International Journal for Quality in Health Care 16:211-218 (2004)
International Journal for Quality in Health Care vol. 16 no. 3 © International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
A pressure ulcer audit and feedback project across multi-hospital settings in the Netherlands
1 Department of Nursing Science and 2 Department of Methodology and Statistics, Maastricht University, 3 Centre for Research on Quality in Family Practice, Universities of Nijmegen and Maastricht, the Netherlands, 4 School of Nursing and Faculty of Medicine, American University of Beirut, Lebanon
Objective. To examine whether participating in a pressure ulcer prevalence survey and receiving feedback results in an improvement in quality of care.
Design. Cross-sectional studies from 1998 to 2002 were compared over time.
Setting. Sixty-two acute care hospitals in the Netherlands.
Study participants. Patients hospitalized at the moment of the surveys.
Interventions. Each hospital was given hospital-specific performance data and national aggregate data, and peer comparisons to improve the quality of care.
Main outcome measures. The case-mix-adjusted prevalence of pressure ulcers of grade 
2, the percentage of high-risk patients receiving adequate prevention, and the total number of enabling conditions present were compared between successive surveys using multi-level analysis, in order to estimate a linear trend model and trend differences for each hospital.
Results. The case-mix-adjusted prevalence of pressure ulcers decreased over the 5-year period, while the percentage of patients receiving adequate prevention and the total number of enabling conditions present increased. The total number of enabling conditions had a significant effect on the decrease in case-mix-adjusted prevalence: more enabling conditions led to a lower case-mix-adjusted prevalence (
2 = 125; degrees of freedom = 1; P < 0.00). The percentage of patients receiving adequate prevention also had an effect on the change in case-mix-adjusted prevalence, with a higher percentage leading to a lower case-mix-adjusted prevalence. This effect, however, was not significant.
Conclusions. Monitoring prevalence and giving feedback results in an improvement in quality of care in terms of pressure ulcer prevention. It is very important to continue conducting surveys to avoid attention moving away from this topic, which may in turn lead to a deterioration in the quality of pressure ulcer care. Further research to find the most effective feedback approach is needed.
Keywords: audit, case-mix adjustment, feedback, pressure ulcers, quality improvement
Address reprint requests to Gerrie J. J. W. Bours, Maastricht University, Department of Nursing Science, PO Box 616, 6200 MD Maastricht, the Netherlands. E-mail: g.bours{at}zw.unimaas.nl
Accepted for publication December 10, 2003.
Pressure ulcers are a serious problem in Dutch health care settings, as was confirmed by the first national prevalence survey in 1998 [1]. This survey revealed prevalence rates of 23% in acute care hospitals, 33% in nursing homes, and 21% in home care. The main goals of the national surveys were to assess the magnitude of the problem and to reduce the number and severity of pressure ulcers [2]. To date, five national prevalence surveys have been carried out in various health care settings. After each survey, the results were fed back to the participating institutions at ward level and at hospital level. The institutions were also provided with comparable figures for the national level, which they could use for benchmarking [3–7]. On the basis of the literature, we expected that continuous monitoring and feedback of performance data to hospitals would influence actual care provision to patients [8–10]. Moreover, it was found that most of the coordinators of the participating institutions were indeed planning or implementing activities to change pressure ulcer management after the first audit and feedback [11]. However, it was not clear whether this change in care provision showed a pattern of improvement over 5 years, nor whether it had an impact on the prevalence rates at the hospitals. The purpose of the present study was therefore to examine whether regular participation in the pressure ulcer prevalence surveys and receiving feedback results in a reduced prevalence and an improvement in the management of pressure ulcers over time. In addition, it assessed the extent to which improved policies for the prevention of pressure ulcers result in lower prevalence.
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Methods |
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Design
Five annual national surveys were carried out between 1998 and 2002, involving systematic data collection to assess the prevalence of pressure ulcers in various health care settings and various patient groups. A trained coordinator, usually a nurse specializing in wound care, was responsible for data collection in each setting. The coordinator selected and trained a team of nurses to perform the assessments within the institutions. Each patient had to be examined by two nurses, one from the patient’s own ward and one who was unfamiliar with the patient, to ensure reliability. Reliability was found to be good [12,13]. A detailed description of the procedure has been provided previously [1].
Sample
The majority of the settings in the national surveys were acute care hospitals. A total of 76 acute care hospitals participated voluntarily in the five surveys. Hospitals that participated more than once during these 5 years were compared between surveys to determine what changes had occurred over time in the prevalence and management of pressure ulcers. Table 1 gives an overview of the numbers of hospitals participating in these 5 years and the numbers of patients registered.
