1 INTRODUCTION

Pressure ulcers are preventive health problems that cause suffering and additional costs due to increased healthcare needs, especially among elderly and fragile patients. However, through risk assessments and teamwork, health and well-being can be improved by managing the risk factors (WHO, 2020). Therefore, the current study intended to contribute to the knowledge about the staff's documentation of pressure ulcers into the medical records in a hospital setting.

2 BACKGROUND

Pressure ulcers are a global health problem [12.8% prevalence rate globally] that cause tissue damage due to continuous pressure and friction in connection with movement and/or use of medical equipment (Li et al., 2020). Cell deformation is a recognized important mechanism of cell damage as well besides ischemia caused by pressure or friction which triggers inflammatory processes (Mervis & Phillips, 2019). In Europe, the prevalence is around 14.5%, which is higher than that in Asia [3%] (Li et al., 2020). The European Pressure Ulcer Advisory Panel [EPUAP], National Pressure Ulcer Advisory Panel, [NPUAP] and Pan Pacific Pressure Injury Alliance [PPPIA] (EPUAP/NPUAP/PPPIA, 2019) have developed an international classification system [categories 1–4] as follows: (1) includes redness, painful with no fade, no blanchable, pressure and temperature differences between the affected area and surrounding skin; (2) describes pressure ulcers as partial tissue damage, partial thickness loss, open pink-red wound without fibrin coating, bone, tendon or muscle involved; (3) full thickness tissue loss at the location; and (4) involves the bone, tendon or muscle and fibrin, and/or has visible necrosis (EPUAP/NPUAP/PPPIA, 2019).

Research (Gunningberg et al., 2017) has shown differences in staff knowledge about pressure ulcers. Registered nurses [RN, 26.5%] were more knowledgeable than assistant nurses [AN, 16.5%] in background causes, and why they worked more preventive than AN. Risk factors such as reduced mobility, impaired skin elasticity, cardiovascular disease (Ferguson et al., 2019; Jaul et al., 2018), malnutrition, diabetes, depression and fractures (Bluestein & Javaheri, 2008) were more common among the elderly. Moreover, extended hospital stays [>5 days], oedema, incontinence, abnormal albumin levels and low weight [BMI < 20] also increase the risk of pressure ulcers (Alhaug et al., 2017; Ferguson et al., 2019; Kaşıkçı et al., 2018). Medical equipment such as wheelchairs, beds, oxygen masks, intravenous access and neck collars are other risk factors as they are connected with the skin, with pressure and friction, in moist surfaces (Bluestein & Javaheri, 2008; Jackson et al., 2019; Jaul et al., 2016). Therefore, awareness of vulnerability [for example, in elderly persons] is highlighted, and both risk assessment and skin inspection [for example, within 8 hr of the patient's arrival] are stressed to prevent suffering and unnecessary financial costs due to extended hospital stays (Latimer et al., 2019). In addition, patients with pressure ulcers have both a low quality of life and negative emotions such as frustration, anxiety, and depression (Wu et al., 2018). Therefore, relation between pressure ulcers risk factors, incidence and nursing documentation in hospital is crucial. For example, Li (2016) describes that staff nurses at intensive care units perform poorly documenting pressure ulcers due to appearance, staging and treatment, why patient's needs due to nursing interventions are limited. Integrating evidence-based pressure ulcer prevention within electronic health records, EHR, requires regulatory reporting to improve nursing flow by providing clinical decision support (Gilbert, 2015). For example, more comprehensive documentation was found in EHR compared with paper records; however, there were shortcomings due to documentation in both systems (Tubaishat et al., 2015). Moreover, comparing patient examinations with patient record contents, patient's records lacked documentation of pressure ulcers and preventive interventions (Hansen & Fossum, 2016).

