Commentary on Tannen A, Dassen T and Halfens R (2008) Differences in prevalence of pressure ulcers between the Netherlands and Germany – associations between risk, prevention and occurrence of pressure ulcers in hospitals and nursing homes. Journal of Clinical Nursing 17, 1237–1244

Abstract

Tannen et al. (2008) investigated, in their extensive study, (n = 31,381) German and Dutch nursing homes and hospitals by nationwide surveys whether any potential differences in preventive activities can account for the varying occurrence of pressure ulcers. The prevalence rate was significantly higher in the Dutch than in the German sample. The researchers conclude that some of the variance in pressure ulcer prevalence can be explained by varying pressure ulcer prevention. One of the prevention interventions examined was nutrition intervention which, however, in the logistic regression model, did not have predictive value on prevention of pressure ulcers. We have also investigated the prevalence of pressure ulcers as a part of our nutritional study in all nursing homes (n = 20) and in all long-term care hospitals (n = 7) in the city of Helsinki (Muurinen et al. 2003, Soini et al. 2004), in Finland. Of all the residents (>65 years) in the nursing homes, 82% (n = 1983) and of the residents in long-term care hospitals, 75% (1084) participated in the study. Trained nurses carried out the assessment of residents’ nutritional status by Mini Nutritional Assessment (MNA) test (Guigoz et al. 1997). The test is well-validated and widely accepted screening instrument for nutritional status of older people. When the score (range 0–30) is <17 the resident is considered to suffer from malnutrition, 17–23·5 indicates a risk for malnutrition and >23·5 a good nutritional status. The question of pressure ulcer prevalence (yes/no) is included in the MNA-test. We also collected data concerning demographics, medical diagnoses and nutritional care of all residents by a structured questionnaire. The residents were old: mean age of the whole population was 82·8 years and 78·7% was female. Of the nursing home residents, 15·1% suffered from pressure ulcers whereas the respective figure for the long-term care hospitals was 22·1% (p < 0·001). The pressure ulcers were significantly associated with being malnourished according to the MNA, having lower BMI, being bed-ridden and having the diagnosis of diabetes and not having diagnosis of dementia. Those with pressure ulcers were more often administered nutritional supplements (Table 1). Altogether 29% of nursing home residents and 57% of long-term care hospital patients suffered from malnutrition according to the MNA. Contrary to the Tannen et al.’s results, our study suggests that older residents’ nutritional status seems to be a very important factor associated with the prevalence of pressure ulcers. Both low MNA points and lower BMI were associated with pressure ulcers. Tannen et al. used nutritional intervention as one covariate in their logistic regression model testing for prevention of pressure ulcers, and it did not show any predictive value. As our study shows, the nutritional intervention may be a response to poor nutritional status as those with pressure ulcers were administered more often nutritional supplements. The patient at risk of pressure ulcers may have both poor nutritional status and be on nutritional intervention at the same time. Therefore, poor nutritional status may be a confounding factor behind the variable ‘nutritional intervention’. Thus, it cannot be concluded that nutritional intervention is useless in the prevention of pressure ulcers. We investigated the true nutritional status of the residents which seems to be strongly associated with occurrence of pressure ulcers. Our results are in line with Hengstermann et al. (2007). It has also been shown in several studies that nutritional supplements may decrease the risk of pressure ulcers (Bourdel-Marchasson et al. 2000, Houwing et al. 2003). The prevalence of the pressure ulcers in our samples was remarkably lower than in the Dutch nursing homes but somewhat higher than in the German nursing homes. Moreover, the respective prevalence in our long-term care hospitals was significantly lower than in Dutch hospitals and similar to German hospitals. Our nursing home sample is in some respects comparable to the Tannen et al. nursing home sample: the mean age is similar and the proportion of females is comparable. However, the proportion of bed-ridden/chair-fast persons is lower in our sample (32%). The hospital samples, however, are not comparable: the mean age of Dutch and German hospital samples is significantly lower than in ours.