J. R. E. Haalboom

Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers.

Abstract Objective: To evaluate whether risk assessment scales can be used to identify patients who are likely to get pressure ulcers. Design: Prospective cohort study. Setting: Two large hospitals in the Netherlands. Participants: 1229 patients admitted to the surgical, internal, neurological, or geriatric wards between January 1999 and June 2000. Main outcome measure: Occurrence of a pressure ulcer of grade 2 or worse while in hospital. Results: 135 patients developed pressure ulcers during four weeks after admission. The weekly incidence of patients with pressure ulcers was 6.2% (95% confidence interval 5.2% to 7.2%). The area under the receiver operating characteristic curve was 0.56 (0.51 to 0.61) for the Norton scale, 0.55 (0.49 to 0.60) for the Braden scale, and 0.61 (0.56 to 0.66) for the Waterlow scale; the areas for the subpopulation, excluding patients who received preventive measures without developing pressure ulcers and excluding surgical patients, were 0.71 (0.65 to 0.77), 0.71(0.64 to 0.78), and 0.68 (0.61 to 0.74), respectively. In this subpopulation, using the recommended cut-off points, the positive predictive value was 7.0% for the Norton, 7.8% for the Braden, and 5.3% for the Waterlow scale. Conclusion: Although risk assessment scales predict the occurrence of pressure ulcers to some extent, routine use of these scales leads to inefficient use of preventive measures. An accurate risk assessment scale based on prospectively gathered data should be developed.

Statement of the European Pressure Ulcer Advisory Panel —pressure ulcer classification: differentiation between pressure ulcers and moisture lesions

Apressure ulcer is an area of localized damage to the skin and underlying tissue caused by pressure or shear and/or a combination of these. The identification of pressure damage is an essential and integral part of clinical practice and pressure ulcer research. Pressure ulcer classification is a method of determining the severity of a pressure ulcer and is also used to distinguish pressure ulcers from other skin lesions. A classification system describes a series of numbered grades or stages, each determining a different degree of tissue damage. The European Pressure Ulcer Advisory Panel (EPUAP) defined 4 different pressure ulcer grades (Table 1).1 Nonblanchable erythema is a sign that pressure and shear are causing tissue damage and that preventive measures should be taken without delay to prevent the development of pressure ulcer lesions (Grade 2, 3, or 4). The diagnosis of the existence of a pressure ulcer is more difficult than one commonly assumes. There is often confusion between a pressure ulcer and a lesion that is caused by the presence of moisture, for example, because of incontinence of urine and/or feces. Differentiation between the two is clinically important, because prevention and treatment strategies differ largely and the consequences of the outcome for the patient are imminently important. This statement on pressure ulcer classification is limitedto the differentiation between pressure ulcers and moisture lesions. Obviously, there are numerous other lesions that might be misclassified as a pressure ulcer (eg, leg ulcer and diabetic foot). Experience has shown that becauseof their location, moisture lesions are the ones most often misclassified as pressure ulcers.2-3 Wound-related characteristics (causes, location, shape, depth, edges, and color), along with patient-related characteristics, are helpful to differentiate between a pressure ulcer and a moisture lesion

Pressure ulcer risk in hip fracture patients

Hip fracture patients have a high risk of pressure ulcers (PU). We followed 121 hip fracture patients for the development of pressure ulcers and evaluated a risk assessment tool for sensitivity and specificity. More than half of the patients presented with PU, mostly stage I. Risk factors for PU were high age and the length of time on the operating table. The risk assessment tool had a low predictive value, however. It is thus hard to predict which patients will develop PU and which will not. Accordingly, we propose maximum preventive measures against PU for all patients presenting with hip fractures.

Non-EEA-doctors in EEA-countries: doctors or cleaners?

Background: Migration of non-EEA doctors to EEA-countries has become a common phenomenon. As coordination within the EEA has not yet been established, every EEA-country is re-inventing the wheel of assessment of foreign medical degrees and developing additional programmes for non-EEA doctors. There is hardly any knowledge about assessment procedures in other EEA-countries. Aim: To examine how 10 European Economic Area (EEA) countries deal with non-EEA doctors. Both national and university policies regarding non-EEA doctors were examined. Methods: This was a qualitative study based on two structured questionnaires. One was used for staff members of national health departments and the other was used for staff members of university medical faculties. Staff members from the health departments of mid-European and north European countries, and staff members from universities in Austria, Belgium, Denmark, France, Germany, Norway, Sweden, UK, Spain, and The Netherlands participated in the study. Results: There is no EEA directive concerning non-EEA doctors. Each EEA country, therefore, has devised its own policy towards non-EEA doctors. To enable non-EEA doctors to obtain a full license, thereby preventing them from ending up as unskilled labourers, the health departments in the Nordic countries and the UK have developed a ‘fast-track’ process for non-EEA doctors. In Austria, Belgium, and The Netherlands, however, non-EEA doctors are more dependent on programmes offered by university medical faculties. The situation in Germany is between these two extremes. As a rule, the programmes for non-EEA doctors in Belgium, Germany, and The Netherlands are two to three times longer than in the Nordic countries (18–36 months vs. 12–18 months, respectively). Financial aid is not available in most countries. Conclusion: As the influx of non-EEA doctors is increasing, harmonisation within the EEA is strongly advisable. As long as there is no EEA directive about non-EEA doctors, the assessment procedures (diploma evaluation, medical-knowledge tests, language requirements, length of additional programmes, etc.) need to be coordinated.