Under Swedish law (Swedish Code of Statutes, 2010), pressure ulcers are described as a care injury, a complication that could be avoided. Therefore, to ensure patient safety, systematic improvement is stressed. Moreover, the World Health Organization (2020) highlighted that a positive work environment and teamwork motivated health professionals to document, prevent and analyse healthcare injuries. One way to improve the quality of care is to use a national quality register. Sweden has around 100 quality registers (acute, community health care), one of which is Senior Alert [SA], a structured and preventive register [mostly used in community care for those who are 65 years and older] to identify risks and analyse their causes within four pre-selected areas, one of which is pressure ulcers. SA includes risk assessments, planning and implementation of preventive measures, which are thereafter followed up and evaluated. Research about SA showed that staff members, for example, RN, performed continuous evaluation of care events [hospitalization, home health care] in close collaboration with the patient (Edvinsson et al., 2015; Rosengren et al., 2012). Even though staff members reported different and time-consuming routines SA improved the cooperation and increased security at work, which contributed to equal care when the same checklist was used (Lannering et al., 2017). In addition, the modified Norton Scale, a risk assessment tool with high sensitivity, low specificity (Park et al., 2016), and satisfactory validity (Šateková et al., 2017), is recommended to prevent and/or taking care of pressure ulcers (Edvinsson et al., 2015; Lannering et al., 2017; Rosengren et al., 2012).

In Sweden, another systematic approach used to prevent care injuries such as pressure ulcers is the Green Cross, a structure that follow-ups on the complications in everyday healthcare situations at the care unit through a risk assessment (Schwarz et al., 2021). To improve the quality of care, first-line managers are crucial as gatekeepers and quality markers to safeguard health care through a satisfied work environment. One suggestion is to include person-centredness, based on the patient's experiences, wishes, resources and abilities, and enable trust and shared decision-making grounded in the patient's narrative. Team workers [staff, patients and relatives] and partnerships should create and document health plans that promote patient safety, health and well-being (GPCC, 2021; Rosengren, 2016). In summary, the risk factors for pressure ulcers are well known. Even though they can prevent pressure ulcers from causing damage, improvements are needed to acknowledge and manage risk factors to help us estimate the risk of developing pressure ulcers. Hence, the aim of this study was to describe and analyse the documentation of pressure ulcers and focused on the medical records from an internal medicine ward in a university hospital in western Sweden.

3 METHODS

4 RESULTS

The results are presented in four parts: documentation of the pressure ulcers within the medical records [N = 1,458; 797 females, 661 males; n = 31; 22 female, 9 male; +80 n = 20] admitted in a specific ward during the year 2019 [January 1 to December 31], documentation of the definition and the location of tissue damage [PU = 198], documentation of the pressure ulcers within the final note [n = 46] and point prevalence measurement [PPM] of the pressure ulcers [n = 3].

5 DISCUSSION

The aim of this study was to describe and analyse the documentation of pressure ulcers and focused on the medical records from an internal medicine ward in a university hospital in western Sweden. The results showed variation in the prevalence [2.1%–6.7%] of pressure ulcers documented in the medical records [care plans/final notes]. However, the PPM of inpatients in the ward in March 2019 showed a significantly higher prevalence of 21%. Moreover, documentation of all care events in a specific ward during 2019 [for patients older than 18 years] also showed a lower number [3.2%] than international [12%] measurements (Li et al., 2020).

Conclusions could be drawn based on what documentation strategies or routines were carried at the ward level. The low percentage in current results may reflect low prevalence but may also indicate a lack of documentation of the pressure ulcers in the ward. This has been demonstrated in other studies (Li, 2016) and is linked to patient safety (Andersson et al., 2018). Improvement due to routines and quality of content within the documentation process is therefore highlighted to facilitate high-quality care (Swedish Code of Statues, 2010). Moreover, 68 risk assessments out of the 1,458 care events were conducted, and 94% of the patients [those older than 65 years] in the specific ward received no risk assessment. This was contrary to the national and international recommendations that risk assessments were needed for all patients aged 65 years and older, especially patients at risk (Edvinsson et al., 2015; Lannering et al., 2017; Rosengren et al., 2012). One way to increase the number of risk assessments is to pinpoint one RN at each shift [day, evening] to be responsible for risk assessment within 24 hr [for example, 8 hr after admission], and thereafter conduct care plans for patients at risk of pressure ulcers (Latimer et al., 2019). This suggestion aims to prevent pressure ulcers, a complication [care injury] that can be avoided through systematic improvements which ensures patient safety (WHO, 2020).

