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A study examining rates of medical staff recognition of pressure ulceration in hospital inpatients
  1. Jonathan Blackman1,
  2. Joe Walsgrove1,
  3. Indunil Gunawardena2
  1. 1Department of Cardiology, Royal Bournemouth Hospital, Bournemouth, UK
  2. 2Department of Geriatric Medicine, Royal Bournemouth Hospital, Bournemouth, UK
  1. Correspondence to Dr Indunil Gunawardena, Norfolk and Norwich University Hospital, 2 Turnberry, Norwich, NR4 6PX, UK; indunil.gunawardena{at}nhs.net

Abstract

Background The incidence of pressure ulceration among UK hospital inpatients has been estimated at 10.2–10.3%. These patients are at increased risk of developing osteomyelitis and subsequent sepsis. This study sought to test whether medical staff recognition rates of hospital inpatients with pressure ulceration were low and to consider underlying causes and potential solutions.

Methods Interviews were conducted with nursing staff on multiple wards in July 2012 to obtain a definitive list of patients with pressure ulcers, with their corresponding location and grade. Junior members of medical teams with responsibility for the same group of patients were independently interviewed and asked to identify all patients who they knew to have pressure ulcers. The number correctly identified by the medical teams was compared with the total number of known pressure ulcers to produce a recognition rate. Patients with clinical evidence of sepsis were highlighted.

Results Twenty-seven patients on five wards were identified by nursing staff as having pressure ulceration areas. Nine patients were stated to have multiple pressure ulceration areas, giving a total of 38 pressure ulcers. Medical teams correctly identified eight of 27 (29.6%) of these patients. The correct site and grade was identified in four of 38 (10.5%) and two of 38 (5.3%) cases, respectively. Of these patients 14/27 (51.8%) had evidence of infection. In this subgroup five of 14 (35.7%) were correctly identified as having pressure ulceration areas.

Conclusions The lack of medical awareness could lead to delayed recognition of deep-seated infection or osteomyelitis. Reasons for this are likely to be multifactorial and require a combination of cultural change, improved education and improved information sharing.

  • Geriatric Medicine
  • Wound Management

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Introduction

A pressure ulcer is defined as a localised injury to the skin or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear or friction.1 Their prevalence among UK acute care hospital inpatients has been estimated at 10.2–10.3%.2 It has long been known that the presence of pressure ulcers is associated with an increased risk of mortality in hospital, with one study suggesting a relative risk increase of 1.9–3.1.3 Indeed, recently published data from the UK Office for National Statistics showed that during 2011 in England and Wales pressure ulcers were listed as a direct cause of death in 78 hospital inpatients and as a contributory factor in a further 540.4 A patient with a pressure ulcer is immediately in a higher risk category for mortality and is at risk of developing secondary complications including osteomyelitis.5 ,6 It would therefore seem crucial that medical staff are aware of patients with pressure ulceration both as an aid to identifying the most vulnerable patients and in order to initiate early investigation and treatment of associated complications.

The Royal Bournemouth Hospital is an acute 711-bed district general hospital, which in common with many other UK south coast institutions serves a proportionally increased retired and elderly population. It has four dedicated acute elderly medicine wards. In view of the higher than average age of admission, the patient population is likely to be at increased risk of pressure ulceration.

The extent to which doctors are able to identify patients with pressure ulceration has not been explored previously. The main objective of this simple study was to test what proportion of patients with confirmed pressure ulceration would be recognised by medical teams responsible for their care. Further objectives included finding the proportion of correctly identified sites and grades of ulcer as well as the proportion of patients in whom the knowledge of pressure ulceration could be crucial to their ongoing management; that is, patients with intercurrent sepsis. Reasons for potential low recognition rates were considered and ways in which this could be improved are suggested.

Methods

Inclusion criteria

All inpatients from four elderly medicine wards and a single general medical ward with elderly medicine requirements were selected for inclusion. These wards were chosen due to their relatively high proportion of patients with pressure ulceration and because their doctors were based by ward rather than consultant team.

