The Belgian pressure ulcer risk assessment project: Is assessing mobility and skin status a more accurate, reliable, and feasible approach to assess pressure ulcer risk in hospitalised patients?

Dear Editors,

1.

Pressure ulcers (PUs) are localised injuries to the skin and/or underlying tissue, usually occurring over a bony prominence, as a result of pressure or pressure combined with shearing.1 The first publication related to PU, identified in the Medline database, dates back to 1886.2 More recently (15 June 2019), a search strategy combining the search terms “pressure sore,” “bed sore,” “pressure ulcer,” “pressure injury,” and “decubitus” using the PubMed search engine, revealed a total of 69 797 publications. Although a solid body of knowledge exists on PU epidemiology, aetiology, pathophysiology, associated factors, prevention, and treatment, they remain a significant healthcare problem for individuals suffering from reduced mobility and non‐mobility.

PU development follows either a “top‐down” or a “bottom‐up” trajectory.3, 4 The top‐down pathway is initiated superficially (epidermis/dermis) and is mainly related to shearing causing detachment of epidermis and dermis.5 The bottom‐up pathway is initiated at the bone‐muscle interface at weight bearing bony prominences, and is responsible for the development of deep tissue injuries. Deep tissue injuries are mainly caused by sustained compression of subcutaneous tissues.4 The tissue damage progresses trough the fascia and subcutaneous fat towards the skin.3

Building on the latter, PU severity ranges from non‐blanchable erythema over partial‐thickness skin damage, to full‐thickness tissue destruction.1 Non‐blanchable erythema and oedema (leading to changes in skin/tissue hardness) are key visual indicators for inflammation related to ischaemia, ischaemia‐reperfusion, cellular deformation, or impaired lymphatic drainage.3 The latter is initiated by the release of inflammatory mediators (eg, cytokines).4

Predicting the risk of an individual to develop a PU by assessing factors that are associated with increased risk is key in the decision to allocate preventative interventions (yes/no). A plethora of risk assessment scales is available to support clinicians in performing that assessment. Over 40 risk assessment scales are available,6 all of them dealing with sensitivity (identifying true risk) and specificity issues (identifying true non‐risk). The complexity of the tools results in low outcome reliability.

To address the limitations of the existing risk assessment tools and instruments, the PU Risk Primary or Secondary Evaluation Tool (PURPOSE‐T) has been developed.7 Based on PU risk evidence, expert consultations, and a thorough clinical evaluation, the following specific key risk factors were selected: immobility/inactivity and skin assessment.8 Nevertheless, the implementation of PURPOSE‐T in practice is still quite complex for the ward/community nurses because of a three‐step assessment process that has to be followed per patient: screening, full assessment, and a final assessment decision. Therefore, Ghent University Hospital (UZGent) and the University Center for Nursing and Midwifery at Ghent University further simplified the tool to a two‐item assessment:

1. Immobility and inactivity, defined as (spontaneous) repositioning and evidence about a reduced sensory perception (pain and numb feeling) at the pressure points.

2. The presence of one or more PUs category I‐IV.

UZGent implemented the new tool in 2016; the University Hospitals of Leuven (UZLeuven) implemented the tool in 2017. Preliminary clinical tests for a hospital‐wide implementation have been performed since 2016.

Following the implementation of the Belgian Pressure Ulcer Risk Assessment Project, UZGent reported a significant increase of the proportion of patients that were assessed daily for PU risk (from 50% to 85%). The proportion of patients at risk remained stable at 25%, but the PU prevalence rates decreased from 5.27% in 2015 to 3.89% in 2016 and 4.08 and 4.01% in 2017 and 2018, respectively. Earlier research demonstrated that only 10.8 till 13.9% of patients at risk received adequate prevention.9 Following the implementation of the project, adequate prevention rates around 80% were reported in UZ Gent.

UZLeuven reported a screening proportion of 95% on admission and an increase of 10% of the proportion of patients found at risk for PU development (from 20% to 30%). The Hospital Woundcare Support Team (WST) expected this increase, while in the past, an undocumented underestimation of the PU risk was reported. A more positive mindset towards PU prevention was reported by the WST because of the increase in adequate use of preventative measures. During in‐hospital consultations by the WST, they notice that prevention is more often adequately used than in the past. Prevalence rates (categories 1‐4) remained stable between 5% and 7%; however, a limited decrease of the incidence rates (categories 2‐4; 0.62% in 2015, 0.49% in 2017 to 0.45% in 2018) was observed. Following the implementation of the project, the continuation of the PU prevention protocol starting on each department including the emergency room and between each department became more streamlined with the result that adequate prevention rates around 75% were reported in UZ Leuven.

A first pilot observational study in 2018 performed by UZLeuven compared the predictive validity of Norton risk assessment and the new PU risk assessment tool. No clear differences were yet observed.10

2. NEXT STEPS

Other hospitals in Belgium are presently adapting their risk assessment protocols in a similar way as UZGent and UZLeuven because of its ease of use. We presume that the challenge of a nurse‐driven, structurally, thoroughly, and timely screening of patients at risk of PU development could be solved by implementing this new risk assessment. It remains to be established if this new way of assessment can really make a difference in detecting more accurately the patients who are at highest risk of developing PUs, based on the key risk factors of mobility/activity and skin status. We plan to conduct further research into this new risk assessment, to implement it nationally and to investigate options to generalise this more internationally.