International Prevalence Measurement of Care Problems (LPZ) 2009-2010 At a glance Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 1 Praxisprojekte 2008 31-5-2011 11:55:32
Colofon LPZ research group Netherlands Prof. R.J.G. Halfens, project leader Prof. J.M.G.A. Schols, senior researcher Dr J. M.M. Meijers, researcher Dr J. Neyens, researcher N. C. van Nie MSc, researcher S. Rijcken MSc, research assistant S. Wolters MSc, research assistant LPZ research group Germany Prof. S. Bartholomeyczik, project leader S. Reuther MSc, researcher LPZ research group Austria Prof. C. Lohrmann, project leader S. Schönherr, BSc, MSc, researcher S. Schüssler, BSc, MSc, research assistant S. Klein, MA, research assistant LPZ research group Switzerland Prof. S. Saxer, project leader LPZ research group New Zealand Dr J. Weststrate, project leader Copyright: Maastricht University, School for Public Health & Primary Care / CAPHRI, Department of Health Services Research, 2011. The reproduction of texts of this brochure, wholly or in part, is permitted, provided that the source is mentioned. When you refer to this brochure please use the following reference: Halfens R.J.G., Schols J.M.G.A., Bartholomeyczik S., Reuter S., Saxer S., Lohrmann C., Schönherr S., Weststrate J., Nie van N.C. (2011). International Prevalence Measurement of Care Problems (LPZ): 2009-2010 At a glance. Datawyse, Maastricht. Design and printing: Datawyse, Maastricht Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 2 31-5-2011 11:55:32
Preface This is the first joint report of the International Prevalence Measurement of Care Problems, known as the LPZ (Landelijke Prevalentiemeting Zorgproblemen). Each year, a large number of institutions take part in this health care monitor. Originating in the Netherlands, nowadays it is also carried out in Germany, Austria, Switzerland and New Zealand. Each country reports its results annually in a country specific and more extensive report. These national reports provide a good overview of the policy, prevalence, prevention and treatment of measured care problems. Those who need precise information on the care provided in their own country will find the reports of recent years to be excellent sources of information. However increasing numbers of participants are interested in the international results. Therefore we have developed this brochure. It provides an overview of the most important results and is therefore useful for a broader audience. For more specific information we refer to the national reports. In this brochure the results of the measurements in 2009 and 2010 are combined to give a broader overview. Only the results of hospitals and nursing homes are included in this brochure. For those who are interested to take part in the LPZ, this brochure contains two reviews written by experts in which they tell about their experiences and implementation of the Dutch National Prevalence Measurement of Care Problems (LPZ) in the institution where they work. You can order more brochures from the LPZ group or download it from our website (www.lpz-um.eu). For the national reports we refer to the project leaders of the individual countries. We hope you enjoy reading this brochure. On behalf of the LPZ research groups, Prof.dr. R.J.G. Halfens 1 Preface Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 1 31-5-2011 11:55:32
Measuring leads to improvement One of the strongest interventions for change in institutions is feedback and audit. This is exactly what the LPZ intends to do. Measuring care problems brings them to the awareness of caregivers, managers, policymakers and politicians. And indeed, the LPZ results show that awareness genuinely leads to improvement in daily practice. To give an example: the more times an institution participated in a malnutrition measurement, the higher its reduction in malnutrition prevalence. In other words, measuring helps! And clearly this is not due to the measurement itself. Obviously, one must do something to initiate change. Based on the LPZ results, health care institutions can start improving their care performance by looking what is done in daily routine regarding prevention, interventions and quality indicators. Also the LPZ results give politicians insight into the quality of care, and if necessary they can initiate programmes to improve care on a national level, as has happened in the Netherlands. A few years ago the Dutch government started financial supported additional national health care improvement programmes. These programmes included Zorg voor Beter ( Care for Better ) for the chronic sector and Sneller Beter ( Cure Faster ) for the acute sector. The LPZ results demonstrated that participation in these programmes helped reduce malnutrition prevalence. Measuring care problems e.g. pressure ulcer, incontinence, malnutrition, falls and restraints and intertrigo, is necessary to ensure continued focus on these issues. Focused improvement programmes, in turn, are necessary to offer institutions concrete guidelines for change. 2 Preface Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 2 31-5-2011 11:55:32