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Data collection
The data collection instrument designed for this study was based on a literature review and a Delphi panel with 34 experts in the field of pressure ulcers. The instrument was field tested in an acute care hospital, a nursing home, and a home care agency, and was found to be reliable and feasible [12]. The instrument included six categories of items to be collected. The first three were the characteristics of the institution, the characteristics of the ward (an estimate of enabling conditions for pressure ulcer prevention present at hospital and ward level), and the characteristics of the patients (such as age, sex, date of admission, and reason for admission). The fourth category involved risk assessment using the Braden scale, with two additional risk factors (malnutrition and incontinence). The Braden scale is one of the best known and most widely used tools for evaluating pressure ulcer risk, with proven validity and reliability for risk assessment [14–17]. Malnutrition was added because it was felt to be more important than the nutrition item included in the Braden scale (defined as dietary intake). The incontinence item was added because the Braden scale does not distinguish between moist (perspiration) and wet (urine). The fifth category of items involved grading the pressure ulcers according to internationally accepted grading systems, defining stage I as non-blanchable discoloration; stage II as partial thickness skin loss involving the epidermis, blisters, or shallow ulcers without undermining of adjacent tissue; stage III as full thickness skin loss, involving damage or necrosis of the epidermis and/or dermis not extending to underlying bone, tendon, or joint; and stage IV as full thickness skin loss, involving damage or necrosis of the epidermis and/or dermis extending to underlying bone, tendon, or joint [18,19]. Furthermore, each pressure ulcer was linked to its identifying stage with respect to site, origin, time of first observation, and dressing. The sixth category related to the prevention of pressure ulcers. This category included the type of support surface used, the use of cushions in a chair, and the use of other devices such as heel protectors, as well as the preventive interventions of repositioning, preventing malnutrition, and patient education. Repositioning was defined as planned repositioning at least every 3 hours as noted in the nursing records, while preventing malnutrition was defined as the adjusting of food intake by a dietician, and patient education was defined as giving each patient a booklet with clear information about the cause and prevention of pressure ulcers.
Feedback
Feedback was defined as the sharing of non-judgmental information to provide hospitals with insight into any discrepancies (positive or negative) between their performance and a standard in order to elicit change [20]. After each survey, the hospitals received a computer-generated report about their results at ward and hospital levels. Results at national level were fed back in a written report. The reports included information about the prevalence of pressure ulcers by grade, preventive interventions used for patients at risk (Braden value 
20), with or without pressure ulcers, and preventive interventions used for patients at low risk (Braden value >20), with or without pressure ulcers. Furthermore, feedback was given about wound dressings used for pressure ulcers, by grade, and whether these dressings were in accordance with the Dutch guidelines on pressure ulcers [21]. Furthermore, information was provided about the characteristics of the population (demographics, reason for admission, and risk assessment according to the Braden scale). In addition, the report explained how these feedback figures had to be interpreted, and a mock report was provided which illustrated how the national results could be compared with the results at hospital level to derive recommendations for improvement of the pressure ulcer prevention strategies. Since 2001, case-mix-adjusted prevalence rates were provided to allow them to assess their relative performance.
Effect measures
The effect measures used to evaluate the results of auditing and feedback were the prevalence of pressure ulcers, the percentage of patients receiving adequate prevention, and the total number of enabling conditions present. These measures were expected to improve as a result of the monitoring and feedback activities. The prevalence of pressure ulcers was defined as the proportion of persons with a stage II pressure ulcer or worse within the total number of persons who were physically examined during the survey. As case mix may change over time, a case-mix-adjusted prevalence rate was calculated to ensure that the differences in rates were not due to differences in case mix [22–24]. Adequate prevention was defined as the proportion of patients with impaired mobility and/or activity (i.e. scoring <3 on the relevant items of the Braden scale) being provided with a dynamic support system or a static support system combined with repositioning according to a time schedule [25]. We calculated a sum score for the 11 enabling conditions used in each survey to evaluate the quality of the pressure ulcer prevention policy (see Table 2). Enabling conditions 8 and 9 were combined because they both assess the management of preventive materials. An affirmative answer about the presence of either condition 8 or 9 resulted in a positive score on this item. Scores ranged from 0 (minimum quality) to 10 (maximum quality).
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Exclusion
In calculating the prevalence of pressure ulcers, children <13 years of age were excluded from the database, because only a few hospitals had included paediatric wards in their audit. Furthermore, risk factors for developing pressure ulcers, which are important in adjusting for case mix, may be different for children because their skin does not have the problems associated with the aging process in adults [26,27]. Also excluded were those patients already suffering from pressure ulcers on admission, as settings could not prevent these lesions by performing adequate activities.