Furthermore, our results show a difference in the number of care plans performed by RNs [higher number] in relation to AN [lower number]. The abovementioned professional differences in the documentation of the pressure ulcers show the need for potential improvement involving all team members in nursing with the objective of ensuring patient safety. However, Swedish health care lacks the legal support for AN to document care plans in the medical records. Therefore, national, regional and local routines could be discussed considering the educational perspectives and nursing objectives. Education of staff and patient due to pressure ulcers is one tool to improve health care. Research (Morente et al., 2014) shows the value of e-learning tools as ePULab contributes to effective strategies for education on diagnosis and treatment of pressure ulcers, that is, impact on clinical decision-making which improve quality of health care. Moreover, Al Mutair et al. (2021) highlight that implementation of pressure ulcers prevention programme, PUPP reduce hospital-acquired pressure ulcers via culture of care integration. Another example is use of photographs together with categorization of the same wound to identify pressure ulcers (Ham et al., 2015).

For patient safety (Swedish Code of Statutes, 2010), it seems appropriate that AN document risk assessment and tissue damage/status due to daily caring activities such as personal hygiene, dressing, etc. Staff's responsibility for the documentation in the medical records, for example, to conduct care plans in line with PCC (Ekman et al., 2011; Rosengren, 2016) is not sufficient. Furthermore, other potential reasons for the limited documentation of pressure ulcers in the medical records may include high workload, stress and lack of routines. Therefore, work environments that facilitate teamwork are stressed to prevent and/or reduce pressure ulcers by using resources grounded in partnerships (Ekman et al., 2011; GPCC, 2021; Rosengren, 2016). One successful intervention that has been implemented at several Swedish hospitals is the Green Cross, which uses traffic light [red, yellow, green] to identify risks and patterns in care events, such as pressure ulcers (Schwarz et al., 2021). In addition, research (Kim et al., 2019) stresses that limited participation and experience of systematic preventive work negatively affects self-confidence, and therefore, fear of being blamed for pressure ulcers arises. This may be an explanation for the limited documentation in the specific ward.

Our results are consistent with a previous study (Børsting et al., 2018; Lavallée et al., 2018) which showed that elderly [those aged 70 years and older] persons were at risk. However, 80.0% of our inpatients who had pressure ulcers were female, which was a higher proposition than in previous studies (Hyun et al., 2019; Kim et al., 2019). However, research has also indicated that there were no differences due to gender (Lichterfeld-Kottner et al., 2020). One explanation could be the lack of documentation among male patients or that female patients in the ward were older. To develop efficient routines for the systematic documentation of pressure ulcers in the medical records, one or two RNs could be responsible for performing regular reviews/audits of inpatient care plans using practical examples. Audits and regular discussion at staff meetings would increase staff's awareness and could result in improved documentation of pressure ulcers and greater data accuracy (D'emeh & Rosengren, 2015; Hansen & Fossum, 2016; Li, 2016; Tubaishat et al., 2015). Furthermore, pressure ulcers and other tissue damage were most common in the sacrum and heel (Zhou et al., 2017), which is why increased awareness of the risk factors is important for managing day-to-day nursing activities. One way is to use the same international classification system namely 1–4 (EPUAP/NPUAP/PPPIA, 2019) within the medical records, to improve systematic documentation. By facilitating teamwork towards common goal about same structure using international classification system, namely 1–4 in the documentation processes, could prevent pressure or friction (Mervis & Phillips, 2019) among patients at risk who use medical equipment (Jaul et al., 2016). Misunderstanding due to the definition and localization of the pressure ulcers could be managed by above systematic and structured documentation (EPUAP/NPUAP/PPPIA, 2019). Uncertainty occurs when unclear descriptions, such as “on the leg,” are used, and therefore, staff members need to double-check where the pressure ulcers are located. Moreover, definitions as “liquid” or “redness” exemplify deficient formulations documented in care plans, these adjectives refer to the nature of the wound, not the type, which also increases risk of misinterpretations. Use of the same terminology due to definition and localization (EPUAP/NPUAP/PPPIA, 2019) in care plans would increase patient safety in line with the Swedish law (Swedish Code of Statutes, 2010). In addition, variations in the definitions of tissue damage could explain a seemingly low-pressure ulcers prevalence, and why the “right” prevalence may arise to the same level as reported in other studies (Li et al., 2020; SALAR, 2020) if and when documentation was specified and systematic performed of all patients at risk (EPUAP/NPUAP/PPPIA, 2019). Therefore, health professionals are required to keep medical records to enable team members [patients included] to understand the content of health care.