Nursing interview process

In order to determine which patients on each ward had areas of pressure ulceration, short informal ward-based interviews were held with members of nursing staff conducted by JB and JW. If the clinical lead for the ward was unavailable, interviews were held with each nurse with responsibility for separate bays in the ward. This was considered the most efficient method of obtaining a definitive list of patients with pressure ulceration due to the fact that nurses routinely record all known pressure ulcers on initial ward admission documentation, on daily nursing patient lists and on a daily basis in the patient's case notes. In addition, they are uniquely placed to identify developing areas of pressure ulceration that may not have been documented on admission. In order to build the most definitive list possible, reference to any documentation or discussion with any other nursing staff members was permissible.

The following data were collected from the nursing staff:

  • grade of staff member interviewed;

  • ward type;

  • patient date of birth;

  • patient hospital number;

  • site of pressure ulcer;

  • grade of pressure ulcer.

Medical staff interview process

Having identified a list of patients with pressure ulceration areas, two members of the medical team from each ward then underwent short, informal, ward-based interviews. Any grade of doctor was permissible from FY1 (first year post-qualification) to SpR (registrar). Doctors were interviewed separately and reference to any written lists was permissible. Those looking after patients for less than 48 h at the time of the interview were excluded. This was to avoid data being potentially skewed by the presence of locum staff or doctors returning from absence who may not know the individual details of any patient having only worked on the ward for a limited period of time. Information was collected on two separate weekday afternoons in July 2012. All interview participants were consented and were aware of the objectives of the study. In the interests of patient safety, any discrepancy between the nursing and medical opinion as to whether a patient had a pressure ulcer was addressed immediately after the interviews. Confidentiality was maintained through appropriate disposal of any patient identifiable data.

Data analysis

Additional data regarding whether patients identified as having pressure ulceration areas had evidence of sepsis were also collected. For the purposes of this study sepsis was defined as a patient currently prescribed antibiotics or the presence of systemic inflammatory response syndrome criteria within the previous 7 days. These data were collected by examining drug charts, blood results and observation charts.

The proportion of patients with pressure ulceration correctly identified by the medical staff was calculated by comparing the total number of patients with pressure ulceration identified by the nursing staff (the definitive list) versus the number identified by the medical staff. When a patient was correctly identified by the medical team, further comparisons were made to determine if the correct site and grade was also known. Further analysis was undertaken to determine the recognition rate for the subgroup of patients with sepsis.

Results

A total of 27 out of 158 patients (17.1%) were identified through interviews with eight nursing staff as having pressure ulcers. Only eight out of 27 patients were identified by the 10 doctors interviewed as having pressure ulcers, a recognition rate of 29.6%.

The correct site was identified in four cases (sacrum identified in three cases, heel in one case) and the correct grade in only two (grade 4 in one case, grade 2 in one case). Therefore, out of a total of 38 ulcers, the proportion of the correct site and grade identified by medical staff stood at 10.5% and 5.3%, respectively (see table 1 and figure 1).

Table 1

Recognition rate by patient, site and grade of pressure ulcer

Of the 27 patients with pressure ulceration, 14 had evidence of intercurrent sepsis (51.8%), and as such recognition of pressure ulceration could be crucial in their ongoing management. Five of 14 (35.7%) of these patients were identified by the medical teams as having one or more pressure ulcers.

The site and grade of every ulcer was immediately available from all nursing staff interviewed and revealed a wide range of sites and severity (see tables 2 and 3). Table 3 also shows a weak tendency for the recognition rate of pressure ulceration to improve with increasing severity of ulcer.

Table 2

Site of ulcer

Table 3

Grade of ulcer

A total of four out of 158 patients was identified by medical staff to have pressure ulceration areas that the nursing staff were unaware of.

Figure 1

Proportion of pressure ulcers identified by patient, site and grade.

Discussion

The proportion of pressure ulcers identified by medical staff stood at an average of 29.6%. Poor recognition rates were broadly universal between medical teams and grades of doctor, ranging from 10% to 50%. While further research is required, we currently have no reason to suspect that these results are exceptional compared to other hospitals. Knowledge of the correct location of pressure ulcers was even more limited, with only approximately 10.5% being correctly identified. Only 5.3% were correctly graded by the medical team. In addition, only 35.7% of patients with clinical evidence of infection were identified by the medical team as having a pressure ulcer.