Studievoortgangsproblemen van buitenlandse artsen die instromen in een hoger jaar van de opleiding geneeskunde

Buitenlandse artsen van wie de diploma’s niet gelijkgesteld worden door de minister van VWS, vragen veelvuldig toelating tot medische opleidingen om in de toekomst in Nederland als arts te kunnen werken. In de laatste tien jaren hebben meer dan 1000 buitenlandse artsen via de Commissie Instroom Buitenlandse Artsen (CIBA) hiertoe een verzoek ingediend. In 2004 is berekend dat bijna 90% van deze artsen feitelijk start met een aanvullende opleiding geneeskunde.Daar er geen gegevens bekend waren over de voortgang van deze buitenlandse artsen in de aanvullende studietrajecten, is in dit onderzoek het studieverloop van alle 99 ingestroomde buitenlandse artsen in de cohorten 2002 en 2005 door de studieadviseurs geinventariseerd. Gebleken is dat bij 38 studenten sprake was van studieproblematiek; de overige 61 studenten studeerden zonder problemen. De matige beheersing van de Nederlandse taal en de gebrekkige medische kennis en vaardigheden vormden de hoofdmoot van de problematiek. Ook werden attitudeproblemen vastgesteld. Naast de opleidingsgerelateerde problemen signaleerden de studieadviseurs ook problemen rond verblijfsstatus en levensfase (zoals studiefinanciering, huisvesting en zorg voor partner en/of kinderen). Opvallend was dat van de instroom in het cohort van 2002 71% een vluchtelingenstatus had, terwijl van de instroom in het cohort van 2005 het merendeel (57%) in het kader van gezinsvorming in Nederland verbleef. De gemiddelde leeftijd bij de start van de aanvullende studie was 35 jaar.Geadviseerd wordt om aandacht te blijven besteden aan de verbetering van de Nederlandse taal. Tevens is het van belang dat de expertise op het gebied van de begeleiding van buitenlandse artsen door studieadviseurs en studentendecanen niet verloren mag gaan. (Herfs PGP, Haalboom JRE. Studievoortgangsproblemen van buitenlandse artsen die instromen in een hoger jaar van de opleiding geneeskunde. Tijdschrift voor Medisch Onderwijs 2008;27(2):90-98.)

Het zelfoordeel van buitenlandse artsen over hun VWS-assessment-competenties bij de start van de opleiding geneeskunde in Nederland

Onder verantwoordelijkheid van het ministerie van Volksgezondheid, Welzijn en Sport is voor alle buitenlandse artsen met een buiten de Europese Economische Ruimte (EER) behaald diploma, en die in Nederland werkzaam willen zijn als arts, een assessment-procedure ontwikkeld. Deze procedure is per 1 december 2005 ingevoerd en beoogt de kwaliteit van de instroom, gemeten naar Nederlandse maatstaven, te verbeteren. Het assessment bestaat uit twee aspecten: toetsing van algemene kennis en vaardigheden (o.a. Nederlandse taal- en communicatievaardigheid, Engelse leesvaardigheid, kennis van de ICT, kennis van de Nederlandse gezondheidszorg) en toetsing van medische en klinische kennis en vaardigheden. Er zijn vijf mogelijke uitkomsten: kennis is gelijkwaardig, noodzaak van aanvullend programma van een, twee of drie jaar of van volledige opleiding. Onderzocht is hoe de buitenlandse artsen, die in de twee jaren voorafgaand aan de invoering van de assessment-procedure via de Commissie Instroom Buitenlandse Artsen (CIBA)-procedure zijn ingestroomd, zelf hun competenties bij de aanvang van hun aanvullende opleiding geneeskunde beoordelen. In totaal werden 157 buitenlandse artsen aangeschreven waarvan 106 (68%) respondeerden. In het algemeen zijn zij van mening dat het niveau van hun algemene en medische kennis en vaardigheden redelijk aansluit bij de eisen die vanuit de Nederlandse gezondheidszorg gesteld worden. Dit komt echter niet overeen met de indrukken van opleiders. Zij geven aan dat het grootste probleem de beheersing van de Nederlandse taal is. Verbetering daarvan tijdens de opleiding geneeskunde en zelfs daarna is in hun optiek noodzakelijk.