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Results of the 2008 – 2009 International Pressure Ulcer Prevalence™ Survey and a 3-Year, Acute Care, Unit-Specific Analysis
Abstract
The National Quality Forum has identified a pressure ulcer as a hospital-acquired condition (HAC) that is high-cost and high-volume and may be preventable with implementation of evidence-based guidelines. The Center for Medicare and Medicaid Services no longer reimburses acute care facilities for the ancillary cost of facility-acquired (FA) ulcers. Benchmarking patient safety indicators, such as FA, may help facilities reduce pressure ulcer rates.
The purpose of this observational, cross-sectional cohort study was to report the International Pressure Ulcer Prevalence Survey™ (IPUP) in the United States in 2008 and 2009. In addition, previously collected data (2006/2007) were used to evaluate and report general and unit-specific prevalence rates in acute care facilities. The overall prevalence and FA pressure ulcer rates were 13.5% and 6% (2008, N = 90,398) and 12.3 and 5% (2009, N = 92,408), respectively. In 2008 and 2009, overall prevalence rates were highest in long-term acute care (22%). FA rates were highest in adult intensive care units (ICUs) and ranged from 9.2% (general cardiac care unit [CCU]) to 12.1% (medical ICU) in 2008 and from 8.8% (general CCU) to 10.3% (surgical ICU) in 2009. In 2009, 3.3% of ICU patients developed severe FA ulcers (Stage III, Stage IV, eschar/unable to stage, or deep tissue injury). In 2009, approximately 10% (n = 1,631) of all ulcers were described as device-related. The most common anatomic locations for device-related ulcers were the ear (20%) and sacral/coccyx region (17%). Both the overall and FA pressure ulcer prevalence rates were lower in 2008 and 2009 than in 2006 and 2007. Results indicate that, although overall prevalence trends are encouraging, there is a stark contrast from the desired state, especially in adult ICUs.
Potential Conflicts of Interest: The authors disclose they are all employees of and/or own stock in Hill-Rom, Inc.
Please address correspondence to: Catherine VanGilder, MBA, BS, MT, CCRA, Hill-Rom, Inc., 8510 Jadewood Drive, Wilmington, NC 28411; email: Catherine_vangilder@hill-rom.com.
A pressure ulcer is a serious complication fraught with pain,1-3 decreased quality of life,4-7 and the expenditure of substantial caregiver time and healthcare dollars.8-12 The formation of a new pressure ulcer while hospitalized has been defined by the National Quality Forum14 (NQF) as a hospital-acquired condition (HAC) that is high-cost and high-volume and may be preventable with implementation of evidence-based guidelines. As of October 1, 2008, the Center for Medicare and Medicaid Services (CMS) no longer will pay for the ancillary cost of care for a facility-acquired pressure ulcer.14 However, HealthGrades, Inc.15 recently reported that 445,028 pressure ulcers developed in almost 14 million Medicare patients (32 cases/1,000 patients) from 2005 to 2007 and cost $2.41 billion in excess healthcare costs, demonstrating a gap from the desired goal. Of the persons who developed ulcers, 42,213 (9.5%) died; however, these were “all cause deaths” and like other reports16 that state that pressure ulcers were not an independent variable for mortality, pressure ulcers may not be the primary cause of death.
Preventing pressure ulcers has become a key focus of many healthcare institutions in the US and throughout the world. Whether all pressure ulcers are preventable is still under debate, but the actions of the NQF and the CMS have refocused pressure ulcer prevention efforts across acute care facilities.
Prevalence surveys provide a way for healthcare institutions to benchmark their facilities against national prevalence rates as well as report progress in their own institution year over year. Prevalence is defined as “a cross-sectional count of the number of cases at a specific point in time, or the number of people with pressure ulcers who exist in a patient population at a given point in time.”17 Pressure ulcer prevalence is measured by counting the number of patients with pressure ulcers divided by the number of patients surveyed.18 Facility-acquired (FA) prevalence is the number of patients with either new ulcers or who did not have their ulcers documented as present on admission (POA). Therefore, FA prevalence is driven by both the formation of new ulcers and the lack of documentation of existing ulcers.