This low recognition rate could potentially be highly clinically significant for two main reasons. First, if medical staff are unaware of the presence of pressure ulcer areas, diagnosis of their potential complications, for example, osteomyelitis or deep-seated soft tissue infection is much less likely to be made. This could potentially delay treatment with appropriate antimicrobial agents. Second, the presence of pressure ulceration is a predictor of increased morbidity and mortality; awareness of this may aid patient care by helping to identify the most at-risk groups on the ward.

Four patients were identified by the medical teams as having pressure ulceration that the nurses were not aware of. Three patients had a history of pressure ulceration but no active lesions and one patient was incorrectly identified.

There may be multiple reasons for low recognition rates. Limited emphasis is placed on the issue of pressure ulceration at medical school. Prevention, inspection and care of pressure areas are all typically routinely performed by nursing staff. This may lead to a perception among medical staff that it is a nursing issue only. Formal exchange of information regarding pressure areas between the medical and nursing teams typically occurs only during multidisciplinary meetings. It may be that attendance is sporadic among junior doctors or that information is not relayed or retained. Medical and nursing teams may not exchange information optimally; for example, medical ward rounds are typically held separately, with only intermittent nursing involvement. Interruptions to the continuity of care provided on the ward through frequent junior staff changes may also contribute to a lack of detailed patient knowledge.

Addressing all of these issues is therefore extremely challenging and requires predominantly a cultural shift as opposed to specific local intervention. In particular, education at medical school level regarding the burden, morbidity and mortality of pressure ulceration and especially its potential significance in the context of a septic screen is required. This would naturally require reinforcement in the early foundation years post-graduation from senior medical staff, particularly during medicine for the elderly rotations within which the issue is most widespread. Increased emphasis of pressure areas especially in the septic patient during multidisciplinary meetings may also aid this process. An increased presence of nursing staff on the medical ward round, as recently advocated by the Royal College of Physicians,7 could also accrue significant benefits in terms of information sharing and team working, which would potentially extend well beyond pressure ulceration alone.

Limitations of the study include relatively small patient numbers. In addition, despite interviewing representatives from each elderly care team, this comprised only 10 doctors, providing a small sample size. The study was designed to provide a ‘real life’ snapshot of the situation on the wards on that day, accepting that drawing robust conclusions about overall recognition rates may be difficult. Sampling was undertaken from a single site; however, we have no reason to expect vastly different recognition rates in other centres. Finally, the only method to produce an absolutely exhaustive list of all patients with pressure ulceration would have been to examine each inpatient fully. This was clearly unacceptable and as such nurses were interviewed to provide the next best surrogate for this.

In summary, there is a low recognition rate of pressure ulceration among medical staff, the causes of which may well be multifactorial. A combination of cultural change, improved education regarding the importance and risks of pressure ulceration at an early stage in medical training and strategies to improve information sharing between doctors and nurses are required to give the recognition of pressure ulceration the priority it deserves.

Main messages

  • There is a significant incidence of pressure ulceration in UK hospitals posing an increased risk of morbidity and mortality.

  • Medical team recognition rates of patients with pressure ulceration were poor, with less than one-third correctly identified.

  • The lack of medical awareness could lead to delayed recognition of deep-seated infection or osteomyelitis.

  • Reasons for this are likely to be multifactorial, requiring cultural change, improved education and improved information sharing.

Current research questions

  • Reasons for poor recognition and scope for qualitative study.

  • Extent to which the pattern of low recognition is repeated in other centres.

  • Is there a direct correlation between recognition rate and outcome in patients with pressure ulceration?

Key references

  • Yoshikawa TT, Livesley NJ, Chow AW. Infected pressure ulcers in Elderly. Clin Infect Dis 2002;35:1390–96.

  • Redelings MD, Nolan LE, Sorvillo F. Pressure ulcers: more lethal than we thought? Adv Skin Wound Care 2005;18:367–72.

  • Kithri V, et al. Ward Rounds. In Medicine: Principles for Best Practice 2012. Royal College of Physicians and Royal College of Nursing. http://www.rcplondon.ac.uk/sites/default/files/documents/ward-rounds-in-medicine-web.pdf

References

View Abstract

Footnotes

  • Contributors JB: Study design, data collection. Analysed data and drafted paper. JW: Data collection. IG: Conception of study, final approval of drafted paper.

  • Competing interests None.

  • Ethics approval This was an observational style study with no treatment changes.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.