Informative article on Pressure Ulcers based upon 6 year sequential Acute Care Data.
ADVANCES IN SKIN & WOUND CARE • VOL.17 NO. 9 490 WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
National Prevalence and Incidence
Study: 6-Year Sequential Acute
Care Data
Kathy T. Whittington, MS, RN, CWCN, and Robin Briones, BBA
Pressure ulcers (PrUs) remain a critical health care issue,
with patients hospitalized in the acute care setting
receiving treatment for approximately 2.5 million PrUs
each year.1 The annual cost of treating nosocomial PrUs is
estimated at $2.2 to $3.6 billion.1 In the guideline on PrU
treatment from the Agency for Healthcare Policy and
Research (now the Agency for Healthcare Research and
Quality)2 and in a 2001 monograph from the National
Pressure Ulcer Advisory Panel (NPUAP),3 it was suggested
that prevalence and incidence surveys be conducted as part of
a PrU quality initiative. See Table 1 for definitions of prevalence
and incidence.
The NPUAP monograph, Pressure Ulcers in America:
Prevalence, Incidence, and Implications for the Future,3,4 reviewed articles published and indexed from January 1, 1990, through December 21, 2000. In the 9 PrU prevalence studies that were
reviewed, prevalence rates in the acute care setting ranged
from 10% to 18%.3,4 Pressure ulcer incidence was reported in 2
database reviews and 7 clinical observations.3,4 Incidence rates
in the acute care setting were reported between 0.4% and
38%.3,4 In the studies reviewed in the monograph, the medical
record was typically used to evaluate PrU presence on admission.
3 Those PrUs with no documentation were considered
nosocomial.
METHODS
To assess incidence and prevalence of PrUs in acute care health
care organizations (HCOs), a National Prevalence and
Incidence Study was launched in March 1999.5 This study represented
a collaboration between KCI USA, Inc, San Antonio,
TX, and Novation, LLC, Irving, TX. KCI markets advanced
wound care systems that incorporate its proprietary vacuumassisted
closure (V.A.C.) technology, and therapeutic surfaces
designed to address the complications associated with immobility
and obesity (eg, PrUs and pneumonia). Novation is the
supply company for VHA, Inc, a network of more than 2200
ABSTRACT
OBJECTIVE: To provide health care organizations with a benchmark to measure pressure ulcer prevalence and
incidence.
SUBJECTS: Medical, surgical, and intensive care unit patients at participating health care organizations.
DESIGN: Pressure ulcer prevalence was measured during a predetermined 24-hour period at each participating
health care organization, using a standardized data collection form. Incidence was measured over the average
length of stay determined for each participating health care organization. Patient demographics, pressure ulcer
stages, pressure ulcer locations, and contributing factors were collected during the study. Collected data forms
were audited prior to being submitted to a central site for database entry, analysis, and report generation.
RESULTS: Pressure ulcer prevalence ranged from a low of 14% (2001 and 2002) to a high of 17% (1999). Incidence
ranged from a low of 7% (2001, 2003, 2004) to a high of 9% (2000). Comprehensive reports were delivered to the
participating health care organizations, with each health care organization’s data compiled to create a comparison
database.
CONCLUSION: A standardized methodology for prevalence and incidence study data collection/reporting has been
developed and used in successive studies and years. This provides a tool to help health care organizations measure
the effectiveness of interventions, improve patient outcomes on an ongoing basis, and begin trending analysis.
ADV SKIN WOUND CARE 2004;17:490-4.
Kathy T. Whittington, MS, RN, CWCN, is Director, Clinical Development, and Robin Briones, BBA, is Outcomes Process Manager, for KCI USA, Inc, San Antonio, TX. The authors have
disclosed that they are employees of KCI USA, Inc. Submitted April 7, 2004; accepted in revised form August 12, 2004.
Reprinted from ADVANCES IN SKIN & WOUND CARE
Vol. 17 No. 9 November/December 2004
Copyright © 2004 by Lippincott Williams & Wilkins
Printed in U.S.A.
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NATIONAL PREVALENCE AND INCIDENCE STUDY: 6-YEAR SEQUENTIAL ACUTE CARE DATA
Table 2.
