New advances in pressure ulcer prevention and management: an Australian perspective
09/02/10 | Pressure ulcers, Service development and delivery, Skin integrity | Keryln Carville
This short report describes how innovative research helped to standardise data collection for pressure ulcer prevalence in Australia. Adoption of this approach and the implementation of national guidelines in 2001 led to reduced pressure ulcer rates and to several state-wide prevalence surveys. New data collection tools, including the use of mobile phone technology for immediate centralised analysis, and the implementation of new interactive initiatives such as the WoundsWest Education Program will be discussed.
Page (1) Points
- International benchmarking data on pressure ulcer prevalence and incidence can help to raise awareness and reduce PU occurrence
- Although an increasing number of international health services are gathering data, there is a lack of consensus around the methodology employed leading to benchmarking difficulties
Key innovations in Australia
- Standardising a methodological approach to benchmarking
- Using mobile phone technology to collect pressure ulcer data
- Introducing an online wound management education programme.
"There is an immense amount of zinc rubbing but I have not met with a single observation as to whether there was a danger of bed sores"
(Florence Nightingale, 1881) 
Miss Nightingale's observation on reading the nurse probationers' diaries was indeed prudent and ahead of contemporary thinking. It was not until 80 years later that health professionals, and nurses in particular, were using risk assessment tools for predicting pressure ulcers . It proved to be as equally long before a scientific approach was adopted to ascertain the physiology of pressure ulcer formation and determine the best evidence for their prevention and management.
This report focuses on the developments in Australia that have contributed to implementation of national guidelines, an interactive online educational programme and the use of mobile phone technology to facilitate accurate data collection and immediate remote analysis of data.
HISTORY OF PREVALENCE STUDIES IN AUSTRALIA
The first published study on pressure ulcer prevalence in Australia appeared in 1983, when the comparative prevalence rates of two hospitals were reported . An increasing number of surveys were conducted during the 1990s, but there were discrepancies in the methods employed to collect data . These discrepancies were mainly found in the testing methods, including the tools used, the pressure ulcer education provided, the inter-rater reliability testing, the populations surveyed, skin inspections versus documentation audits, the staging systems employed, and the endpoints .
International benchmarking data on pressure ulcer prevalence and incidence has the potential to contribute to positive outcomes in the prevention of these debilitating wounds. However, while an increasing number of international health services are gathering such data, the opportunity for effective benchmarking is being lost because of a lack of consensus around the methodology employed.
Page (2) Points
- The innovative work of Dr Prentice has helped to standardise the approach to pressure ulcer prevalence data collection
- This led to state-wide surveys using Prentice's methodology. Over time there was a significant reduction in pressure ulcer occurrence
Standardising a methodological approach to data collection
In 2000, Prentice's PhD research did much to standardise the approach to pressure ulcer prevalence data collection in Australia . Prentice conducted a prospective quasi-experimental study in 10 tertiary hospitals across the country, which involved pre and post tests of the staff's pressure ulcer knowledge.
Prevalence surveys were also conducted in five of these hospitals and involved inter-rater reliability testing of the surveyors/data collectors and a skin inspection of all consenting patients. Baseline measures were then compared with the results of further prevalence surveys, which were conducted six months later following the implementation of the Australian Wound Management Association's (AWMA) Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers . This study demonstrated that the implementation of an education programme and the AWMA guidelines could reduce pressure ulcer rates, as the prevalence went down to 22% (p<0.002) from 26.5% at baseline [4,6].
Due to the success of this study, Prentice's methodology, data collection tools and protocols were subsequently adopted by the Health Departments of Queensland, Victoria, South Australia and Western Australia and used to conduct extensive surveys. Individual healthcare agencies also adopted this method and one effectively demonstrated its suitability in a community setting .
Another group of researchers demonstrated the effectiveness of Prentice's methodology when they conducted a multisite study across 23 nursing homes in four states and a population of 1,956 residents, and demonstrated a reduced prevalence of pressure ulcers in elderly care facilities .
The advantages of standardising a methodological approach for prevalence studies conducted in Australia have facilitated agency and national benchmarking as well as across different care settings.