Statistical analysis
The case-mix-adjusted prevalence was calculated by multiplying the ratio of observed to expected rates by the mean of the rates observed in each year. This method has been extensively described in a previous article, although new coefficients were calculated using the data from the 1998 survey [24]. The model was cross-validated using the data from all successive surveys. The c-statistic, reflecting the ability of the model to assign a higher probability of risk to patients with pressure lesions, varied between 0.83 and 0.85. Values >0.70 are generally considered good [23]. Model calibration was tested with the Hosmer–Lemeshow goodness-of-fit test [28]. This test showed significant differences between the observed and expected values for the years 1999, 2000, and 2002 when the same ß-coefficients were used. However, after new coefficients had been calculated for each year, these differences were no longer significant (P-values ranged from 0.25 to 0.41). These analyses were done using the Statistical Package for Social Sciences (SPSS), release 10.1.
To evaluate changes in the effect measures, multi-level analysis was used to estimate a linear trend model and trend differences for each hospital. The advantage of a hierarchical linear model approach for repeated measures is that all available data can be incorporated in the analyses, rather than only those cases with complete data [29]. Level-one units were measurement moments, while level-two units were hospitals that had participated more than once in the national survey. The deviance test, or likelihood ratio test, was used to assess the significance of the fixed parameters and to test the random parameters of the models.
The influence of the percentage of patients receiving adequate prevention and the total number of enabling conditions present on the case-mix-adjusted prevalence was also assessed using a hierarchical linear model, with the case-mix-adjusted prevalence as the dependent variable and the total number of enabling conditions present and the percentage of patients receiving adequate prevention as the independent variables.
The multi-level analyses were performed using the Mlwin program [30].
A test assessing whether the variance of the random intercepts or of a random slope is zero was one-sided. All other tests were two-sided. An 
value of 0.05 was used for all tests.
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Results |
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Study sample
The analyses were based on the databases of surveys from 1998 to 2002. After the exclusion of children and patients admitted with pressure ulcers, a total of 46079 observations remained for the analyses, including 9402 patients in 1998, 8566 patients in 1999, 8554 patients in 2000, 8312 patients in 2001, and 11245 patients in 2002. In all the survey years,
54.0% of the patients were female. Table 3 presents the characteristics of the patients for the 5 survey years for those factors that were incorporated in the model for case-mix adjustment. A total of 62 hospitals participated more than once: 20 hospitals participated twice, 19 hospitals participated three times, four hospitals participated four times, and 19 hospitals participated in all five surveys.
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Changes over time
Table 4 presents the changes over time of the case-mix-adjusted prevalence, the percentage of patients receiving adequate prevention, and the total number of enabling conditions present. It shows that the case-mix-adjusted prevalence decreased by 0.41% with every measurement [95% confidence interval (CI) –0.70 to –0.13], which means that the case-mix-adjusted prevalence for hospitals that participated in all five years declined from 9.54% to 7.47% (see Table 4). This decrease was the same for each hospital, as the random coefficient for time was not significant [2 = 0.42; degrees of freedom (df) = 2].
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In successive surveys, the percentage of patients receiving adequate prevention increased by 1.43% (95% CI 0.37–2.48), which means that hospitals that participated in all 5 years provided adequate prevention to 7.13% more patients at risk. This increase was also the same for each hospital (2 = 1.96; df = 2).
The total number of enabling conditions present increased by 0.43 (95% CI 0.21–0.66) between each survey, which means a total increase from 5.38 to 7.54 in 5 years of participation. As the random coefficient for time was significant (2 = 23.16; df = 2), this increase differed between the hospitals. In fact, the variance of this coefficient (0.36) shows that there were also hospitals in which the total number of enabling conditions present decreased.
Influence of adequate prevention and enabling conditions on the case-mix-adjusted prevalence of pressure ulcers
To examine whether the case-mix-adjusted prevalence had been influenced over time by the enabling conditions and the percentage of patients receiving adequate prevention, a hierarchical linear model was used, with the case-mix-adjusted prevalence as the dependent variable and the total number of enabling conditions present and the percentage of patients receiving adequate prevention as the independent variables. The results of this analysis are presented in Table 5. The total number of enabling conditions present had a significant effect on the change in case-mix-adjusted prevalence (2 = 125; df = 1; P < 0.00), with the presence of more enabling conditions leading to a lower prevalence of pressure ulcers. This effect was the same for all hospitals, as the random coefficient of the enabling conditions was not significant (2 = 3.629; df = 2; P > 0.05). The percentage of patients receiving adequate prevention also had an effect on the change in case-mix-adjusted prevalence, in that a higher percentage led to lower case-mix-adjusted prevalence. However, this effect was not significant (2 = 0.347; df = 1; P > 0.05). The effect was not the same for all hospitals, however, as the random coefficient was significant (2 = 16.826; df = 2; P < 0.001).
