Pressure ulcer is a common complication in hip fracture surgery and convalescence. Earlier prevalence studies have demonstrated a lower prevalence in Southern Europe than in Northern Europe. In patients with hip fractures, specific risk factors for developing pressure ulcers, apart from those included in standardised risk assessment are not fully understood. Correct classification of Category I pressure ulcers is a prerequisite for planning preventive measures. It is also mandatory for the reliability of prevalence studies. Until now subjective tests such as finger-press test and visual assessment have been utilised in clinical practice. An objective method has hitherto been lacking. Planning and delivering good nursing care to patients who are at risk of, or already have, manifest pressure ulcers should be built on proper documentation. Degree of documentation of pressure ulcer prevalence and risk factors in patients with hip fractures versus elective hip replacement surgery has hitherto not been investigated. Scrutiny of medical records for these diagnoses and identification of potential differences should therefore be of interest.Aim: - To investigate prevalence and incidence of pressure ulcers upon arrival and at discharge from hospital, and to identify potential intrinsic and extrinsic risk factors for the development of pressure ulcers in patients admitted for hip fracture surgery. To establish the inter-rater reliability between blanching and non-blanching erythema, assessed by two independent assessors. The secondary purpose was to investigate potential correlations between risk factors and pressure ulcers. - To explore if a non-invasive objective method could differentiate between blanching/nonblanching erythema in the sacral area of patients undergoing hip fracture surgery. - To investigate the degree of documentation regarding risk assessment, preventive measures taken, prevalence and severity of pressure ulcers, in patients undergoing surgery for hip fractures or elective hip replacements at admission and during hospital care at an orthopaedic unit.Results: The prevalence of pressure ulcers in Southern Europe was lower compared to Northern Europe. Specific risk factors such as dehydration (p=.005), moist skin (p=.004), pulmonary disease (p=.006) and diabetes (p=.005) were identified. The finger-press test and visual assessment of Category I pressure ulcers were both unreliable methods with low interrater reliability. The proportion of patients with persistent discoloration differed significantly between the assessors from Day 1 to Day 5 (p = .013). Reflectance spectrophotometer used was proven to deliver high precision regarding classification of non-blanchable erythema (Category I pressure ulcers). Documentation of pressure ulcers, risk assessment, body mass index and prevention at admittance was unsatisfactory in patients undergoing hip surgery.

BACKGROUND: While there is growing awareness of quality problems in healthcare systems, it remains uncertain how best to accomplish and sustain improvement over time.

OBJECTIVE: To report on the design and application of quality improvement theme months in orthopaedic nursing, and evaluate the impact on pressure ulcer as an example.

DESIGN: Retrospective mixed method case study with time series diagrams.

SETTING: An orthopaedic department at a Swedish university hospital.

METHOD: The interventions were led by nursing teams and focused on one improvement theme at a time in two-month cycles, hence the term 'improvement theme months'. These included defined objectives, easy-to-use follow-up measurement, education, changes to daily routines, "reminder months" and data feedback. The study draws on retrospective record data regarding one of the theme topics, pressure ulcer risk assessment and prevalence, in 2281 orthopaedic admissions during January 2007-October 2010 through point prevalence measurement one-day per month. Data were analysed in time series diagrams and through comparison to annual point prevalence data from mandatory county council-wide measurements prior to, during and after interventions from 2003 to 2010. By using document analysis we reviewed concurrent initiatives at different levels in the healthcare organisation and related them to the improvement theme months and their impact.

RESULTS: The 46 monthly point prevalence samples ranged from 28 to 66 admissions. Substantial improvements were found in risk assessment rates for pressure ulcers both in the longitudinal follow-up (p<0.001) and in the annual county council-wide measurements. A reduction in pressure ulcer rate was observed in the annual county council-wide measurements. In the longitudinal data, wider variation in the pressure ulcer rate was seen (p<0.067); however, there was a significant decrease in pressure ulcer rates during the final ten-month period in 2010, compared to the baseline period in 2007 (p=0.004). Improvements were moderate the first years and needed reinforcement to be maintained.

CONCLUSIONS: The theme month design and the way it was applied in this case showed potential, contributing to reduced pressure ulcer prevalence, as a way to conduct quality improvement initiatives in nursing. For sustainable improvement, multi component interventions are needed with regular monitoring and reminder efforts.