According to the PPM measurement, 21.4% of the inpatients in the specific ward suffered from pressure ulcers at the time when the PPM was performed, which could be considered as high due to the results of the medical record review [2.1%–3.3%]. However, these results need to be considered with caution because of the limited number of patients included [3/14 = 21.4%] compared to the review of all care events [n = 1,458] documented in the medical records during the year 2019. Considering that half of the patients were elderly [older than 80 years], the results can be considered reasonable compared to that of an earlier study (Gunningberg et al., 2017). However, risk assessment in connection with the PPM showed that patients [not at risk] suffered from pressure ulcers (Díaz-Caro & García Gómez-Heras, 2020), according to the Modified Norton Scale, mostly during the first week of their hospital stay. Therefore, it is important for all staff members to prevent pressure ulcers among patients (Bluestein & Javaheri, 2008; Ferguson et al., 2019; Gunningberg et al., 2015; Jackson et al., 2019; Kaşıkçı et al., 2018), in line with professional ethical codes for RN (ICN, 2021) about health and well-being. In summary, systematic use of Green Cross (Schwarz et al., 2021) and simplifying a structured the documentation procedure (Larsson et al., 2019) of medical records (EPUAP/NPUAP/PPPIA, 2019) is highly recommended to prevent pressure ulcers, especially among the elderly (Khor et al., 2014).

6 CONCLUSIONS

The results showed variation in the prevalence [2%–21%] of pressure ulcers documented in the medical records and one day's measurement, [PPM], resulted in lower number [3.2%] than international [12%] measurements (Li et al., 2020). Education [staff, patients, relatives] is one way to sustain a decrease of pressure ulcers via culture of care integration. A uniform documentation drawn by the entire team across professional boundaries within medical records facilitates high-quality healthcare delivery, such as preventing pressure ulcers. Health professionals, such as nurses, need to define and locate tissue damage and systematically categorize the pressure ulcers in an early stage using risk assessments within 24 hr of admission to healthcare settings. By improving practices, such as by using Green Cross as a tool for continuous improvement, risk assessment within 8 hr of arrival and continuous skin assessment during hospital stay can be implemented. Routines and guidelines should be redeveloped so that all staff members [RN, AN] document care plans within medical records. Regular personal meetings with pinpointed responsible staff members at each work shift, and thereafter follow-up processes, could implement regular learning activities on a daily basis and increase awareness of preventable care injuries, such as pressure ulcers. These updated routines may hopefully results in improved health and well-being due to decrease of pressure ulcers at the ward level.

FUNDING INFORMATION

The authors received no financial support for this article.

CONFLICT OF INTEREST

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

ETHICS STATEMENTS

No ethical approval due to Swedish law that stressed that health professionals were obligated to continuously improve patient safety (Swedish Code of Statutes, 2010, 2017). All data analyses were performed by all authors to reduce personal values and followed the routines for scientific work. Ethical considerations were followed throughout the study, such as information, confidentiality to protect personal aspects and utilization to improve high quality of health care (Codex, 2021; Polit & Beck, 2017).