Annual magnifying glass Each year, the LPZ places health care under the magnifying glass at a specific time (April and/or November). Patients and residents of hundreds of hospitals, nursing and residential homes, home care and other health care facilities are involved. The defining characteristic of the LPZ is that all patients are examined on the same day in all institutions for several care problems which might develop during their admittance. Nurses, caregivers and doctors receive instructions and go in pairs from bed to bed to examine patients in their institutions. The home care sector also is involved in this measurement, but spreads its examinations over four days. The LPZ thus annually collects large amounts of data which show how many patients suffer from pressure ulcers, incontinence, malnutrition, how many have fallen or have been physically restrained during their stay in the institutions, and intertrigo. These are all problems which many patients end up facing but which can be reduced through attentive nursing, care and treatment. In addition to the frequency with which these care problems occur, the LPZ also records what the institutions do to prevent and treat these care problems. In this way, it also shows what still needs to be done. Participating institutions can view their own results and benchmark them with the results of similar institutions to see how well they are doing. The combination of the results of all participating institutions provides insight into the general quality of national and international basic care, and how this care is developing. Figures In this brochure only the results of hospitals and nursing homes in the different countries are presented. Other health care organisations, such as home care or rehabilitation centres, are not included, while the number of participating organisations is too low for an international comparison. Data from 2009 and 2010 is combined to have sufficient facilities per country. In 2009 and 2010, a total of 922 hospitals and nursing homes with 4,249 wards participated in the study. Only informed patients older than 18 years were included. There were almost 90,000 patients in total. In most countries participating institutions are free to choose the care problems they wish to measure. Therefore not all organisations measured all care problems. The number of participants is mentioned by each care problem separately. International comparison The LPZ gives a unique possibility to compare data between countries, due to the fact that the same definitions, same instruments, same method and same in- and exclusion criteria are used. However data must be interpreted with care. The participating organisations are not a random selection of the existing organisations, even though they participated on a voluntary basis. In the Netherlands it has been shown that organisations who participated at the start of the LPZ in 1998 had better figures than those 3 Annual magnifying glass Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 3 31-5-2011 11:55:32
who started later on, which suggests that these organisations were more motivated to enhance their quality of care. Therefore the results of Germany, Austria, Switzerland and New Zealand can be an underestimation of the problems, while they just started with the measurement. Another factor which must be taken into account in the interpretation is that the type of organisations differed between countries. A nursing home in the Netherlands differs from a nursing home in New Zealand. When looking only at the mean number of patients per nursing home in both countries, we see a big difference (86 versus 32 patients). In spite of these differences, a comparison of the results between countries is still important. It not only gives insight into the quality of care per country but also gives a global idea about the degree of quality of care of a country in comparison to the other countries. Furthermore it is important to get insight into possible reasons for differences between countries. Table legend GH = general hospitals NH = nursing homes 4 Annual magnifying glass Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 4 31-5-2011 11:55:32