State-wide prevalence surveys
The Victorian Quality Council (VQC) used Prentice's methodology to conduct state-wide public hospital pressure ulcer prevalence surveys in 2003 (PUPPS 1), 2004 (PUPPS 2) and 2006 (PUPPS 3) . The VQC surveys demonstrated a gradual reduction in pressure ulcer prevalence in public hospitals from 26.5% in 2003, through to 20.8% in 2004 and 17.6% in 2006. This represented a significant overall reduction of 33% in the number of patients who developed pressure ulcers in the state. In addition, the 2006 survey revealed a 25.1% increase in the use of a risk assessment tool (RAT) and a 22.3% increase in the use of pressure redistribution devices since 2003.
Further improvements included the routine documentation of pressure ulcers in patient records (86.7% of stage 3 and 87.5% of stage 4 ulcers); the use of existing protocols and policies (35.4% to 71.3%) and the availability of patient literature and mattress replacement programmes. However, two-thirds of pressure ulcers proved to be hospital-acquired and this figure remained relatively unchanged across all of the surveys .
The use of Prentice's methodology and tools resulted in similar successes by WoundsWest in Western Australia (WA). WoundsWest is an initiative of the Ambulatory Care and Chronic Disease Management Reform Program and is run in partnership with the Western Australian Department of Health, Curtin University of Technology and Silver Chain Nursing Association. WoundsWest conducted state-wide prevalence surveys of all wounds that involved conducting skin inspections and documentation audits in all 86 public hospitals across WA in 2007, 2008 and 2009 [10-12].
Page (3) Points
- New data collection tools include the use of mobile phones with smart technology to record data electronically for immediate analysis
- Results from the state-wide surveys led to a number of initiatives including an online wound management programme
Introducing mobile phones for electronic data collection
Mobile phones were used by WoundsWest to allow surveyors to record data on every wound found during the three consecutive state-wide wound prevalence surveys. This innovative paperless data collection method used smart phone technology and ComCare™ Mobile, which had been developed and provided by Silver Chain and previously used by community nurses to record and upload wound assessments and management plans at the bedside. During the surveys, wound locations were plotted on a human outline ('digiman') on smart phone screens using ComCare™ Mobile technology (Fig 1). The data was then uploaded and accessible immediately for remote analysis.
Fig 1. ComCare™ Mobile on smart phone used for data collection.
Wounds were broadly categorised as acute (surgical and trauma), pressure ulcers, skin tears, leg ulcers, burns, malignant lesions and 'other' – the prevalence of all wounds was 49% in 2007, 48% in 2008 and 43% in 2009 [10-12].
Pressure ulcer prevalence was reported to be 11%, 12% and 9% respectively, which demonstrated a 33% decrease in pressure ulcers between 2008 and 2009. An increase of 44% in the number of pressure ulcer risk assessments performed was found when the data from 2007 data was compared to that from 2009 .
A pressure-redistributing device was found to be in situ in 21% more patients in 2009 as compared to 2007  and it was determined that 4,236 bed days were saved in 2009 due to the 6% reduction in hospital-acquired pressure ulcers, resulting in a significant saving to WA Health of $3.7 million .
INTRODUCING INITIATIVES THAT MAKE A DIFFERENCE
As a result of the WoundsWest surveys and the availability of reliable pressure ulcer data, new initiatives were implemented including:
- A mattress replacement and pressure redistribution equipment programme for public hospitals across the state 
- The distribution of patient literature on pressure ulcer prevention on admission 
- The WoundsWest Online Wound Management Education Program (see below).
An innovation in pressure ulcer education
Western Australia's WoundsWest Online Wound Management Education Program is a core component of the WoundsWest Project. It involves the interdisciplinary development of 16 online wound management education modules, which are designed to assist clinicians and health services to deliver best practice in wound management and reduce preventable wounds and adverse wound management outcomes.