NATIONAL PREVALENCE AND INCIDENCE STUDY DATA: ACUTE CARE SUMMARY
Prevalence Incidence
Year Assessed Occurrences Average, % Assessed Occurrences Average, %
2004 31,969 4956 16 9643 639 7
2003 31,717 4779 15 10,080 639 7
2002 30,559 4427 14 9026 624 8
2001 24,026 3445 14 7545 502 7
2000 22,455 3501 16 6719 524 9
1999 17,510 2710 17 5455 386 8
Table 1.
DEFINITIONS OF PREVALENCE AND INCIDENCE
Prevalence (point prevalence) is defined as the number of
patients (cases) with a pressure ulcer (PrU) in a specific population
at a specific time, usually evaluated on a one-time,
cross-sectional basis.1 A prevalence study reports the number
of patients with PrUs, but does not specify which patients
arrived at a health care organization (HCO) with a PrU and
which patients developed a PrU after admission.
Incidence is the number of patients (cases) who develop a
PrU after admission to the HCO. Initially assessed as PrUfree,
these patients develop 1 or more PrUs during a specific
period.1 The incidence population consists of patients
remaining in the HCO who were PrU-free on the day of the
prevalence survey. An incidence study report may be used as
an HCO quality indicator or to determine the compliance and
effectiveness of prevention interventions.
REFERENCE
1. Cuddigan J, Berlowitz D, Ayello E. Pressure ulcers in America: prevalence,
incidence, and implications for the future: an executive summary of the National
Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care 2001;14:
208-15.
community-owned HCOs and their physicians, and the
University Health System Consortium.
The survey methodology has remained consistent since the
first survey,5 allowing data comparison from year to year.
HCOs receive standardized education videos, data collection
forms, and instructions. Participating HCOs conduct a point
prevalence study during a predetermined 24-hour period.
After appropriate training, HCO staff members assess the
patients and complete forms for those patients with PrUs. The
prevalence form includes a field that indicates whether the
PrU observed on the prevalence day was “noted on the admission
record or nursing note.” Because prevalence numbers
contain old and new PrU cases, a chart review determines if
the PrU(s) was documented on the patient’s admission
assessment or nursing note. If no documentation can be
found, the PrU is marked on the prevalence form as “not
documented.”
The incidence survey date is determined using the average
length of stay for each unit. Only data from those patients
included in the prevalence survey and negative for PrUs on the
prevalence survey day are reported. The HCO staff members
assess patients and complete a form for each patient with a
Table 3.
PATIENT GENDER IN PREVALENCE STUDIES
No
Total Male Female Answer
Year Patients () () (%)
2004 4956 2255 (46) 2582 (52) 119 (2)
2003 4779 2182 (46) 2501 (52) 96 (2)
2002 4427 2063 (47) 2274 (51) 90 (2)
2001 3445 1592 (46) 1777 (52) 76 (2)
2000 3501 1710 (49) 1736 (50) 55 (2)
1999 2710 1326 (49) 1324 (49) 60 (2)
Table 4.
PATIENT AGE IN PREVALENCE STUDIES
Age Age Age No
Total 0–64 65–94 95+ Answer
Year Patients () () () ()
2004 4956 1303 (26) 3506 (71) 75 (1) 72 (1)
2003 4779 1460 (31) 3280 (69) 0 (0) 39 (1)
2002 4427 1304 (29) 3091 (70) 0 (0) 32 (1)
2001 3445 988 (29) 2397 (70) 0 (0) 60 (2)
2000 3501 1071 (31) 2404 (69) 0 (0) 26 (1)
1999 2710 767 (28) 1942 (72) 0 (0) 1 (0)
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NATIONAL PREVALENCE AND INCIDENCE STUDY: 6-YEAR SEQUENTIAL ACUTE CARE DATA
then compiled to generate a national database report for comparison.
More HCOs completed the National Prevalence and
Incidence Study in 2004 than in previous years, increasing from
115 HCOs in 34 states in 1999 to 240 HCOs in 43 states in
2004. An average length of stay of 5 days was determined by
using the bed size of the participating facilities to calculate a
weighted average; approximately 5 days elapsed between
prevalence and incidence studies.