Participants In our study, 149 hospitals and 768 nursing homes participated in 2009 or 2010. Most of these are from the Netherlands. In Germany only nursing homes were invited. Most patients were female, especially in the nursing homes. In the hospitals, the percentage of females seems somewhat higher in New Zealand than in the other countries, while for the nursing homes this seems true for Austria. The mean age of patients also differs between hospitals and nursing homes. Patients in nursing homes are almost 17 years older than patients in hospitals. In the Swiss hospitals and the German nursing homes patients are somewhat younger compared to the same organisations in the other countries. Table 1 Number of participants of LPZ The Netherlands Austria Switzerland New Zealand Germany Characteristics of participants GH NH GH NH GH NH GH NH NH Number of organisations 112 662 29 24 3 4 5 15 63 Number of wards 1399 2123 249 106 52 14 34 16 256 Response (%) 93.1 94.4 75.9 80.8 99.0 93.1 78.9 82.1 83.4 Number of participating patients 21703 53953 3977 2193 663 228 631 389 4284 Percentage of women 51.1 73.9 54.4 83.7 48.3 69.7 59.0 71.5 77.5 Mean age 65.6 83.1 66.6 83.1 60.3 84.5 67.3 84.2 82.1 Mean care dependency 62.5 49.8 65.9 38.9 64.2 52.2 60.2 49.0 42.3 More important than differences in gender and age is the degree of the patients care dependency in each country. This varies in the hospitals of the participating countries between the values of 60.2 and 65.9, which is not a big difference on a scale (Care Dependency scale (CDS)), measuring 15 aspects of care dependency by means of a 5-point Likert Scale. Sum scores between 15 (completely dependent) and 75 (almost independent) can be obtained. In nursing homes this difference seems to be bigger, namely from 38.9 to 52.2. Patients in Austria are more care dependent than the patients in Switzerland. Assuming the same quality of care in both countries, one would expect, based on the care dependency of the patients, higher prevalence rates of the measured care problems in Austria. 5 Annual magnifying glass Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 5 31-5-2011 11:55:32
Pressure ulcers Recommendation The lowest prevalence of pressure ulcers can be found in German nursing homes. It shows that these nursing homes use the highest number of preventive measures, especially regarding pressure reduction/distribution and skin care. It is recommended to adapt this German strategy to the other countries. Prevalence The prevalence of pressure ulcers (excluding category 1) varies between 2.5 and 5.5% (see table 2). Hospitals generally have higher prevalence rates than nursing homes. Comparing the rates between countries and type of organisation is arguable as the population can differ, especially the degree to which they are vulnerable for developing pressure ulcers. Therefore the prevalence rate for only the patients with a risk of developing a pressure ulcer is also calculated. It shows that these prevalence rates are lower in Austria and Switzerland. The hospitals in these two countries have the lowest prevalence rates compared to the hospitals in the Netherlands and New Zealand. With respect to the nursing homes, Germany and Switzerland have the lowest prevalence rates. A comparable picture is apparent when looking at the prevalence of pressure ulcers in their own organisations. The only remarkable difference is that in Austria this prevalence is lower in hospitals than in the nursing homes. Table 2 Prevalence of pressure ulcers (PU) The Netherlands Austria Switzerland New Zealand Germany Prevalence GH NH GH NH GH NH GH NH NH Number of patients 21454 37138 3977 2193 663 228 631 389 1543 PU excl category 1 (%) 5.5 2.8 2.5 5.0 3.0 2.6 8.3 4.1 2.7 PU excl category 1, risk patients (%) 10.2 6.1 7.0 6.5 6.8 3.7 11.8 6.1 4.0 Nosocomial PU excl. cat. 1, risk patients (%) 6.4 4.1 2.7 3.4 4.5 2.8 6.2 2.8 2.0 Prevention In table 3 the preventive measures used are presented. There are huge differences between the countries and type of organisations. Pressure ulcers are caused by pressure, so the best way to prevent them is to reduce or relieve possible pressure by using a pressure reducing mattress, regularly changing patients positions and floating heels. In general the German and Austrian nursing homes used the most preventive methods, while in Switzerland and New Zealand the lowest number of measures is used. The high use of barrier creams to protect the skin in the German speaking countries is remarkable. The use of heel protectors and sheepskins are low in all countries, although the use of a sheepskin in New Zealand is relatively high. 6 Pressure ulcers Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 6 31-5-2011 11:55:32
