion is considered to be a reversible grade
(Halfens, Bours et al. 2001). However, a grade 2 lesion is an irreversible situation
with a visible skin break and a wound that requires active treatment. Another issue in
relation to identification of grade 1 PU’s is that nurses make the most mistakes in
assessing them accurately (Beeckman, Schoonhoven et al. 2007) (Defloor,
Schoonhoven et al. 2006).

Point prevalence measures only what is present at one moment in time. So PU point
prevalence makes no distinction between patients who were admitted to the ward with
a PU or without a pressure ulcer. So it may well be that a ward/unit where the
prevalence figure is above the institutional average, admitted a number of patients
with an existing pressure ulcer(s) in the days before the assessment. In order to rule
this option out for those wards, the PU prevalence is measured during a period of 4 to
6 weeks on randomly selected days of the week. If the mean PU point prevalence is
still above the institutional average it is most likely this ward/unit has a problem in
preventing PU development. This observation justifies the undertaking of an
incidence study.

Step 3
If required, an incidence study should be performed on the specified ward/unit during
a period of 4 to 8 weeks. Depending on the speciality, patients may be assessed every
day (most hospital wards/ units), three times a week (long-term care) or once a week
(district nursing). The rule of thumb for this is the shorter the patient length of stay the
more frequently you have to assess in order not to miss out on any patients.
Data is collected on the following:
• Is the patient at risk of developing a PU as assessed by the nurse in terms of
yes or no
o Risk assessment scales can be used in this process but the outcome
may not necessarily be the same decision the nurse takes. This is due to

The views expressed in this article are not necessarily the ones held by the New Zealand Wound Care Society 6
 the poor predictive value of PU risk assessment instruments. The NICE
guidelines (Rycroft-Malone. 2001)suggest an assessment based on a
risk assessment scale and of the assessment of the nurse. If there is
discrepancy, the nurse makes the final decision about the risk
• What type of PU preventive measures are taken when the patient is lying down
and/or sitting?
o Only the preventive interventions that are described in the guidelines
are required. Recording of other preventive measures is optional as
they will not be regarded as effective in prevention of PU.
• Lastly we assess the PU grade at the locations that are typical for PU
development.

Data is gathered over the pre-determined period of time (ie daily, three times weekly,
weekly for 4-8 weeks) and the following indicators are calculated.
1. The number of patients developing a PU. A distinction can be made between
PU’s developed at the heel and other locations. This can be valuable as PU’s at
the heel can severely handicap patients.
2. The number of patients at risk receiving permanent (24- 48 hrs) adequate
preventive measures during lying and sitting. (Patients are at risk as identified
by the nurse and/or if the patient has a PU grade 1-4).
3. The number of patients with PU’s increasing in grade and/or becoming more
serious which requires adaptation of preventive measures.
4. The number of patients developing PU’s despite preventive measures.

By calculating the clinical indicators, hotspots (areas of high incidence) can easily be
identified. For example high levels of indicator # 2 can be interpreted as compliance
with guidelines and awareness of risk factors in patients by the nursing staff.
Education and managerial support in highlighting the requirement to utilise guidelines
appropriately are possible interventions in order to improve this indicator.
It is recommended that subsequent random audit be performed to monitor
improvement in this area. If indicator #4 exceeds the preset threshold, investigation of
the quality of the preventive interventions may be recommended

The views expressed in this article are not necessarily the ones held by the New Zealand Wound Care Society 7
Each indicator covers a critical area in the prevention of PU’s and assists staff and
managers to focus on the specifics requiring improvement. A more detailed
explanation in calculating the clinical indicator can be found in the article produced
by the EPUAP (Defloor, Clark et al. 2005).

Conclusion
PU point prevalence and incidence measurements are useful strategies in assessing the
current status of ward/unit performance in PU prevention. Each has a specific role and
function in assessing the quality of care given in this area. Prevalence measurements
should be carried out at least annually in every healthcare institution.
Following on from this, wards/units within healthcare institutions that have a low
performance should perform an incidence study in order to identify those factors that
are responsible. This again helps healthcare organisations to use their resources
effectively.

Preferably, a nation wide PU point prevalence should be carried out in New Zealand.
Such an incentive would identify the magnitude of the problem and guide the setting
of care priorities. Ideally results should be nationally pooled together and presented
anonymously. Preferably the Ministry of Health, as gatekeeper for the quality of care,
should stimulate such a procedure by supplying the necessary financial resources.
Outsourcing to a New Zealand university in to coordinate and analyse such a national
project is the best option as this guarantees an objective scientific rigour to the project
that is essential in order to make meaningful decisions that ultimately will benefit the
patient, the nurse and the organisation.

The views expressed in this article are not necessarily the ones held by the New Zealand Wound Care Society 8
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The views expressed in this article are not necessarily the ones held by the New Zealand Wound Care Society 9