Assessments of pressure ulcer prevalence within facilities may direct a focused prevention effort and create an effective resource utilization strategy. Several healthcare organizations and facilities have reported substantial reductions of pressure ulcer prevalence and incidence after implementing a quality improvement initiative.19-23 The Institute for Healthcare Improvement (IHI) expanded a campaign to assist facilities in developing and sharing best practices and provides a forum for reporting success stories associated with pressure ulcer reduction and other patient safety initiatives.19 One example is a December 2006 report. The Sisters of the Third Order of Saint Francis’ (OSF) Medical Center in Peoria, IL implemented a comprehensive pressure ulcer prevention program called “Save Our Skin” and reduced overall FA pressure ulcers from 9.4% in 2001 to 3.1% in 2003.19 A 2009 report shows Onslow County Hospital, Jacksonville, NC, reduced FA pressure ulcer incidence by half following a 2-year (March 2007 to March 2009) process improvement program that involved quarterly pressure ulcer prevalence and incidence surveys.20 Ascension Health’s (St. Vincent Hospital, Jacksonville, FL) “SKIN” program reduced FA pressure ulcers from >2.0 ulcers per 1,000 patient days to <1.0 between 2004 and 2006.21 Holmes Regional Medical Center (Melborne, FL) reported a reduction of FA pressure ulcers from an average of 9.2% (2002–2003 data) to 6.6% in 2004, with a focused reduction in the medical intensive care unit (MICU).22 Ballard et al23 reports an intensive care unit (ICU)-focused program where FA ulcers have been reduced from 30% to 7%, and there are many other successful reports. By assessing prevalence and incidence and subsequently creating process improvement programs to address skin care assessment and documentation, staff education, and pressure ulcer prevention interventions, these facilities and others have achieved noteworthy success.
The purpose of this observational, cross-sectional cohort study was to assess pressure ulcer prevalence in 2008 and 2009. In addition, previously published US data (2006/2007) were used to assess general and acute care (AC) unit-specific PU prevalence trends.
Methods
The Hill-Rom (Batesville, IN) International Pressure Ulcer Prevalence™ (IPUP) Survey24 consists of aggregate data from self-selected sites. The survey is available to all healthcare facilities regardless of customer status. The prevalence survey has been conducted in the US since 1989; the first survey served as a benchmark for later surveys conducted in 1991, 1993, 1995, 1999, 2001, 2003, and annually from 2003 to 2009. Sites receive study materials that include data collection forms, educational materials, and general instructions. Participating facilities perform prevalence surveys during a pre-determined 24-hour period within a pre-selected 2- to 3-day window, usually in late February or early March. The 2008 study was conducted between March 11 and 13 and in 2009 data collection occurred from February 24–26, 2009 using previously published methods.24 Although the goal of the survey is to assess all patients admitted to a facility, 100% patient inclusion is not mandated for participation. All generated data are incorporated into the database, even if specific data fields are absent. To evaluate nosocomial PU prevalence changes in the US, previously published prevalence data from 2006-2007 were used.25
Prevalence excluding Stage I is calculated because it has been argued that substantial errors and subsequent data problems associated with assessing Stage I pressure ulcers can occur.26
Data analysis. Data were extracted from the original data sets, sorted by desired fields, and analyzed using simple descriptive statistics.
Results
In 2009, a total of 96,068 patients were surveyed in all care settings. US facilities contributed data on 92,408 patients: 86,932 were in acute care (AC); 1,473 in long-term acute care (LTAC); 2,144 in long-term care (LTC); 1,588 in rehabilitation facilities; and 271 in home care. The geographic distribution of US AC patients is shown in Figure 1, with the largest portions of participants located in the South Atlantic, East North Central, and West South Central regions.
Prevalence in combined care settings was 13.5% in 2008 and 12.3% in 2009; FA prevalence rates were 6% in 2008 and 5% in 2009 (see Table 1). In US AC facilities, pressure ulcer prevalence was 13.1% (6.0% FA) in 2008 and 11.9% (5.0% FA) in 2009. 
Geographically, FA prevalence ranged from approximately 4% in some eastern regions to 8.2% in the Pacific region (see Figure 2); however, data were not evenly distributed. When Stage I ulcers were excluded, overall pressure ulcer prevalence was 9.6% in 2008 and 9.0% in 2009, and FA prevalence was 3.6% in 2008 and 3.2% in 2009. Review of specific care settings showed lower overall and FA pressure ulcer prevalence with the exception of LTC, which had overall prevalence of 11.7% in 2008 and 11.8% in 2009 and FA 4.9% in 2008 and 5.2% in 2009 (see Table 1).
Unit-specific results for 2009. In 2009, approximately one in 10 patients in adult ICUs developed a pressure ulcer; FA prevalence ranged from 8.8% in general cardiac care units (CCUs) to 10.4% in surgical ICUs (see Table 2). Of these pressure ulcers, 65% to 75% were more severe than Stage I. Overall prevalence in adult ICUs ranged from 16.6% in surgical ICUs 20.7% in MICUs. Step-down units and telemetry had 5.1% to 6% prevalence and 11.8% to 13.1% overall prevalence. Medical, med-surg, and surgical floors ranged from 8.6% to 13.4% overall prevalence and 3.9% to 4.3% FA prevalence. Other unit-specific data are shown in Table 2.
Of all patients admitted to ICUs, 3.3% may develop a severe pressure ulcer (Stage III, Stage IV, eschar/unable to stage, or deep tissue injury [DTI]) (see Table 3). AC facilities that have LTAC and LTC units within their organizations had similar FA and overall pressure ulcer prevalence rates when compared to independent LTAC and LTC facilities.