In the 2004 study, 31,969 patients were assessed during the
prevalence study. Of those, 4956 (16%) were found to have 1 or
more PrUs (Table 2); most were Stage I or II PrUs. No documentation
of a PrU on admission could be found for 64% of
patients who had evidence of pressure necrosis during the
prevalence study (Figure 1).
Of patients with no evidence of pressure necrosis in the 2004
prevalence study, 9643 were still hospitalized and available for
reassessment on the incidence survey day. When the second
clinical assessment was completed, 639 PrUs had developed,
translating into an overall incidence of 7% (Table 2).
Tables 3 through 12 list 6 years of demographic data. Because
of the large number of data points used for diagnosis and ulcer
location, only the top 4 diagnoses (Tables 5 and 10) and top 2
Table 5.
TOP 4 PRIMARY DIAGNOSES IN PREVALENCE STUDIES
Total Cardiovascular Gastrointestinal Respiratory Muscular/Neurologic
Year Patients Diagnoses, % Diagnoses, % Diagnoses, % Diagnoses, %
2004 4956 21 12 20 8
2003 4779 19 12 20 8
2002 4427 19 11 23 10
2001 3445 18 12 22 10
2000 3501 20 12 20 11
1999 2710 22 10 23 10
Top 4 diagnoses only displayed in this table; percentages do not add up to 100%.
Table 6.
TOP 2 ULCER LOCATIONS IN PREVALENCE STUDIES
Total
Pressure Sacrum Heel
Year Ulcers () ()
2004 8857 2553 (29) 2255 (25)
2003 8631 2543 (29) 2201 (26)
2002 7932 2295 (29) 2050 (26)
2001 6042 1780 (29) 1508 (25)
2000 6411 1644 (26) 1575 (25)
1999 5214 1383 (26) 1316 (25)
Top 2 ulcer locations only displayed in this table; percentages do not add up to 100%.
PrU.2 The data collection forms are reviewed by the HCO’s
study director and submitted, via scan forms, for analysis and
report generation. The HCO-specific reports are returned to
the participants, and HCO data are compiled to create a
national report.
RESULTS
The yearly prevalence and incidence percentages for the 6
sequential surveys are shown in Table 2. Throughout the 6
years of study data collection, approximately 60% of the
observed PrUs were not noted on the nursing admission note
or form (Figure 1). These data support the review of general
acute care incidence studies in the NPUAP monograph,3
which indicates that the frequently used method of conducting
a chart review to obtain incidence data is far less accurate
than verifying PrU status by clinical examination. A more
accurate measure of incidence is the second observation of
patients who did not have PrUs in the prevalence study but
who were observed to have 1 or more PrUs on the day of the
incidence study.
During 6 years of prevalence and incidence study, data have
been collected in a standardized format from individual HCOs,
Table 7.
TOP 2 ULCER STAGES IN PREVALENCE STUDIES
Total Stage I Stage II
Pressure Pressure Pressure
Year Ulcers Ulcers () Ulcers ()
2004 8857 3722 (42) 3256 (37)
2003 8631 3631 (42) 3106 (36)
2002 7932 3122 (39) 2894 (36)
2001 6042 2448 (41) 2171 (36)
2000 6411 2675 (42) 2174 (34)
1999 5214 2104 (40) 1767 (34)
Top 2 ulcer stages only displayed in this table; percentages do not add up to 100%.
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NATIONAL PREVALENCE AND INCIDENCE STUDY: 6-YEAR SEQUENTIAL ACUTE CARE DATA
Table 9.
PATIENT AGE IN INCIDENCE STUDIES
Year Total Patients Age 0–64 () Age 65–94 () Age 95+ () No Answer ()
2004 639 175 (27) 441 (69) 9 (1) 14 (2)
2003 639 192 (30) 441 (69) 0 (0) 6 (1)
2002 624 175 (28) 447 (72) 0 (0) 2 (0)
2001 502 139 (28) 359 (72) 0 (0) 4 (1)
2000 524 162 (31) 358 (68) 0 (0) 4 (1)
1999 386 104 (27) 282 (73) 0 (0) 0 (0)
Table 10.
