Tracking quality over time: what do pressure ulcer data show?

Objective. To compare the prevalence of pressure ulcers and prevention before and after a quality improvement program; determine whether patient characteristics differed for those who did and did not develop pressure ulcers; identify pressure ulcer prevention implemented at admission and whether prevention and risk factors varied by pressure ulcer severity. Design. Descriptive comparative study based on two cross-sectional pressure ulcer surveys conducted in 2002 and 2006, complemented with a retrospective audit of the electronic health record and administrative system for patients identified with pressure ulcers. Setting. 1100-bed Swedish university hospital. Participants. 612 hospitalized patients in 2002 and 632 in 2006. Main outcome measures. Prevalence of pressure ulcers and prevention (pressure-reducing mattresses; planned repositioning; chair, heel and 30 degrees lateral positioning cushions). Results. Pressure ulcer prevalence was 23.9% in 2002 and 22.9% in 2006. When non-blanchable erythema was excluded, the prevalence was 8.0 and 12.0%, respectively. The use of pressure-reducing mattresses increased while planned repositioning decreased. Those who developed ulcers were older, at-risk for ulcers, incontinent and had longer length of stay. Little prevention was documented at admission. Some prevention strategies and risk factors were related to severity of ulcers. Conclusions. Pressure ulcer prevalence did not decrease, despite a comprehensive quality improvement program. Special attention is needed to provide prevention to older patients with acute admission. Skin and risk assessment, as well as prevention, should start early in the hospitalization. Identifying those persons with community-acquired versus hospital-acquired ulcers will strengthen pressure ulcers as an accurate marker of quality of care for hospitalized patients. If possible, data should be reported by ward level for comparison over time.