Ulcer severity. A total of 17,911 pressure ulcers were recorded in the 86,932 AC patients surveyed in 2009; of these ulcers, 6,589 (36.8%) were FA and included 876 (13.3%) Stage III, Stage IV, eschar/unable to stage; 642 DTI; 4,985 Stage I or Stage II; and 86 unspecified ulcers. Among all ulcers identified, 1,631 (9.1%) were described as “device-related”; of these, 785 were FA and 360 were Stage III/Stage IV/eschar/unable to stage. Of these 360 device-related severe ulcers, 109 were FA. Device-related pressure ulcers were common in all pediatric areas, labor and delivery, burn, cardiac surgery, ICUs, neurology, step-down, and LTC units. The most common anatomic locations for device-related ulcers were the ear (20%), followed by the sacral/coccyx region (17%), heel (12%), and buttocks (10%). 
Overall trends. Unit prevalence data from the 2007, 2008, and 2009 US AC adult surveys show lower overall and FA prevalence rates across a wide range of units (see Figures 3 and 4). Combined ICU data (general, MICU, SICU, CCU) show a 21.2% overall (11.5% FA) prevalence rate in 2007 and a 19.0% over all (9.9% FA) rate in 2009. Lower rates are seen in most units with the exception of renal/urology and geriatric/psych (see Table 3), where a number of device-related pressure ulcers were reported. FA pressure ulcer prevalence rates were lower in 2009 than in 2007 in most units, with exceptions in the emergency department (ED), burn, and surgical units (see Table 3 and Figure 4). The burn and ED units have relatively low numbers of patients; therefore, these findings should be interpreted with caution.
Overall prevalence in pediatric and PICU units was also lower in 2009 than in 2007 with the exception of NICU (see Figure 5), which is not seen in reported FA prevalence (see Figure 6).
Discussion
The results of this study show a trend toward lower overall pressure ulcer prevalence rates during the last 3 years. This trend is observed in most hospital units with a few exceptions. However, a gap remains between what is desired in AC US facilities and the FA pressure ulcer prevalence data in this study, especially in ICUs where 3.3% of all patients admitted develop a severe pressure ulcer (Stage III, Stage IV, eschar/unable to stage, DTI). Although slightly lower than the 2008 rates, data from this 2009 study show a 11.9% overall and 5% FA pressure ulcer prevalence rate in AC facilities. The prevalence of severe pressure ulcers (Stage III, Stage IV, eschar/unable to stage, DTI) was highest in adult ICUs (3.3%). LTC (4.4%) and LTAC (3.2%) units also have high severe FA pressure ulcer prevalence rates, trends fairly well identified in previous literature.27 Device-related pressure ulcers represented approximately 9% of all identified pressure ulcers and 11.9% of the FA pressure ulcers, suggesting that this should be an important pressure ulcer prevention focus area.
Vollman28 reports that one of the basic drivers of improved patient safety and pressure ulcer reduction is for nurses to understand their unit-based incident rate of patient safety indicators, as well as to compare their incident rate against national benchmarks. The results of this study may assist facilities in their efforts to benchmark current prevalence to like units. Many healthcare organizations are reporting improvement in preventing FA pressure ulcers.19-23 Focus on pressure ulcer prevention in healthcare has increased over the last several years, as demonstrated by the attention of many national organizations including the IHI,19 Joint Commission on the Accreditation of Healthcare 
Organizations,29 the CMS,13 the American Nursing Association (ANA),30 and others, possibly explaining the trend observed in the study data.
Although the data suggest that overall pressure ulcer prevalence rates are improving, much research is needed to optimize patient risk assessment, prevention strategies, and treatment of existing ulcers across the healthcare continuum.
Limitations
Most of the study limitations are inherent in the design of observational, cross-sectional cohort studies and the development of pressure ulcers. All data reported by the unit represent the patient’s location at the time of the survey, which may differ from the location where the patient actually developed the pressure ulcer. Also, the determination that a pressure ulcer is FA also depends on assessment and documentation accuracy upon admission. Therefore, the lower FA rate in 2009 could be the result of better documentation of pressure ulcers that were present on admission. If documentation improved, reported overall prevalence could be expected to be higher, while FA prevalence would decrease. Also, while the result of the prevalence surveys cannot be interpreted to indicate decreased incidence, the larger sample size, the fact that more than two data points (2 years) are available, and the consistency of the observed trend all are encouraging. Finally, the geographical distribution of participating facilities was not uniform, participation was voluntary, and the results have not been validated by the sponsor.
Conclusion
Aggressive preventative care is essential for pressure ulcer prevention and may require substantial, but often scarce, resources. By understanding which units within a facility have the highest pressure ulcer rates, management can make informed decisions as to where to focus resources and prevention efforts.
The survey data indicate that prevalence rates were 1.2% lower in 2009 than in 2008, which is encouraging. Many facilities19-23 have reported substantially decreased pressure ulcer prevalence and incidence rates, suggesting that pressure ulcer prevention efforts can be effective. Only additional benchmarks and continued data sharing will help demonstrate whether preventive efforts are working.
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