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Discussion |
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This study shows that regularly measuring the prevalence of pressure ulcers and giving feedback about the findings results in a decrease in pressure ulcers and an increase in the use of adequate preventive interventions and enabling conditions. It seems that the total number of enabling conditions present and the percentage of patients receiving adequate prevention are both intermediary factors in decreasing the prevalence. Examination of the association between these factors and the decrease in the case-mix-adjusted prevalence, however, showed that only the association with the number of enabling conditions present was significant. No significant effect was found for adequate prevention use. This can be explained by the very restrictive definition of adequate prevention, which applied only to immobile and/or chairfast or bedfast patients. These patients are very vulnerable to developing pressure ulcers and providing them with adequate prevention may not have the intended preventive effect. After all, not all pressure ulcers are preventable [31]. Furthermore, adequate prevention, defined as the proportion of patients with impaired mobility and/or activity being provided with a dynamic support system or a static support system combined with repositioning according to a time schedule, may easily be overestimated. Errors may arise if patients are scored as receiving repositioning, but in fact do not receive adequate repositioning, as such patients may be at higher risk of developing a pressure ulcer. This misclassification may mask a significant effect of adequate prevention.
The influence of adequate prevention on the case-mix-adjusted prevalence was not the same for all hospitals. This means that in some hospitals, the case-mix-adjusted prevalence might have shown a greater decrease, remained unchanged, or in the most extreme case might even have increased compared with other hospitals. This may also have resulted from our definition of adequate prevention, which included only supportive beds or mattresses and repositioning. If hospitals provided other preventive interventions than those covered by our definition, for instance heel or elbow protectors, to patients at high risk of developing pressure ulcers, the association between adequate prevention and case-mix-adjusted prevalence may turn out differently for these hospitals. However, the design of the study did not allow for a detailed evaluation of all these preventive activities.
Hospitals participated in our study voluntarily. This selection procedure may have led to overestimations in the findings, as these hospitals were very motivated to initiate activities to improve their pressure ulcer prevention policy. Actually, participating in the national survey was among the first activities undertaken by many hospitals [32].
The quality of care had improved over the 5 survey years, as the prevalence of pressure ulcers had decreased, while the total number of enabling conditions present and the percentage of patients receiving adequate prevention had increased. Although we used an uncontrolled study design that did not protect against the possibility that the observed improvements may have been caused by sudden changes or secular trends, we believe that these improvements were indeed triggered by the audit and feedback mechanism. Audit and feedback have been found to influence actual care provision to patients in controlled as well as uncontrolled studies [9,10,33–36]. In addition, the link between programme participation and improvement in the management of pressure ulcer care was confirmed by additional research carried out after the first and third audit and feedback rounds. This additional research has shown that, in general, the feedback on the results of the audit was disseminated to most levels in the participating institutions and that a variety of activities was performed to stimulate the prevention of pressure ulcers [11,32].
Pressure ulcers are a topic that does not generate a great deal of interest, and many health care professionals fail to recognize the importance of maintaining competence and keeping abreast of new developments. Previous research had shown that there were major flaws in the prevention of pressure ulcers [1]. Monitoring and feedback may serve as a trigger to focus attention on the pressure area care in order to improve the quality of care. Quality assurance and education have been found to have a greater positive impact on topics attracting little interest than on those drawing a great deal of attention [37,38]. Although Barczak et al. [39] did not find a decrease in the national prevalence in the United States after four national surveys, their study did not use case-mix- adjusted prevalence rates to assess changes over time, so the lack of improvement may have been caused by differences in case mix.
In our study, the improvements found under the influence of monitoring and feedback were small. It must be remembered, however, that the effects of audit and feedback on the performance of health care professionals are generally found to be small to moderate, and it is not yet clear what the most effective feedback should look like [9]. The only intervention we used was auditing pressure ulcer data and feeding back the results, which is in fact a passive quality improvement strategy. Combining feedback with more active interventions, such as educational materials or meetings, the use of opinion leaders, or face-to-face interactions, may result in greater benefits [40–42].
In conclusion, monitoring the prevalence of pressure ulcers and giving feedback results in an improvement of the quality of care for pressure ulcers, as was demonstrated by a decrease in the prevalence of pressure ulcers, an increase in the use of adequate prevention, and a greater number of enabling conditions present. It is very important to continue conducting such surveys to avoid attention moving away from this topic, which may in turn lead to a deterioration in the quality of pressure ulcer care. Further research to find the most effective feedback approach is needed.
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