Table 3 Preventive measures used for patients at risk of pressure ulcer per country (%) The Netherlands Austria Switzerland New Zealand Germany Preventive measures GH NH GH NH GH NH GH NH NH Number of patients 21454 37138 3977 2193 663 228 631 389 389 AD-mattress 91.6 64.6 44.0 75.7 16.4 16.5 61.3 52.0 52.0 Position change 25.5 14.7 29.1 41.7 39.9 10.1 26.1 20.3 20.3 Floating heels 22.9 17.6 29.8 36.6 32.1 20.2 15.9 4.9 4.9 Heel protector 5.6 4.1 5.9 16.0 4.1 3.7 2.1 8.1 8.1 Preventing shortage of liquid and nutrition 40.8 31.0 23.6 32.9 29.1 20.2 28.0 37.0 37.0 Information and instruction 26.0 15.2 28.8 28.7 19.8 17.4 17.3 20.7 20.7 Barrier cream 14.3 33.4 63.5 89.3 47.8 71.6 24.0 44.7 44.7 Sheepskin 0.1 0.9 0.2 2.7 0.4 5.5 0.7 11.4 11.4 Mean number of measures 2.27 1.82 2.25 3.24 1.90 1.65 1.75 1.99 1.99 Four categories of pressure ulcers Category I: Non-blanchable erythema Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (Bruising indicates deep tissue injury). This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation. Category III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling. The depth of a Category III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category III pressure ulcers. Bone/tendon is not visible or directly palpable. Category IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. 7 Pressure ulcers Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 7 31-5-2011 11:55:33
Structural indicators Besides measuring prevalence and preventive measures, some structural indicators on organisational and ward level have also been measured. Examples include whether the organisation has guidelines for prevention and treatment, if health care workers get refresher courses, and if somebody on the ward specialises in the care of pressure ulcers. It shows that the Dutch organisations fulfil most of these indicators, which seems logical as the measurement already exists for much longer in the Netherlands. In Switzerland the lowest number of indicators is fulfilled. Table 4 Mean number of fulfilled structural indicators: pressure ulcers The Netherlands Austria Switzerland New Zealand Germany Level GH NH GH NH GH NH GH NH NH Number of institutions /wards 110/1380 464/1441 29/249 24/106 3/52 4/14 5/34 2/16 26/85 Organisational level (9 indicators) 7.8 7.4 5.5 4.2 3.7 3.3 3.8 7.5 6.4 Ward level (8 indicators) 5.9 6.5 5.9 5.8 4.0 5.2 5.0 6.3 6.2 8 Pressure ulcers Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 8 31-5-2011 11:55:33
Malnutrition Recommendation In almost all countries the screening of patients at admission can be enhanced, and subsequently also the supply of energy enriched diet or snacks or other oral nutritional supplements. Malnutrition Malnutrition is often caused by less than normal food intake or enhanced need and indicated by unintentional weight loss, combined with a low body mass index (lower than 18.5; for clients age 65 or older BMI lower than 20). According to these criteria almost one fourth of the patients is malnourished. Table 5 shows there are no significant differences between the countries and the type of organisation, although in New Zealand somewhat more patients are malnourished. Table 5 Prevalence of malnutrition (%) The Netherlands Austria Switzerland New Zealand Germany Prevalence GH NH GH NH GH NH GH NH NH Number of patients 13450 34070 3977 2193 663 228 245 389 4284 Malnutrition 22.8 20.2 25.1 25.7 24.7 21.9 26.8 30.5 23.0 Screening and treatment To determine whether patients are vulnerable for malnutrition one of the things that is important to know is their weight on admission to the institution. This will show whether their weight has increased or decreased over time. As table 6 shows, not all patients are screened for malnutrition, although there are big differences between countries and types of organisations. In the German nursing homes almost all patients have been screened, while in the Swiss nursing homes only one fourth has been screened. The measures taken when patients have a risk for malnutrition also differ greatly between the countries and types of organisations. For instance, in Austrian nursing homes 65% of patients who have a risk of malnutrition were consulted by a dietician, but this figure was only 6% in the Swiss nursing homes. Energy-enriched diet and snacks, and/or other nutritional supplements are most often given in the German nursing homes, and are given the least in the Swiss, New Zealand, and Dutch nursing homes. Enteral tube feeding and intravenous feeding are less used in most countries, although in Swiss hospitals it is used somewhat more. 9 Malnutrition Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 9 31-5-2011 11:55:33