Page (4) Points
- The WoundsWest Online Wound Management Education Program comprises a Core Module and evolving specialty wound modules
- There are plans to include a wellbeing and independence module in the online programme
The Education Module Framework (Fig 2) comprises a Core Module, which provides information on general wound healing, assessment and management principles and options. Initially, it was determined that specialty wound modules such as pressure ulcers, burns, skin tears, acute surgical wounds, traumatic wounds, plastics (skin grafts and flaps), leg ulcers, foot ulcers and malignant wounds were the modules most likely to be required. However, the 2007 WoundsWest Prevalence Survey identified a large number of wounds (61%) amongst obstetric patients  and it was deemed prudent to add a specific obstetric wound module, which would meet the specific needs of midwives and obstetricians.
Fig 2: WoundsWest Education Program
The module framework will also include a wellbeing and independence module, which will be developed to provide clinicians with expanded information, and health consumers with relevant information on nutrition, mobility, activity, pressure off-loading interventions and equipment (all modules are available online at no cost to the user (Figs 3 and 4) and can be accessed at: www.health.wa.gov.au/woundswest/education)
Fig 3: WoundsWest Pressure Ulcer Module
Fig 4: WoundsWest Pressure Ulcer Module: Support Surfaces
Page (5) Points
- The Australian Wound Management Association (AWMA) have established the Australian Pressure Ulcer Advisory Panel to review their evidence-based guidelines
- The guidelines will be presented at the AWMA meeting in March 2010 for external review
- The development of guidelines, including the recent NPUAP/EPUAP publication, can help to stimulate international debate and influence current clinical practice
DEVELOPING CLINICAL GUIDELINES
Over the past two decades guidelines for pressure ulcer prediction, prevention and management have emerged from a variety of international sources, such as the EPUAP and NPUAP. The benefits of such guidelines for practice, patients and practitioners are well acknowledged (see Clark M, 2009)
In 1996, the AWMA established a Pressure Ulcer Interest Subcommittee, which was charged with the task of developing evidence-based guidelines for the prediction and prevention of pressure ulcers. The impact of these guidelines, published in 2001  has improved patient care outcomes and reduced pressure ulcer prevalence nationally [4-9,12]. In 2007, AWMA began the task of establishing an Australian Pressure Ulcer Advisory Panel (APUAP) in line with similar international groups. The APUAP is currently reviewing and expanding the previously mentioned guidelines and plans to make these available in March 2010.
IMPORTANT INFLUENCES ON PRACTICE
A personal perspective
Reflecting upon what would be the most important sentinel paper or clinical experience that impacted on my practice with regards to pressure ulcer prevention or management, I feel that the influences have been many. I immediately call to mind the suffering of patients with extensive pressure ulceration, and the first time I saw limb sacrifice performed in order to use limb tissue to cover an enormous sacral pressure ulcer when all other means of tissue repair had been exhausted.
Similarly, my day to day practice has been affected by early research confirming that certain 'traditional' practices, such as the use of the rubber ring or water filled gloves  are damaging or of no benefit to patients. The development, publication and implementation of pressure ulcer staging tools [13,14,15] risk assessment tools and guidelines [2,5,14,15] have also had a major impact on my practice.
Data illustrating the implicit and explicit costs associated with pressure ulcers is another good stimulus for preventing pressure ulcers . There is little doubt, that extended lengths of hospital stay associated with pressure ulcers, especially those that are hospital acquired, cannot be tolerated in this current economic climate [10-12,16].
In addition, national and international pressure ulcer peak bodies exert an important influence through publications and conferences such as those hosted by the EPUAP and NPUAP. These in turn stimulate professional debate and examination of the evidence for practice change.
On 24-27 March 2010 the AWMA will host their biennial conference in Perth, WA and this conference will have a strong focus on pressure ulcer prevention and management. At this meeting the AWMA will also launch their updated guidelines for external review.
The APUAP are currently exploring the establishment of a pan-Pacific alliance of pressure ulcer organisations incorporating countries in the region. Their immediate goal is to work towards a pan-Pacific consensus on pressure ulcer guidelines, with the long-term vision of a worldwide alliance of pressure ulcer organisations and the development of internationally recognised guidelines. This would expand access to pressure ulcer literature in languages other than English, eliminate the need for overlapping guideline research and provide widespread access to guidelines for developing countries.
Keryln Carville RN, STN(Cred), PhD, Silver Chain Nursing Association & Curtin University of Technology, Western Australia
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