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Science, Practice and Education Any patient can develop a PU dependent on its individual comorbidity, the performed procedures and the intensity of nursing care. An American analysis on changes in the percentage of licensed nursing staff in Pennsylvanian hospitals between 1991 and 1997 led to the conclusion that almost all complications are seen more often in hospitals with fewer licensed nursing staff, in particular pressure ulcers and pneumonia 14 . A Swedish group who examined the problem of pressure ulcers in intensive care wards reported that 58 % of nursing staff think lack of time was a significant factor whenever pressure ulcer risk was not properly evaluated or aid devices were employed either inadequately or not at all 15 . For Germany, our analyses indicate that a low number of full-time employees in nursing homes had an influence on the incidence of pressure ulcers both as primary and as secondary diagnosis 16 . There is no predominant principal diagnosis which is associated with a relevant number of PUs. Older people having PU documented as an additional diagnosis in Germany in 2005 had femur fracture in 6.9 %, heart failure in 5.4 % and pneumonia in 5.2 % as the most frequent principal diagnosis 4 . It remains unclear if there is a specific risk associated with these diseases if it is just a selection of old and immobile patients. In contrast in those presenting with PU as the principal diagnosis the classical risk factors faecal and urinary incontinence seem to have a relevant impact either on the development of PU or on the admission to hospital. These patterns of comorbidity did not change in the period from 2005 to 2011 as we did not expect it to change 17,18 . Limitations Although routine data in the electronic patient record are frequently used for secondary purposes, there is currently no systematic analysis of coding quality in Germany 10 . Whether coding matches reality as a prerequisite for further use of the data in medicine and health politics has to be investigated in controlled trials. Thus, we cannot estimate the rate of wrong coding of the grades or the localizations of pressure ulcers. In conclusion, in Germany the rate of cases hospitalized with the principal diagnosis PU did not increase whereas the rate of PU documented in hospitalized patients increased from 2005 to 2011. Thus, PU is still a relevant problem. This analysis pointed out some specific aspects in PU localization and comorbidity that show the multidimensional dimension of the problem. m Acknowledgement We thank Referat VIII A 1 from the Federal Statistical Office for extracting and providing the data from the DRG-Statistik. References 1. Amlung SR, Miller WL, Bosley LM. The 1999 National Pressure Ulcer Prevalence Survey: a benchmarking approach. Adv Skin Wound Care. 2001;14:297-301. 2. Lahmann NA, Halfens RJ, Dassen T. Pressure ulcers in German nursing homes and acute care hospitals: prevalence, frequency, and ulcer characteristics. Ostomy Wound Manage. 2006;52:20-33 3. Scott JR, Gibran NS, Engrav LH, Mack CD, Rivara FP. Incidence and Characteristics of Hospitalized Patients with Pressure Ulcers: State of Washington, 1987 to 2000. Plast. Reconstr. Surg.2006;117:630 4. Kröger K, Niebel W, Maier I, Stausberg J, Gerber V, Schwarzkopf A. Prevalence of pressure ulcers in hospitalized patients in Germany in 2005: data from the Federal Statistical Office. Gerontology. 2009;55:281-7. 5. Gunningberg L, Stotts NA, Idvall E. Hospital-acquired pressure ulcers in two Swedish County Councils: cross-sectional data as the foundation for future quality improvement.Int Wound J. 2011;8:465-73. 6. Vangilder C, Macfarlane GD, Meyer S. Results of nine international pressure ulcer prevalence surveys: 1989 to 2005. Ostomy Wound Manage. 2008;54:40-54. 7. Vandenkerkhof EG, Friedberg E, Harrison MB. Prevalence and Risk of Pressure Ulcers in Acute Care Following Implementation of Practice Guidelines: Annual Pressure Ulcer Prevalence Census 1994-2008. J Healthc Qual. 2011 Jan 11. doi: 10.1111/j.1945-1474.2010.00127.x. 8. Kottner J, Wilborn D, Dassen T, Lahmann N. The trend of pressure ulcer prevalence rates in German hospitals: results of seven cross-sectional studies. J Tissue Viability. 2009;18:36-46. 9. Mueller-Bergfort S, Fritze J. Diagnose- und Prozedurendaten im deutschen DRG-System. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2007;50:1047-1054 10. Stausberg J. Quality of coding in acute inpatient care. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2007;50:1039-1046. 11. Wilborn D, Grittner U, Dassen T, Kottner J. The National Expert Standard Pressure Ulcer Prevention in Nursing and pressure ulcer prevalence in German health care facilities: a multilevel analysis. J Clin Nurs 2010;19:3364-71. 12. Groeneveld A, Anderson M, Allen S, Bressmer S, Golberg M, Magee B, Milner M, Young S. The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital. J Wound Ostomy Continence Nurs. 2004;31:108-120 13. Clegg A, Kring D, Plemmons J, Richbourg L. North Carolina wound nurses examine heel pressure ulcers. J Wound Ostomy Continence Nurs. 2009;36:635-9. 14. Unruh L. Licensed nurse staffing and adverse events in hospitals. Med Care 2003; 41:142-52 15. Strand T, Lindgren M. Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: a descriptive cross-sectional study. Intensive Crit Care Nurs 201026: 335-342 16. Kröger K, Becker R, Weiland D, Lax H, Priebel J, Maier I. Regional differences in the incidence of inpatients with pressure ulcers in Germany. J Public Health 2012; 10.1007/s10389-012-0504-0 17. Arndt KA, Dohrendorf H, Tannen A, Braumann A, Dassen T. Prevalence of urinary incontinence in hospitals and nursing homes: an underestimated problem. Pflege Z. 2006;59:635-638. 18. Tabali M, Kollross CM, Braumann A, Tannen A, Dassen T. Fecal incontinence – an analysis of German clinics and nursing homes: breaking the taboo. Pflege Z. 2006;59:639-642. 14 EWMA <strong>Journal</strong> <strong>2014</strong> vol 14 no 1
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