Table 6 Screening and (for patients at risk) treatment (%) The Netherlands Austria Switzerland New Zealand Germany Measures GH NH GH NH GH NH GH NH NH Number of patients 13450 34070 3977 2193 663 228 245 389 4284 Screening 76.0 48.4 65.4 93.1 50.7 22.8 27.3 79.9 98.0 Dietician 50.0 31.4 21.0 65.5 46.1 6.1 19.4 14.0 11.0 Energy (protein) enriched diet 30.2 9.3 12.7 21.0 16.2 1.4 10.4 10.8 19.1 Energy-enriched snacks between meals 25.1 15.0 14.5 28.3 18.0 18.8 20.8 5.9 45.4 Supplementary oral nutrition 21.9 16.0 20.6 28.8 25.3 12.1 20.2 21.0 23.8 Enteral tube feeding 11.5 1.3 6.0 6.1 20.8 4.5 1.6 1.0 7.1 Intravenous feeding 4.5 0.2 12.1 3.0 15.7 0.0 8.1 0.0 2.8 Structural indicators Examples of structural indicators regarding malnutrition are: if all patients are screened at admission, if health care workers get refresher courses on adequate nutritional care, and if they have an information brochure for patient and/or family/informal caregivers. Most indicators are fulfilled in the nursing homes in Germany and Austria at ward level. Table 7 Mean number of fulfilled structural indicators: malnutrition The Netherlands Austria Switzerland New Zealand Germany Level GH NH GH NH GH NH GH NH NH Number of institutions/wards 45/548 243/767 29/249 24/106 3/52 4/14 2/17 2/16 63/256 Institutional level (8 indicators) 6.7 5.2 4.6 4.5 6.3 1.3 2.5 6.0 5.0 Ward level (14 indicators) 8.7 8.4 7.8 10.5 7.4 6.4 6.1 9.8 10.8 10 Malnutrition Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 10 31-5-2011 11:55:33
Incontinence Recommendation Urine incontinence has a high prevalence, especially in nursing homes. In most of the cases a disposable is used. More attention to other preventive measures is recommended. Urinary incontinence Urinary incontinence is defined as any form of urine loss. Urine incontinence is particularly widespread in nursing homes, especially in Austria. In hospitals fewer patients are urine incontinent. Although in Austria most nursing home residents are urine incontinent, they have the lowest number of residents with double (urine and faeces) incontinence. Around two to five percent of the patients in all countries have an incontinence lesion. Table 8 Prevalence of incontinence (%) The Netherlands Austria Switzerland New Zealand Prevalence GH NH GH NH GH NH GH NH Number of patients 5429 16407 3977 2193 1190 228 327 389 Urine incontinence 11.8 58.3 18.1 80.1 18.3 69.4 19.7 52.0 Double incontinence 3.0 26.5 3.8 5.3 1.8 24.7 6.3 19.4 Incontinence lesion 2.4 5.0 1.7 2.4 1.8 3.9 5.3 3.2 Measures As shown in table 9 most measures directed to incontinence are taken in nursing homes. For almost all urine incontinent patients one or more measures are taken. The most used intervention is the use of disposables. In nursing homes almost everyone who is incontinent receives a disposable. Furthermore, especially in nursing homes, a schedule for bathroom visits is used. Bladder training is done more often in hospitals, and adjustments of clothes and environment are done more often in both hospitals and nursing homes in Austria and New Zealand. Looking specifically at the actions to prevent patients from being incontinent (bathroom visits, bladder training, and adjustments of clothes and environment) it becomes clear that in the Netherlands less actions are undertaken. 11 Incontinence Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 11 31-5-2011 11:55:33
Table 9 Measures directed to incontinence (%) The Netherlands Austria Switzerland New Zealand Measures GH NH GH NH GH NH GH NH Number of patients 5429 16407 3977 2193 1190 228 327 389 No actions 43.3 5.4 27.0 3.3 24.0 4.3 30.5 8.1 Disposables 47.2 91.5 66.9 93.5 56.0 93.2 57.3 86.3 Schedule for bathroom visits 9.7 37.7 10.5 50.4 16.0 27.8 14.6 43.1 Bladder training 2.4 0.6 5.7 2.0 12.0 0.0 6.1 0.5 Clothing adjustments 4.8 6.5 18.4 36.3 4.0 4.3 15.9 28.9 Environmental adjustments 1.5 2.2 19.8 26.1 12.0 13.6 4.9 22.3 Structural indicators About half of the indicators on organisational and ward level is fulfilled. Switzerland and New Zealand differ a little from the Netherlands and Austria, but due to the low number of organisations and wards it is dangerous to generalise this outcome. Table 10 Mean number of fulfilled structural indicators: incontinence The Netherlands Austria Switzerland New Zealand Level GH NH GH NH GH NH GH NH Number of institutions/wards 37/375 199/604 29/249 24/106 2/9 4/14 3/21 2/16 Organisational level (7 indicators) 4.2 4.1 3.3 2.6.5 1.5 3.7 6.5 Ward level (5 indicators) 2.4 3.4 2.8 3.1 2.1 2.0 1.6 3.6 12 Incontinence Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 12 31-5-2011 11:55:33
