Report on the prevalence of skin ulcers in a home health agency population

Advances in Wound Care,  Nov/Dec 1999  by Meehan, Marge,  O'Hara, Lucy,  Morrison, Yolanda M

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Pressure ulcers were defined as "any lesion caused by unrelieved pressure resulting in damage of underlying tissue, usually found over bony prominences" (Hill-Rom study methodology, unpublished). All patients of the participating HHAs were assessed using the Braden Scale.4 The Scantron form also allowed the HHAs to record the score from any routinely used risk assessment tool for the purpose of internal scoring outcomes. Only the Braden Scale score, however, was used for computing the risk assessment level of participating patients in this study. Scores were recorded on Side 2 of the Scantron form, regardless of ulcer status, establishing the denominator for the prevalence calculation. Patients deemed at low risk for pressure ulcers (Braden Scale score >19) were then eliminated from any further assessment. For those patients assessed to have ulcers, Side 2 of the form was then completed and included caregivers in the household, the patient's continence status, history of recent hospitalizations (within the past 6 months), Braden and non-Braden risk assessment scores (if applicable), type of support surface utilized, stage and location of existing pressure ulcers, and type of topical management being used for each wound.

Side I of the Scantron form was completed only for those patients who had at least I pressure ulcer. Side I captures demographic, nutritional, and wound documentation information and diagnosis data. A designated nurse within each HHA collected these data elements through retrospective chart review. Classification of the origin of ulcers documented during the survey was based on chart review of admission skin status for those patients found to have ulcers. The pressure ulcer staging system used for the survey was devised by the National Pressure Ulcer Advisory Panel (NPUAP) and adopted by the Agency for Health Care Policy Research (AHCPR).5

Two additional wound description options-Stage V and Stage VI-were provided to allow further delineation of observed ulcers, based on presenting characteristics. Stage V was used to capture ulcers that presented with an eschar covering and were therefore unstageable. Stage VI was used for wounds that were neither hyperemic nor covered with eschar. The ecchymotic designation was defined to include those wounds that presented with visible hemorrhagic damage but with intact skin. In participating HHAs, the standard was to complete physical assessments within 24 hours of admission and included the determination of the presence of any manner of skin breakdown. If ulcers were not included in documentation within 24 hours of admission, they were considered nosohusial6 (ie, acquired in the home, not in the community or hospital) in origin. In-service instructions for completion of Side I of the Scantron form were provided to designated individuals within the HHA responsible for completing the data fields.

The Scantron form design, consistent with the approach taken in both the longterm care and acute care prevalence surveys conducted through Hill-Rom, provides for information to be recorded on wounds found only over bony prominences. This form design feature is utilized to reduce the potential artifact of including wound data for ulcers that are not principally influenced or caused by pressure. Although other ulcers may appear over bony prominences, such as diabetic and arterial ulcers, they are most likely to have had pressure as a significant factor in their development.