TOP 4 PRIMARY DIAGNOSES IN INCIDENCE STUDIES
Cardiovascular Gastrointestinal Respiratory Muscular/Neurologic
Year Total Patients Diagnoses, % Diagnoses, % Diagnoses, % Diagnoses, %
2004 639 18 15 21 9
2003 639 20 11 22 9
2002 624 20 11 25 11
2001 502 25 9 20 14
2000 524 21 12 20 14
1999 386 23 12 23 11
Top 4 diagnoses only displayed in this table; percentages do not add up to 100%.
ulcer locations (Tables 6 and 11) are listed for each year. It is
interesting to note that the diagnosis, ulcer location, and age
are similar for all 6 years.
Each participating HCO receives a report containing
all data collected for every year it completed the study.
Specific listings include “ulcers not noted on the nursing
admission record,” ”prevalence and incidence by unit type,”
“pressure ulcer location and stage,” “primary diagnosis,”
and “contributing factors.” The HCOs can use these data
to assess quality of care and to compare outcomes—
from year to year and with similarly sized facilities.
The 6 years of data from the National Prevalence and
Incidence Study support the Pressure Ulcers in America
recommendation that “sequential national studies, with a
rigorous methodologic design, should be used to determine
the ‘true’ incidence of pressure ulcers in the acute care
setting.”3
CONCLUSION
Information and trending charts for the national data have
been presented. Individual HCOs are challenged to apply
trending analysis to their respective data and sequential prevalence
and incidence studies versus benchmarking against the
Table 8.
PATIENT GENDER IN INCIDENCE STUDIES
Total Male Female No
Year Patients () () Answer (%)
2004 639 277 (43) 343 (54) 19 (3)
2003 639 294 (46) 333 (52) 12 (2)
2002 624 292 (47) 322 (52) 10 (2)
2001 502 224 (45) 267 (53) 11 (2)
2000 524 268 (51) 249 (48) 7 (1)
1999 386 185 (48) 193 (50) 8 (2)
Figure 1.
SKIN BREAKDOWN NOT NOTED ON ADMISSION
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Table 11.
TOP 2 ULCER LOCATIONS IN INCIDENCE STUDIES
Total
Pressure Sacrum Heel
Year Ulcers () ()
2004 890 280 (31) 239 (27)
2003 879 262 (30) 253 (29)
2002 826 280 (34) 247 (30)
2001 686 206 (30) 203 (30)
2000 718 202 (28) 192 (27)
1999 597 183 (31) 154 (26)
Top 2 ulcer locations only displayed in this table; percentages do not add up to 100%.
Table 12.
TOP 2 ULCER STAGES IN INCIDENCE STUDIES
Total Stage I Stage II
Pressure Pressure Pressure
Year Ulcers Ulcers () Ulcers ()
2004 890 520 (58) 315 (35)
2003 879 537 (61) 302 (34)
2002 826 475 (58) 306 (37)
2001 686 397 (58) 241 (35)
2000 718 413 (58) 243 (34)
1999 597 329 (55) 211 (35)
Top 2 ulcer stages only displayed in this table; percentages do not add up to 100%.
national data. This information is available for implementation
by the HCOs to develop changes in nursing care related to
maintaining skin integrity as part of each HCO’s continuous
quality improvement program. ?
REFERENCES
1. Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison of costs in
medical vs. surgical patients. Nurs Econ1999;17:263-71.
2. Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice
Guideline, No. 15. AHCPR Publication No. 95-0652. Rockville, MD: Agency for Health Care
Policy and Research; December 1994.
3. Cuddigan J, Ayello EA, Sussman C, editors. Pressure Ulcers in America: Prevalence,
Incidence, and Implications for the Future. Reston, VA: NPUAP; 2001. p 25-48.
4. Cuddigan J, Berlowitz D, Ayello E. Pressure ulcers in America: prevalence, incidence, and
implications for the future: an executive summary of the National Pressure Ulcer Advisory
Panel monograph. Adv Skin Wound Care 2001;14:208-15.
5. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence
and incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000;27:
209-15.