Falls Recommendation Around ten percent of the patients in nursing homes fell in the month preceding the measurement, and one third of them suffered from injury due to this falling. Prevention of falls and fall injuries is therefore of utmost importance. Figures show that this is not always the case. Falls A fall is defined as an unintentional change in position that results in a person coming to rest on the ground or other lower level. In this study the prevalence of falls is calculated as having fallen one or more times during the last month. In New Zealand the prevalence of falls is higher than in the other countries. Remarkably in Switzerland, the prevalence of falls in nursing homes is higher than in hospitals, while in the other countries this is the other way around. The reason for this is that patients who have been fallen and have a serious injury will be admitted to the hospital. This also explains why more patients in hospitals have an injury and often a more serious injury. Prevention Table 11 Prevalence of falls, and fall injuries (%) The Netherlands Austria Switzerland New Zealand Prevalence GH NH GH NH GH NH GH NH Number of patients 4657 23287 3977 2193 663 228 327 389 Falls 13.7 9.3 15.2 8.9 7.1 16.3 27.5 15.1 Injury 65.3 35.0 58.6 36.2 38.2 41.7 77.6 28.6 Serious injury (such as hip fracture) 60.0 15.9 39.5 11.3 38.5 13.4 59.2 5.6 Prevention As expected, falls are more often prevented in nursing homes than in hospitals. However the countries differ in the degree of prevention. In Austria falls are prevented more often than in the Netherlands. The same situation occurs when looking into the prevention of fall injuries. Injuries are more often prevented in nursing homes, and in Austria more often than, for example, in the Netherlands. 13 Falls Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 13 31-5-2011 11:55:33
Table 12 Prevention of falls and fall injuries The Netherlands Austria Switzerland New Zealand Measures GH NH GH NH GH NH GH NH Number of patients 4657 23287 3977 2193 663 228 327 389 Prevention of falls 30.2 66.3 42.6 90.4 27.6 78.9 50.8 71.2 Prevention of fall injuries 3.0 10.8 5.6 30.3 6.3 25.9 13.8 12.9 Structural indicators Around half of the indicators on organisational and ward level are fulfilled. Switzerland seems to fulfil less of the indicators, but due to the low numbers of organisations, it is dangerous to generalise. Table 13 Mean number of fulfilled structural indicators: falls The Netherlands Austria Switzerland New Zealand Indicators GH NH GH NH GH NH GH NH Number of organisations/wards 28/303 279/863 29/249 24/106 3/52 4/14 3/21 2/16 Organisational level (5 indicators) 2.5 3.5 3.4 2.8 1.7 2.3 2.7 3.5 Ward level (5 indicators) 2.5 3.6 3.4 3.8 1.6 2.9 2.9 4.6 14 Falls Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 14 31-5-2011 11:55:33
Physical restraints Recommendation Physical restraints, and especially bed rails, are most often used in nursing homes. Due to the fact that bed rails can be dangerous when patients want to leave the bed, it is recommended to look for other preventive measures to prevent patients from falling. Physical restraints Physical restraints are interventions such as bed rails, bed-straps, nursing blankets, deep chairs and chair tables which are used to prevent dangerous or risky situations. Health care workers often use physical restraints to prevent falls. Table 14 shows that physical restraints are more often used in nursing homes than in hospitals. The only country in which this does not apply is New Zealand. Most used restraints are bed rails, especially in hospitals. The only exception is Switzerland where the use of bed rails is low in hospitals in comparison with the other countries and types of organisations. Other restraints are used only incidentally, with the exception of bed straps in the Dutch hospitals and behaviour influencing medication in the Dutch nursing homes. Table 14 Prevalence of physical restraints The Netherlands Austria Switzerland New Zealand Prevalence GH NH GH NH GH NH GH NH Number of patients 4657 23287 3977 2193 663 228 327 389 Physical restraints 11.0 23.8 6.8 31.1 8.2 24.6 24.4 9.9 Bed rails 92.3 66.8 96.7 89.7 48.1 82.1 97.4 81.6 Nursing blankets 3.8 3.0 0.0 0.1 1.9 1.8 0.0 0.0 Bed straps 10.4 2.6 1.1 0.0 3.7 3.6 0.7 2.6 Behaviour influencing medication 4.2 20.3 2.9 2.5 0.0 8.9 0.0 0.0 15 Physical restraints Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 15 31-5-2011 11:55:33
Due to the low number of structural indicators it is difficult to compare the countries and type of organisations. Table 15 Mean number of fulfilled structural indicators: physical restraints The Netherlands Austria Switzerland New Zealand Number of institutions/wards 28/303 279/863 29/249 24/106 3/52 4/14 3/21 2/16 Number of institutions 28 279 29 24 3 4 3 2 Organisation level (3 indicators) 1.7 2.7 2.0 2.5 1.0 1.5 2.3 3.0 Ward level (3 indicators) 1.7 2.3 1.8 2.2 1.3 2.3 1.5 2.8 16 Physical restraints Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 16 31-5-2011 11:55:33
Intertrigo Recommendation In Austria fewer patients have intertrigo than in the Netherlands. In Austria patients are washed more often with PH-neutral soap. Furthermore most patients receive a barrier cream/spray, or other local antifungal preparation, and their skin is inspected each day. It is recommended that in the Netherlands more attention be paid to patients with intertrigo. Intertrigo Intertrigo is an irritated and damaged place where the skin layers rub against each other. They are most frequent in the groin area or under the breasts. Data on intertrigo is only available in the Netherlands and Austria. In the Netherlands the percentage of patients with intertrigo is higher than in Austria, and in the nursing homes of both countries the percentage is also higher than in hospitals. Table 17 shows that Austrian health care workers pay more attention to the treatment of intertrigo. In general most patients with intertrigo are washed every day, with special attention to dry the folds of the skin. In Austria patients are washed more often with PH-neutral soap. Furthermore most patients receive a barrier cream/spray, or other local antifungal preparation, and their skin is inspected each day. Table 16 Prevalence of intertrigo (%) The Netherlands Austria GH NH GH NH Number of patients 7123 14039 3977 2193 Intertrigo 7.7 13.7 3.7 5.9 Table 17 Interventions to treat intertrigo (%) The Netherlands Austria Prevalence GH NH GH NH Number of patients 7123 14039 3977 2193 Daily washing/drying folds of skin 69.8 83.2 87.7 96.1 Washing without soap / washing with PH-neutral soap 17.5 32.7 45.2 41.1 Local antifungal preparation, barrier cream 65.1 77.8 73.3 82.9 Daily observation of the skin and folds of the skin 64.0 80.0 87.0 94.6 No measures 7.4 2.8 1.4 0.0 17 Intertrigo Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 17 31-5-2011 11:55:33
Structural indicators In the Netherlands more structural indicators, especially at organisational level, are fulfilled than in Austria. Table 18 Mean number of fulfilled structural indicators: intertrigo The Netherlands Austria Indicators GH NH GH NH Organisational level (6 indicators) 4.2 3.4 1.1 1.4 Ward level (5 indicators) 2.9 2.9 2.6 2.6 18 Intertrigo Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 18 31-5-2011 11:55:33
Experiences from the field This chapter consists of two reviews written by experts in which they tell about their experiences and implementation of the Dutch National Prevalence Measurement of Care Problems (LPZ) in the institution where they work. Ine Smeets, Lückerheide nursing home Ine Smeets works as a specialised nurse at Lückerheide nursing home in Kerkrade, the Netherlands. The nursing home is part of the care organisation Meander Groep Zuid-Limburg. She mainly deals with pressure ulcers and the regulation concerning BOPZ (involuntary psychiatric hold). After Ine followed in-service training, she started working in the geriatric department of the general hospital in Sittard and after a year and a half, she was hired by her current workplace. Soon after that, she was introduced to the world of pressure ulcers and in the 18 years that followed, pressure ulcers played an ever bigger role. In 2000, she was appointed chair of the pressure ulcers house committee and she joined the Decubitus Stichting Oostelijk Zuid-Limburg, a foundation in which various health care institutions link and work together in the field of pressure ulcers. From this foundation, the institutions started participating in the LPZ in 2001. The LPZ measurement Ine remembers the first time the Lückerheide clinic participated in the LPZ well. The first time was a big disappointment. It cost us a lot more work and energy than I had expected. In the years after that, however, it went a lot smoother. We knew what to expect and what preparations we had to make, and the observers also knew what had to be done. Nowadays, it s always a special event. Everyone knows when the measurement day is, and afterwards we have a sandwich together and evaluate the measurement. For the observers, it is an inspiring experience every time and looking beyond the doors of your own department is very encouraging. An important effect of the measurement is that we become aware of the problem. An annual measurement is vital in this. Every year, you can see the awareness increase around the time the measurement takes place. We have also gained insight into what happens in the various departments regarding pressure ulcers. As a result of the LPZ results we have started reporting cases of pressure ulcers to one person and we have also started checking the use of mattress toppers. Every year, the results are published in a report, which I then send to the pressure ulcers committee, all management staff, doctors and board members. The department staff are informed during the work meeting. Future Although we made a great effort, there is still so much to do. Looking back, I can see we have increased our knowledge of pressure ulcers, which is one of the reasons we are able to meet our residents physical demands better, and thus decrease the number of cases of pressure ulcers. 19 Experiences from the field Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 19 31-5-2011 11:55:33
In the near future, we will focus on developing two issues: we will frequently examine the pressure wounds together and we will make sure that bedridden patients change position more consistently. I think we have made a fantastic effort, but there is always room for improvement. I m sure that there will be issues in the future that need our attention and hopefully, we will be able to address them diligently. Nanneke Niesten, Vivre foundation Nanneke Niesten has been a dietician at the Vivre foundation in Maastricht, since 2001. She got her dietetics degree in 1981 and worked with the intellectually disabled for a few years before switching to the nursing home sector. Within the dietetics department, there are three dieticians that work a total of 53 hours a week. They work for all the nursing homes within the Vivre foundation, which means they have around 700 clients. The main focus of their work is direct patient care. In recent years, however, dieticians have also become more and more involved in the developments of nutrition and everything it involves. The LPZ measurement Vivre has participated in the LPZ every year since 2000 and the dietetics department has been involved in the preparation of the measurement since 2005. Nowadays, Vivre carried out all the modules. The dieticians have been structurally training the people that carry out the LPZ malnutrition measurement for the last two years. The annual training is considered a positive experience. Furthermore, the results are discussed with the institutional coordinator of the dietetics department every year. One of the policy issues that Vivre is dealing with as a result of the outcome of the measurement is the participation in the Vilans improvement project Eten en Drinken ( Nutrition and Fluids ), which focuses on a better mealtime ambiance and implements the national ActiZ nutritional guideline, which includes a weighing policy. In addition, Vivre has developed a more elaborate personal nutrition protocol on the basis of the national guideline. One of the things that is incorporated in the protocol is that the clients have to be weighed once every three months. The dieticians have been closely involved in the development of the protocol and use the LPZ data for presentations and training within the organisation. They will not, however, incorporate the data in the dietetics department policy developments. Nanneke thinks the LPZ is a great initiative, because it ensures that more attention is paid to the various care problems. She notices that, because of the initiative, the number of consultation requests increases after an LPZ measurement. What s more, it is of vital importance that the data gives the management more insight into the quality of the care that is provided. 20 Experiences from the field Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 20 31-5-2011 11:55:33
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Datawyse Universitaire Pers Maastricht LPZ research group Maastricht University School for Public Health and Primary Care / CAPHRI Department of Health Services Research Faculty of Health, Medicine and Life Sciences Duboisdomein 30, 6229 DG Maastricht, the Netherlands PO Box 616, 6200 MD Maastricht, the Netherlands T +31 43 388 1559 F +31 43 388 4161 www.lpz-um.eu Brochure_LPZ_2009-2010_At a glance_21x21_v09.indd 22 31-5-2011 11:55:34